Case Study Adime

Assessment
Anthropometric Measurements
62-y.o. F, BMI=21.7 (normal), Ht= 66 or 167.64 cm, Wt=134# or 60.9 kg per standing scale 9/19/13, IBW=130# or 59.1 kg,
%IBW=103%, UBW=259# or 118 kg in Oct. 2012 per pt report, %UBW=51.6% (severe unintentional wt loss of 48.4% x 11 mo.)
Biochemical Data
Labs (09/19/13): Hgb=7(L), Hct=21(L), RBC=2.57(L), Platelet=60 (L), WBC=0.7(L), Lymph=25%, TLC=175 (severe risk), Abs PMN=0.5
(severe neutrophil deficiency), Na=127(L), K+=4.8(N), Cl-=99(N), BUN=28(H), Creatinine=1.21(H), Ca=8(L), Mg=1(L),
TotalPro=15(N), Albumin=2.1(L)
Urine Analysis (9/20/13): + Gram-negative bacilli
Nutrition-Focused Physical Findings
Ample folds of loose skin, pale, no edema; some nausea, BM/BS normal; hair very thin, sparse, and lacking color; shaking chills
visible; extremely weak, fatigued
Subcutaneous fat assessment: orbitals - slightly dark circles, somewhat hallow look; triceps - some depth to pinch but not ample
(indicative of moderate fat loss)
Muscle mass assessment: temples - hollow scooping depression; shoulder - bones slightly protruding; scapula - bones prominent,
significant depression of muscle; thighs - very thin, depression of muscle, no definition, knee prominent; calves - not well
developed; interosseous - depressed area between thumb and forefinger (indicative of severe muscle wasting)
Client History
PMH: Multiple myeloma Dx 03/2013 - 4 cycles Velcade- & decamethasone-based chemo completed, complete remission as of
08/2013; myelofibrosis Dx 03/2013; gout, splenomegaly, rheumatoid arthritis, hypothyroidism, GERD, asthma, anxiety; hx of class
III obesity, hypertension, borderline DMT2 (resolved)
Surgical Hx: Cholecystectomy, tonsillectomy, hysterectomy, MediPort insertion
Social Hx: Patient lives with husband, has an adult daughter away from home. Husband states he works for their building complex
so he is available to come to her aid during those occasions when she needs assistance ambulating (i.e. to the bathroom)
Current Medical Dx: Pancytopenia & febrile neutropenia 2 myelofibrosis
Food and Nutrition History/Medications
Meds: Lenalinomide, levothyroxine, metoprolol, Xanax, Protonix, fentanyl patch
Appetite very poor since 12/2012, early satiety 2 splenomegaly present. Patient is too weak for food prep, husband enjoys
cooking. Taste changes/aversions present (2 previous chemo or current meds). Shellfish allergy.
Diet PTA: TDI is 4 health shakes (another brands version of the hospitals MightyShakes supplement) + a few bites of chicken pot
pie or cereal with 2% milk (4 health shakes = 800 calories, 24 g protein)
Diagnosis
Malnutrition (may have severe malnutrition in the context of chronic disease [NI-5.2]) RT increased energy needs due
to catabolic illness, poor appetite and early satiety AEB severe unintentional wt loss of 48.4% x 11 mo., intake <50%
estimated energy needs x 11 mo., moderate fat loss, severe muscle wasting, myelofibrosis
Intervention
Diet: Regular, neutropenic/low microbial
2132-2436 kcal, 91-122 g PRO, 1827 ml fluid (note: 2-3 L/d recommended for Lenalidomide)
Recommend: 1) Encourage small, frequent meals due to early satiety and fatigue; 2) Health shake oral supplements to be sent to
patients room TID for an extra 600 calories & 18 g pro/d; 3) Educate patient and husband about neutropenic/low microbial diet,
discuss need for increased calorie and protein intake, provide recommendations for easy high calorie/protein foods and ways to
incorporate more calories/protein into already accepted foods; 4) Ask physician to consider appetite stimulant; 5) Ask physician to
consider supplemental enteral nutrition feedings via PEG/PEJ, discuss with patient if aggressive nutrition intervention is desired
Monitoring/Evaluations
Short-term: - Patient verbalization of neutropenic diet restrictions, acceptance of health shakes, oral intake of supplement + foods
>75% of needs, physician order for appetite stimulant, physician opinion of EN
Long-term: - Weight gain rather than loss, adherence to neutropenic precautions (if necessary at time), adherence to and
acceptance of high calorie/protein food modifications, follow up on need/desire for supplemental EN

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