Pagenumber

APOLLO REACH HOSPITAL
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INDEX
S.N
O CONTENT
1 HOSPITAL INTRODUCTION
ABOUT HOSPITAL
AIMS AND OBJECTIVES OF INTERNSHIP
FLOOR PLANNING
DIETARY DEPARTMENT OF HOSPITAL
RESPONSIBILITIES OF DIETICIAN
ROLE OF DIETICIAN
ROLE OF DIETICIAN IN KITCHEN
OUT PATIENT DIET COUNSELLING
THERAPEUTIC DIET IN THE HOSPITAL
FOOD TASTING
ENTERAL AND PARENTERAL NUTRITION
MODIFICATION OF NORMAL DIET
CORONARY ARTERY BYPASS GRAFTING [CABG]

2 CASE STUDIES CHORNIC KIDNEY DISEASE [CKD]
CRANIOTOMY
RENAL CALCULI
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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BIBLIOGRAPHY
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HOSPITAL INTRODUCTION
ABOUT HOSPITAL:
Apollo Hospitals Enterprise Limited is an Indian multinational healthcare group headquartered in
Chennai. Apart from the eponymous hospital chain, the company also operates pharmacies, primary
care and diagnostic centers, and telehealth clinics through its subsidiaries.
The company was founded by Prathap C. Reddy in 1983 as the first corporate healthcare provider in
India. Several of Apollo's hospitals have been among the first in India to receive international
healthcare accreditation by the America-based Joint Commission International (JCI) as well as NABH
accreditation.The first branch at Chennai was inaugurated by the then President of India Zail Singh.
Apollo developed telemedicine services, after starting a pilot project in 2000 at Aragonda, Prathap
Reddy's home village.
In December 2012, Apollo Hospitals sold its 38% stake in Apollo Health Street, the group's
healthcare business process outsourcing division, to Sutherland Global Services for ₹225 crore
(US$42.11 million).
Apollo signed a MoU with Health Education England in April 2017 to provide a large number of
doctors to fill vacancies in the English National Health Service.
Apollo Reach - a first of its kind endeavour to make advanced technology and experienced medical
professionals accessible to the people living in rural and semi urban areas in the country. The Prime
Minister of India Dr Manmohan Singh launched the Apollo Reach Hospitals on Sep
5 2008 at Chennai at a glittering function graced by the Chief Minister of Tamilnadu
Dr.M.Karunanidhi, Union Minister of Finance Shri. P. Chidambaram and Union Minister of Health
Dr. Anbumani Ramadoss. The first Reach hospital at Karimnagar,Andhra Pradesh and the foundation
stone for the hospital at Karaikudi, Tamilnadu were launched. Apollo Reach Hospitals aim to make
world class healthcare accessible to people even in remote areas of the country. Apollo Reach
Hospitals would be 100-150 bedded multispecialty facilities in tier 2 and 3 cities across India and over
the next 24- 36 months; over 200 such Apollo Reach Hospitals all over the country are to be set up.
MISSION STATEMENT:
Our mission is to bring Heathcare of international standards within the reach of every individual. We
are committed to the achievement and maintenance of excellence in education, research and healre for
the benefit of humanity.
VISIONSTATEMENT:
Our vision is to make India as a global healthcare destination
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FACILITIES:
1. Accident, Anesthesiology
2. Critical & Intensive Care
3. Dietetics
4. Emergency
5. MICU (Medical intensive care

unit)
6. Neurology
7. Nephrology
8. Orthopedics
9. SICU (Surgical intensive care

unit)
10. Urology.
FLOOR PLANNING
GROUND FLOOR
A WING
• Emergency
• Treatment room
• Sample collection
• Finance & accounts
• Quality control department
B WING
• MRI
• X-Ray
• CT scan
• Arogyasree/EHS OPD
• Credit cell department
C WING
• OP pharmacy
• 2D echo
• TMT
• Ultrasound
• ECG
• Health check block
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• OPD consultation rooms
• Dietetics department
• Corporate relations
• Human resources
D WING
• Billing department
• Dialysis ward
• OPD consultation rooms
• Healthy heart doctor
• Administrator
• Medical superintendent
• Physiotherapy & rehabilitation
• Mortuary
• Staff canteen
• Visitors lobby
FIRSTFLOOR
• ICU patient attendants waiting lounge
• SICU
• HDU
• MICU
• CICU
• CT- post operative unit Recovery room
• Nursing superintendent’s office
• Family meeting & counselling room
• ETO sterilization room
• Operation theatres
• CSSD
• Cathlab
• OT stores
• OT pharmacy
SECOND FLOOR
• Special rooms
• General wards – male & female
• Learning & development center
• Housekeeping services
THIRD FLOOR
• Blood bank
• IP pharmacy
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• IT department
• Laboratory services
AIMS & OBJECTIVES OF INTERNSHIP

Hospital dietary internship is to gain knowledge and practical experience, the treatment of various
diseases with diet.
OBJECTIVES:
• To Study the various diets associated with the diseases.

• To know the administration pattern and the functioning of dietary department.
• To understand the role and duties of dietician and other staff members in the dietary
department.
• To acquire the dietary skills in the diet counselling.
• To get expertise in various practices of kitchen layout in the hospital.
• To study the cases with the menu plans for various diseases to acquire clarity.
DIETARY DEPARTMENT OF HOSPITAL:
The dietary department is the central point of the diet service in the hospital. It is located in the
outpatient department on the ground floor.
The dietician has to assess the patients and fill in a Nutritional Assessment Form which depicts the
nutritional status of the patient.
This assessment form includes the following criteria
1. Nutritional status based on BMI.
2. Likes and dislikes.
3. Appetite/Food intake/Food tolerance
4. Weight loss/Gain
5. Type of diet
A few signs and symptoms are also kept in mind while assessing the patients which help in better
understanding of the patient's condition.
▪ Nausea
▪ Vomiting
▪ Constipation
▪ Diarrhea
▪ Edema
▪ Ascites
▪ Based on the diagnosis, medical history and present illness the diet of the patient
is decided by the dietician, who then informs to the F&B department.
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ROLE OF A DIETICIAN:
Dieticians are the health professionals, ideally trained to implement and change dietary habits of an
individual or population. One who plans and supervises the preparation of therapeutic or other diets
for individuals or groups in hospitals, institutions, other establishments and for workers in particular
sectors, gives instructions in selection and proper preparation of food according to dietary principles,
performs duties related to nutrition programs and may be responsible for food purchasing on behalf
of an organization or establishment.
RESPONSIBILITIES OF A DIETITIAN:
⮚ Collecting, organizing and assessing data relating to the health and nutritional status of
individual groups and populations.
⮚ Interpreting scientific information and communicating information, advice, education and
professional opinion to individuals, groups and communities.
⮚ Managing client centered nutrition care for individuals by planning appropriate diets and
menus and educating people on their individual nutritional needs and ways of assessing and
preparing their food.
⮚ Planning implementing and evaluating nutrition program with groups. Communities or
population as a part of team. This may be in a community health, public health or food
industries setting.
⮚ Managing food service systems to provide safe and nutritious food by designing nutritionally
appropriate menus and designing and implementing nutritional policies. • Undertaking food
and nutrition research and evaluating practice.
PATIENT COUNSELLING:
Patient counseling is a broad team which describes the process through which health care
professionals attempt to increase patient knowledge of health issues. The process providers for the
exchange of information between the patient and health practitioner. The information gathered is
needed to assess the patient’s medical condition to further design, select, implement, evaluate, and
modify health interventions.
The structure of patient counseling is divided into four groups.
⮚ Introduction
⮚ Counseling contents
⮚ Counseling process
⮚ Conclusion
INTRODUCTION:
• Review the patient record

• Conduct an appropriate patient counseling introduction by self and patient
• Obtain the initial information of patient medical condition
• Assess actual problem of the patient
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COUNSELLING CONTENT:
• Explain the diet and its dietary guidelines

• Suggest the patient which foods have to intake or which foods that must avoid
• As per diseased condition diet should suggest to the patient
• The dietician should know diet plays a major role in the prognosis of disease and that
should be strictly follow the guidelines of diet therapy
• Encourage the patient to follow up the programme in order to remain in sound health
COUNSELLING PROCESS:
• Provide accurate information

• Use language that the patient likely to understand
• Use the appropriate counseling aids to support counseling
• Present the fact and order in logical order
• Maintain control and direction of the counseling session
• Probes for additional information
• Use open-ended questions
• Display effective non-verbal behaviors
CONCLUSION
• Verify that patient is understanding via feedback

• Summaries by acknowledging or emphasizing the key points of information
• Provide an opportunity for final concerns or questions and help them to follow.
DIET PRESCRIPTION:
The formulation is the most important nutritional therapy for each patient. Requirement is
considered with that of initial metabolic, biochemical and anthropometric data obtained by
nutritional assessment of the patient.
➢ The dietary prescription is made on the basics of the patient’s age, activity
pattern, BMI, and type of treatments he /she is undergoing.
➢ Estimation of body weight and its comparison with desirable body weight.
➢ Calculation of daily calorie and other nutrient intake
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➢ Giving a written diet chart along with their calorie for a day, their ideal body
weight, timings of the meals and snacks and guidelines to be followed. A diet
sheet was given to every patient counselled which has the requirement of
calories and the necessary modifications in the diet.
➢ Important focus stressed on their physical activity like walking, exercises,

cycling, outdoors games etc.… as per patient’s choice
➢ Advice is given in terms of cooked foods and volumetric measurements in

order to achieve better competence
➢ To introduce variety and flexibility in diet prescription, provision of exchange

list proves to be good.
The patient is made to know about the approximate quantities and calorie given by the common
foods usually taken. Distribution of calories is done in the diet chart throughout the day per every
meal. The foods to be restricted and allows liberally are also included in the sheet.
ROLE OF DIETICIAN IN KITCHEN:
• Scrutinize compile daily diet indents.
• Supervision of food preparation and ensuring proper food distribution.
• Check food wastage at different levels.
• Establishes and maintains standard of food production and services and sanitation.
KITCHEN
The kitchen is divided into various sections starting with:
• Planning and distributing area
• Breakfast preparation area
• Patient foods preparation area
• Grinding area
• Cutting and storing area
• Room service cabin (for patients)
• Washing area
• Cold storage area
• Storeroom for daily vegetables
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FOOD TASTING:
TASTING is a special feature present at the Apollo hospital which enables a check on the food
prepared in the kitchen, served to the patient. The food should be cooked well to its exact
texture/consistency. It should be cooked properly, appealing, appetizing, and colorful so that it is
accepted gracefully by the patient.
Tasting is done twice a day for lunch and for dinner. This duty of tasting is assigned to dietician. A
Special book is maintained in which tasting register is entered in the food is categorized as very
good, good and satisfactory, not satisfactory. Column for extra comment is also provided. The date
along with time is mentioned to ensure regular checking of food. The supervisor is posted along with
dietician; the remarks are noted and advised to rectify it. If any possible changes can be made, it is
done. Also, it is checked that these mistakes are not repeated to create any inconvenience to the
patient.
DEPARTMENT OF FOOD & BEVERAGE

The hospitals mainly cater food to the patient. It also caters food services to doctors and staff. The
kitchen provides a variety of diets that is normal diet, soft diet, liquid diet, sodium restricted diet,
low potassium diet, high protein diet and low-calorie diet. Production includes large stoves,
evaporation hooks and gas pipelines.
• Equipment used in trolleys, standardized cups for serving

• Kitchen staff includes head cook, assistant cook, helpers. They have a separate dress
code with head scarf. They wear polythene gloves while proportioning food
• Preparation area located decides the staff dining room. The cooking area is well
equipped with cutting and peeling machine. A dough maker, tawa, dal maker, rice
steamer and wet grinder
• Dish wash area is provided for washing big utensils. Free flow of hot water is
provided
• Storeroom is located in the basement. There is facility for both dry and cold storage.
The dry store contains all the non-perishable and semi=perishable items. There is a
cold storage room where perishable fruits and vegetables are stored.
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KITCHEN LAYOUT:
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GENERAL HOSPITAL DIETS:
The Diets given to the patient have been generalized under the following headings:
1. Normal diet
2. Diabetic diet
3. Therapeutic diet
4. Clear fluid diet
5. Full fluid diet
6. Semi solid diet
7. Soft diet
8. Renal diet
9. Low salt diet
10. High fiber diet
11. Bland diet
1. NORMAL DIET
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2. DIABETIC DIET:
Dietary measures are an essential part of the treatment of a diabetic patient who requires a treatment
& a sulphonyl urea drugs & insulin. The diet for a diabetic patient is prescribed in terms of exchange
list. It is a high protein, low fats &a high complex carbohydrate diet.
DIABETIC DIET
3. THERAPEUTIC DIET:
Diet therapy relates to modification of normal diet to meet the needs of the sick individuals. The
normal diet may be modified to provide change in consistency as in fluid & soft diets to increase or
decrease the energy value, to include greater of lesser amount of one or more nutrients, for example,
high protein, low sodium etc., to increase or decrease bulk high &low fiber diets, to provide foods
bland in flavor.
The planning of therapeutic diet implies the ability to adopt the principles of normal nutrition to the
various regimens for adequacy, correctness, economy & palatability. It requires recognition of the
need for dietary supplements such as vitamins &mineral concentrates when the nature of the diet
itself imposes severe restrictions, the patient’s appetite is poor, or absorption & utilization are
impaired so that the diet cannot meet the need of optimum nutrition.
Therapeutic diet begins with normal diet which is modified.
TYPES OF THERAPEUTIC DIETS:
A. CLEAR LIQUID DIET: Clear liquid diet is usually used for 1-2 days after surgery &only
clear fluid are given. This diet gives kcals with electrolytes & no proteins. It does not leave
any residue.
B. LIQUID DIET:
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It is included wherever a patient is unable to chew, swallow solid foods. In conditions like after
surgery, myocardial infraction (first 24 hours), burns and gastroenteritis. It includes all the foods that
are liquid at room temperature.
Clear liquid diet liquid diet
C. SOFT DIET:
This diet is one of the most frequently used routine diets. Many hospital patients are placed on this
until a diagnosis is done. It may be used in acute infection, following patients who are unable to
chew. It is made up of simple easily digested food & contains no harsh fiber& no rich highly
seasoned foods. Patients with dental problems are given mechanically soft diet. It is often further
modified for certain pathogenic conditions as bland diet or low residue diet which includes refined
cereals & simple like bread, egg, chicken, potato, strained fruit juices.
D. LOWFAT/LOW CHOLESTEROL DIET:

This diet is generally prescribed for obese, fatty liver, gallstones& heart patients. A low calorie, low
fat particularly low saturated fat, low cholesterol. High PUFA, carbohydrate &normal protein,
minerals &vitamins are suggested. High fiber diet is also recommended.
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FOODS HAVING CHOLESTEROL LOWERING EFFECTS:
➢ Pectin (apple, guava) lowers the level of serum cholesterol.
➢ Guar gum (extracted from the leaves of cluster beans) has hypo
cholesterol emic effect.
➢ Legumes, vegetables & fruits lower the serum cholesterol.
➢ Turmeric, Bengal gram, onion, fenugreek seeds, soya beans& Garlic

have cholesterol lowering effects.Addition of rice bran oil enhances
the excretion of bile acids &neutral sterol in the faeces.
E. SODIUM&POTASSIUM RESTRICTED DIET:

This diet is generally prescribed for hypertensive &renal patients. Adequate protein (high biological
value) should be given unless there is oliguria develops. A high carbohydrate, sodium &potassium
restricted diet is given. The fluid intake will be adjusted to output including losses in vomiting &
diarrhea.
ENTERAL NUTRITION:
Enteral feeding refers to the delivery of a nutritionally complete feed, containing protein,
carbohydrate, fat, water, minerals, and vitamins, directly into the stomach, duodenum or jejunum.
Gastro enteric tube feeding plays a major role in the management of patients with poor voluntary
intake, chronic neurological or mechanical dysphagia or gut dysfunction and in patients who are
critically ill.
Supplemental parenteral nutrition is used in step –up approach when full enteral support is contra–
indicated or fails to reach the required intake targets
PATIENT SELECTION:
The use of home enteral feeding is increasing worldwide. Multi- disciplinary primary care teams
focused on home enteral nutrition can provide cost –effective care.
Enteral feeding should be considered for malnourished patients or
In those at risk of malnutrition who have a functional gastrointestinal tract but are unable to maintain
an adequate or safe oral intake.
Enteral nutrition is often used for children as well as for adults. Children may require enteral feeding
for a wide range of underlying condition, such as for malnutrition, for increased energy requirement
(e.g., cystic fibrosis), for metabolic disorders and also for children with neuromuscular disorders.
Although it is often a life –saving man oeuvre, the patient’s quality of life may be adversely
affected.
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ENTERAL FEEDING IS BENEFICIAL FOR:
• Critically ill patients, in whom enteral feeding promotes gut barrier integrity and
reduced rates of infection and mortality.
• Postoperative patient with limited oral intake. The complication rate and duration of
hospital stay are reduced by early enteral feeding after:
Elective gastrointestinal surgery / gastrointestinal cancer surgery
Early post-pyloric feeding (duodenal or jejunal) is useful as, although gastric and colonic function is
impaired postoperatively, small bowel function is often normal. Feeding is usually introduced after 1
to 5 days.
Patients with severe pancreatitis without pseudo cyst or fistula complication. Enteral feeding
promotes the resolution of inflammation and reduces the incidence of infection.
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Low –flow enteral feeding may also be useful in combination with parenteral nutrition
to maintain gut function and reduce the likelihood of cholestasis.
ACCESS:
Short-term access is usually achieved using nasogastric (NG) or Naso jejunal (NJ) tubes at an initial
continuous feeding rate of 3mls per hour. Percutaneous endoscopic gastronomy (PEG) or
jejunostomy placement should be considered if feeding is planned for longer than one month.
NG TUBES:
o These are the most used delivery routes but depend on adequate gastric
emptying.
o They allow the use of hypertonic feeds, high feeding rates and bolus feeding
into the stomach reservoir.
o Tubes are simple to insert but easily displaced.
NJ TUBES: [NASTRO-JEJUNUM]
o These reduce the incidence of gastro-oesophageal reflux and are useful in the
presence of delayed gastric emptying.
o Post –pyloric placement can be difficult but may be aided by intravenous
PEG TUBES: [percutaneous endoscopic gastrostomy]
o Indications for gastrostomy include stroke, motor neuron disease, Parkinson’s

disease and esophageal cancer o Relative contraindications include reflux,
previous gastric surgery, gastric ulceration or malignancy and gastric outlet
obstruction.
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o They are inserted directly through the stomach wall endoscopically or
surgically, under antibiotic cover.
PEJ TUBES: [percutaneous endoscopic jejnostomy]

They permit early postoperative feeding and are useful in patients at risks of reflux. They are
inserted through the stomach into jejunum the, using a surgical or endoscopic technique.
This can be difficult and has more complications.
FEED PREPARATIONS:
Various nutritionally complete pre-packaged feeds are available:
• Standard enteral feeds:

These contain all the carbohydrate, protein, fat, water, electrolytes, micronutrients (vitamins and
trace elements) and fiber required by a stable patient.
• Pre-digested feeds:
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These contain nitrogen as short peptides or free amino acids and aim to improve nutrient absorption
in the presence of pancreatic insufficiency or inflammatory bowel disease.
The fiber content of feeds is variable, and some are supplemented with vitamin K, which may
interact with other medications.
Nutrients such as glutamine, arginine and essential omega-3 fatty acids can modulate immune
function. Enteral immune nutrition may decrease major infectious complications and length of
hospital stay in surgical some critically ill patients. Further research is ongoing.
COMPLICATIONS OF ENTERAL FEEDING:
General Complications of feeding:
Tube complications:
 NG tube:
This may cause nasopharyngeal discomfort and later nasal erosions, abscesses and sinusitis.
Fine –bore tubes should be used and replaced in the alternate nostril each month. Large stiff tubes
are particularly unsafe in the presence of varices and insertion of any tube should be avoided for
three days following acute varicella bleed.
 Percutaneous gastrostomy or jejunostomy tubes:

These can lead to complications related to endoscopy plus bowel perforation and abdominal wall or
intraperitoneal bleeding.
Post –insertion complications include stoma site infections, peritonitis, septicemia, peristomal leaks,
dislodgement and gastro colic fistula formation.
All feeding tubes should be flushed with water before and after use, as they block easily. Blockage
can sometimes be removed by flushing with warm water or an enzymes solution, but some tubes
may need to be replaced.
INFECTION:
Bacterial contamination of enteral feed can cause serious infection. Administration sets and feed
containers should be discarded every 24 hours to minimize the risk of infection. Feeds should never
be decanted, and equipment should not be handled.
GASTRO- ESOPHEGEAL REFLUX AND ASPIRATION:

Reflux occurs frequently with enteral feeding, particularly in patients with impaired consciousness,
poor gag reflex and when fed in the supine position. Patients should be propped up by at least 30 ₒ
whilst feeding and should remain in that position further 30 minutes to minimize the risk of
aspiration. Post –pyloric tubes should be used in unconscious patients who need to be nursed flat.
Reflux is more likely with accumulation of gastric residues. Gastric aspirates should be measured
regularly, and the feeding regimen altered or prokinetics added to reduce gastric pooling.
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GASTROINTESTINAL SYMPTOMS:
 Gut motility and absorption are promoted by hormones released during mastication, with
coordinated stomach emptying and the in presence of intraluminal nutrients.
 As the usual physiological mechanisms are bypassed during enteral feeding, gastrointestinal
symptoms such as abdominal bloating, cramps, nausea, diarrhea and constipation are
common.
 Symptoms may respond to reduced feed administration rates, continuous rather than bolus
feeding, alternative feed preparation or the addition of prokinetic agent.
PARENTERAL NUTRITION
Parental nutrition, or intravenous feeding, is a method of getting nutrition into your body through
your veins. Depending on which vein is used, this procedure is often referred to as either total
parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN nutrition delivers nutrients such as
sugar, carbohydrates, proteins, lipids, electrolytes, and trace element to These Nutrients are vital in
maintaining high energy, hydration and strength levels. Some people only need to get certain types
of nutrition intravenously.
The most common side effects of parenteral nutrition are mouth sores, poor night vision, and skin
changes. You should speak with your doctor if these conditions don’t this form of nutrition is used to
help people who can’t or shouldn’t get their core nutrients from food. It’s often used for people with:
• Crohn’s disease
• Cancer
• Short bowel syndrome
• Ischemic bowel disease
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It also can help people with conditions that results from low blood flow to their bowels.
SIDE EFFECTS:
Other less common side effects include:
• Changes in heartbeat
• Confusion
• Convulsions or seizures
• Difficulty breathing
• Fast weight gains or weight loss
• Fatigue
• Fever or chills
• Increased urination
• Jumpy reflexes
• Memory loss
• Muscle twitching, weakness, or cramps
• Stomach pain and vomiting
• Swelling of your hands, feet, or legs
• Thirst
• Tingling in your hands or feet.
ADMINISTRATION OF PARENTERAL NUTRITION:

Parenteral nutrition is administered from a bag containing the nutrients you need through tubing
attached to a needle or catheter.
With TPN, your healthcare provider places the catheter in a large vein, called the superior vena cava
that goes to your heart. Your healthcare provider may also place a port, such as a needleless access
port, which makes intravenous feeding easier.
For temporary nutritional needs, your doctor may suggest PPN. This type of intravenous feeding
uses a regular peripheral intravenous line instead of a central line threaded into your superior vena
cava.
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You’ll most likely complete intravenous feedings yourself at home. It usually takes 10 to 12 hours,
and you’ll repeat this procedure five to seven times a week. Your healthcare provider will provide
detailed instructions for this procedure. In general, you first need to check your nutrient bags for
floating particles and discoloration.
RISKS OF PARENTERAL NUTRITION:
The most common risk of using parenteral nutrition is developing catheter infection. Other risks
include:
• Blood clots.
• Liver disease.
• Bone disease.
It’s essential to maintain clean tubing, needleless access ports, catheters, and other equipment to
minimize these risks.
COMPLICATIONS:
About 5 to 10% of patients have complications related to central venous access.
Catheter-related sepsis occurs in probably ≥ 50% of patients.

Glucose abnormalities or liver dysfunction occurs in >90% of patients.
Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose
often, adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed.
Hypoglycemia can be precipitated by suddenly stopping constant concentrated dextrose infusions.
Treatment depends on the degree of hypoglycemia. Short-term hypoglycemia may be reversed with
50% dextrose IV; more prolonged hypoglycemia may require infusion of 5 or 10% dextrose for 24h
before resuming TPN via the central venous catheter.
Hepatic complications
Include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can develop at any
age but are most common among infants, particularly premature ones (whose liver is immature).
• Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline
phosphatize; it commonly occurs when TPN is started. Delayed or persistent elevations may result
from excess amino acids. Pathogenesis is unknown, but cholestasis and inflammation may
contribute. Progressive fibrosis occasionally develops. Reducing protein delivery may help.
Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized seizures.
Arginine supplementation at 0.5 to 1.0 mol/kg/day can correct it. If infants develop any hepatic
complication, limiting amino acids to 1.0 g/kg/day may be necessary.
Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent
infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions.
Vitamin and mineral deficiencies are rare when solutions are given correctly. Elevated BUN may
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reflect dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral
vein.
Volume overload (suggested by > 1kg/day weight gain) may occur when patients have high daily
energy requirements and thus require large fluid volumes.
Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some
patients given TPN for>3mo.The mechanism is unknown. Advanced disease can cause severe
periarticular, lower-extremity, and back pain.
Adverse reactions to lipid emulsions (e.g., dyspnea, cutaneous allergic reactions, nausea,
headache, back pain, sweating, and dizziness) are uncommon but may occur early, particularly if
lipids are given at>1.0 kcal/kg/h. Temporary hyperlipidemia may occur, particularly in patients with
kidney or liver failure; treatment usually is not required. Delayed adverse reaction to lipid emulsions
include hepatomegaly, mild elevation of liver enzymes, splenomegaly, thrombocytopenia, and
leukopenia and especially in premature infants with respiratory distress syndrome, pulmonary
function abnormalities.
Gall bladder complicationsinclude cholelithiasis, gall bladder sludge, and cholecystitis. These
complications can be caused or worsened by prolonged gall bladder stasis. Stimulating contraction
by providing about 20 to 30% of calories as fat and stopping glucose infusion several hours a day is
helpful. Oral or enteral intake also helps. Treatment with metronidazole, ursodeoxycholic acid,
Phenobarbital, or cholecystokinin helps some patients with cholestasis.
RYLES TUBE FEEDING:
❖ For nasogastric introduction of nutrition and aspiration of intestinal

secretion.
❖ Close distal and coned with radio opaque material for accurate
placement.
❖ Four lateral eyes.
❖ Tube with radio- opaque line, marked at 50- 70 cms from the tip for
accurate placement.
❖ Soft, frosted and kink resistance PVC tubing.
❖ Color coded funnel end connector for easy identification of size.
❖ Length: 105cms. ▪ Sizes: 6 FG to 24 FG.

RE- FEEDING SYNDROME:
• This occurs in previously malnourished patients who are fed with high carbohydrate load
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• Carbohydrates (e.g., glucose) in the feed can cause a large increase in the circulating insulin
level. This results in a rapid and dramatic fall in phosphate potassium and magnesium –with
an increasing extracellular fluid (ECF) volume.
• As the body tries to switch from catabolic (starvation mode) to using exogenous fuel sources,
there is an increase in oxygen consumption, increased respiratory and cardiac workload (may
precipitate acute heart failure and tachypnoea and make weaning from a ventilator difficult).
Demand for nutrients and oxygen may outstrip supply.
Both above can lead to multiple organ failure, respiratory and/ or cardiac failure, arrhythmias,
rhabdomyolysis, seizures or coma, red cell and /or leukocyte dysfunction.
The gut may have undergone some atrophy with starvation, and, with the return of enteral feeding,
there may be intolerance to the feed, with nausea and diarrhea. Feeds should be start slowly and the
electrolytes closely monitored and adequately replaced to avoid these problems developing.
MODIFICATION OF NORMAL DIET:
The nutritional needs of a normal person in his life span are modified according to the demands of
growth and developmental different stages of life.
Diet Therapy can protect the individual from further attack of the disease and restore normal health.
NEED FOR DIET MODIFICATION:
1. When food consumption is interfered.
2. When absorption is interfered.
3. When storage is interfered.
4. When functioning of the tissues impaired or when tissues destroyed.
5. When there is increased excretion of nutrients
6. Increasing nutrient requirement.

NORMAL DIET CAN BE FOLLOWED IN A FOLLOWING WAY:
1. The nutrient content of the diet.
2. Increase/Decrease energy value of the diet.
3. Increase/Decrease bulk of the diet.
4. Including/Excluding specific foods.
5. Consistency.
6. Method of Feeding.
24
CASE STUDY: 1
NEPHROLOGY
Chronic kidney disease, also called chronic kidney failure, involves a gradual loss of kidney
function. Your kidneys filter wastes and excess fluids from your blood, which are then removed in
your urine. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and
wastes to build up in your body.
In the early stages of chronic kidney disease, you might have few signs or symptoms. You might
not realize that you have kidney disease until the condition is advanced.
Treatment for chronic kidney disease focuses on slowing the progression of kidney damage, usually
by controlling the cause. But, even controlling the cause might not keep kidney damage from
progressing. Chronic kidney disease can progress to end-stage kidney failure, which is fatal without
artificial filtering
25
Symptoms
Signs and symptoms of chronic kidney disease develop over time if kidney damage progresses
slowly. Loss of kidney function can cause a buildup of fluid or body waste or electrolyte problems.
Depending on how severe it is, loss of kidney function can cause
• Nausea
• Vomiting
• Loss of appetite
• Sleep problems
• Urinating more or less
• Decreased mental sharpness
• Muscle cramps
• Swelling of feet and ankles
• Dry, itchy skin
• High blood pressure (hypertension) that's difficult to control
• Shortness of breath, if fluid builds up in the lungs
• Chest pain, if fluid builds up around the lining of the heart
Signs and symptoms of kidney disease are often nonspecific. This means they can also be caused by
other illnesses. Because your kidneys are able to make up for lost function, you might not develop
signs and symptoms until irreversible damage has occurred.
26
Causes:
Chronic kidney disease occurs when a disease or condition impairs kidney function, causing kidney
damage to worsen over several months or years. Diseases and conditions that cause chronic kidney
disease include:
• Type 1 or type 2 diabetes
• High blood pressure
• Glomerulonephritis , an inflammation of the kidney's filtering units (glomeruli)
• Interstitial nephritis an inflammation of the kidney's tubules and surrounding structures
• Polycystic kidney disease or other inherited kidney diseases
• Prolonged obstruction of the urinary tract, from conditions such as enlarged prostate, kidney
stones and some cancers
• Vesicoureteral reflux, a condition that causes urine to back up into your kidneys • Recurrent
kidney infection, also called pyelonephritis Risk factors:
Factors that can increase your risk of chronic kidney disease include:
• Diabetes
• High blood pressure
• Heart (cardiovascular) disease
• Smoking
• Obesity
• Being Black, Native American or Asian American
• Family history of kidney disease
• Abnormal kidney structure
• Older age
• Frequent use of medications that can damage the kidneys Complications:
Chronic kidney disease can affect almost every part of your body. Potential complications include:
• Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid
in your lungs (pulmonary edema)
• A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart's
function and can be life-threatening
• Anemia
• Heart disease
• Weak bones and an increased risk of bone fractures
• Decreased sex drive, erectile dysfunction or reduced fertility
• Damage to your central nervous system, which can cause difficulty concentrating, personality
changes or seizures
• Decreased immune response, which makes you more vulnerable to infection
• Pericarditis, an inflammation of the saclike membrane that envelops your heart (Pericardium)
27
• Pregnancy complications that carry risks for the mother and the developing fetus • Irreversible
damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a
kidney transplant for survival
PREVENTION: To reduce your risk of developing kidney disease:

• Follow instructions on over-the-counter medications. When using nonprescription pain relievers,
such as aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others), follow
the instructions on the package. Taking too many pain relievers for a long time could lead to
kidney damage
• Maintain a healthy weight. If you're at a healthy weight, maintain it by being physically active
most days of the week. If you need to lose weight, talk with your doctor about strategies for
healthy weight loss.
• Don't smoke. Cigarette smoking can damage your kidneys and make existing kidney damage
worse. If you're a smoker, talk to your doctor about strategies for quitting. Support groups,
counseling and medications can all help you to stop.
• Manage your medical conditions with your doctor's help. If you have diseases or conditions that
increase your risk of kidney disease, work with your doctor to control them. Ask your doctor
about tests to look for signs of kidney damage.
28
Hemodialysis
Hemodialysis, also called as hemodialysis, or simply dialysis, is a process of purifying the blood
of a person whose kidneys are not working normally. This type of dialysis achieves the
extracorporeal removal of waste products such as creatinine and urea and free water from the
blood when the kidneys are kidney transplant and peritoneal dialysis. An alternative method for
extracorporeal separation of blood components such as plasma or
cells is apheresis
Hemodialysis
Hemodialysis machine
29
Other kidney dialysis names
Specialty nephrology
Hemodialysis is the choice of renal replacement therapies for patients who need dialysis acutely,
and for many patients as maintenance therapy. It provides excellent, rapid clearance of solutes.
A nephrologist (a medical kidney specialist) decides when hemodialysis is needed and the various
parameters for a dialysis treatment. These include frequency (how many treatments per week),
length of each treatment, and the blood and dialysis solution flow rates, as well as the size of the
dialyzer. The composition of the dialysis solution is also sometimes adjusted in terms of its
sodium, potassium, and bicarbonate levels. In general, the larger the body size of an individual,
the more dialysis he/she will need.
30
CASE STUDY-01
PATIENT PROFILE:
Patient name: xxxxx
Age: 70 years
Gender: male
Height: 154cms
Weight: 52kgs
BMI: 21[normal]
IBW: 54 Kgs
Food habits: non vegetarian
Life style: sedentary
Admission no: ARHI.0001224951
Date of admission: 04/5/2024
Duration of stayed: 8 days
Date of discharge: 10/5/2024
Medical Diagnosis: Chronic kidney disease
Plan of care: Hemodialysis
Past medical history: HTN
Present problem : CKD, HTN
31
BIOCHEMICAL PARAMETER
PARAMETERS At time At time Normal ranges
ANALYSIS of of
admissio discharg
n e
HAEMOGLOBIN 10.5 11.4 13.0-17.0 gm%
RBC 2.3 2.7 4.5-5.5

millions/cumm
WBC 11,180 18,190 4000-11000
cells/cumm
PCV 20 24 4.0- 5.5 vol%
PLATELETS 61 60 1.5-4.5 lakhs/cumm
UREA 45.0 27 15-38 mg/dl
CREATININE 10.4 3.2 0.8-1.3 mg/dl
SODIUM 123 131 135-146mmol/L
POTASSIUM 4.1 3.1 3.5-5.1 mmol/L
CHLORIDES 95,0 100.8 98-107 mmol/L
ALBUMIN 4.4 4.2 3.2-5.5
MANAGEMENT AND TREATMENT DETAILS:

ADVICE DISCAHRGE MEDICATION:
S .NO Drug Name DOSAGE Usages
1. Inj.levoflox 500 gm. used to treat bacterial

infections in many different
parts of the body
2. Inj. Lasix 60mg Used to get rid of extra water
by increasing the amount of
urine made
32
3. Inj, Zofer 4mg used to control nausea and
vomiting due to certain
medical conditions like
stomach upset
4. Inj, Pan 40mg Used to manage peptic ulcers,
gastroesophageal reflux
disease
5. Tab. Cardivas 3.125mg Used to treat hypertension,

angina and heart failure
6. Tab, Rozagold 5 mg Used for prevention of heart
attack
DIETARY MANAGEMENT:
OBJECTIVE OF DIETARY MANAGEMENT:
🞆 High protein
🞆 Moderate carbohydrates
🞆 Restricted fluids (1-1.5 lit/day) 🞆 Low Sodium and potassium 🞆 MODIFIED RDA:
NUTREINTS CALICULATED
ENERGY 1400k.cal
PROTEIN 52gms
FAT 30gms
CHO 184gms
33
DIET DURING HOSPITAL STAY:
DATE DIET PRESCRIBED REASON
04-5-2024 Renal and high protein diet CKD on Hemodialysis
34
Menu plan:
TIME MENU
BREAKFAST Milk
MIDMORNING Idli
Ground nut chutney
LUNCH Rice
Bittergourd curry
Curd
EVENING Oranges
Walnuts
DINNER Rice
Chapati
Spinach curry
BED-TIME Buttermilk
35
NUTRITIVE VALUE CALCULATIONS:
Timing Menu Ingredients Qua Ener CHO Prote Fat [gms]

n gy [gms] in
tity[ [Kcal [ gms]
gm./ ]
m
l]
Early Milk Milk 100 29 4.6 2.5 0.1
morning(6:30am)
Breakfast (8 Am) idli Semolina 30 348 74.8 0.4 0.8

blackgram 15 347 59.6 24 1.4
groundnut groundnut 15 567 25 25.3 40.1
chutney chutney
Mid-morning Fruit Apple 59 0.2 0.5

(11 :00Am) 100 13.4
Lunch (1:00 Pm) rice rice 30 346 73 11 0.9

bittergourd bittergourd 100 347 59.6 24 1.4
curry tomato 30 20 3.6 0.9 0.2
onion 30 50 11.1 1 0.1
oil 2.5 900 100
Evening (4:00 Fruits Oranges 100 48 0.7 10.9 0.7

Pm) Dry fruits Almonds 20 655 58.9 20.8 58.9
36
Dinner (8:00 Pm) chapati wheat flour 30 348 73.9 11 0.9
rice rice 30 346 79 6.4 0.4
curry spinach 50 26 3.8 2 0.7
onion 30 20 3.6 0.9 0.2
tomato 30 50 11.1 1 0.1
oil 2.5 900 100
Bedtime(9:00pm) Buttermilk Curd 100 67 4.6 2.5 0.1
TOTAL 1334.5 27.235 200.12

62.23
5
RDA 1400 60 30 210
DIET COUNSELLING:
PRINCIPLE OF THE DIET:
• High protein, moderate fat, moderate carbohydrate with high minerals and vitamins are
suggested. Increased amount of antioxidants is also recommended.
• Good nutrition is required during Hemodialysis
• Keep your weight within the normal range for your age and body frame.
• Reduce your salt and fluid intake to prevent fluid retention that may
DIETARY GUIDELINES:
• After Hemodialysis the patient should know the energy requirement to maintain the healthy
body weight.
• The patient should eat a variety of foods rich in proteins.

• Eggs have high biological value protein.
• Inclusion of fish in the diet is beneficial as they contain omega -3 fatty acids.
37
• Patient should take whole grains, fruits and vegetables increase the antioxidant content in
the diet.
• Egg whites can be given 3-4 in number per day as they contain proteins in it. Egg yolks
contain cholesterol so egg yolks should be restricted to 2-3 per week.
• Five servings of vegetables should be included in the diet not only to meet the requirements
but also, they are rich in antioxidants and fiber.
• If the patient has hypertension, then sodium should be restricted.

• Patients should avoid taking preserved foods.
• Concentrated foods like sweets, chocolates, cakes, pastries, ice creams, fried foods and
pickles should be avoided.
• Heavy meals should be avoided and small and frequent meals should be taken.
• Outside food should be avoided as they are high in sodium
• “ALONG WITH DIET PROPER MEDICATION AND EXERCISE SHOULD BE TAKEN
CARE OF”.
CONCLUSION:
• A 54 years male patient came with diagnosis of CKD (chronic kidney disease), he was
treated using prescribed medication and Hemodialysis
• Patient was discharged in a stable condition.
• Patient is allowed to take healthy diet the patient is advised to take low fat, high protein and
moderate carbohydrates diet with vitamin, minerals and antioxidant rich diet.
38
CASE STUDY-02
INTRODUCTION:
Chronic liver disease occurs when the scar tissue replaces healthy tissue in the body’s liver. Chronic
liver disease is the 12th leading cause of death in the United States. There was a 65% liver disease
increase in deaths due to chronic liver disease between 1999 and 2016. The reason is mainly due to
alcohol consumption, and currently 40% of Americans over drink. The liver is one of the body’s
main filtering systems. Noteworthy functions of the liver are removing waste from the body,
producing amino acids, producing blood clots, making new proteins, and producing bile for
digestion. Additionally, it metabolizes medications into the ingredient needed for wellness in the
body. People experience muscle loss, itching, weight loss and kidney failure with the progression of
liver disease.
If the liver doesn’t work as it should due to chronic liver disease, it causes ill effects throughout the
body. Effects can range from jaundice, high blood pressure, and a swollen abdomen, among others.
Even more severe symptoms can develop if the liver disease is extreme; the liver can be severely
damaged and stop working, resulting in a number of toxins in the blood. Sufferers can even die
from complications from chronic liver disease such as liver cancer.
Common causes of chronic liver disease are:
• Infection
• Alcohol abuse
• Exposure to toxic chemicals
• Blocked or damaged tubes
• Hepatitis A, B, C, D, and E
• Episodes of heart failure
• Viruses
• High cholesterol
• Autoimmune disorders
• Parasitic infection
• Certain medications
39
Heavy Alcohol Use and the Stages of Chronic Liver Disease:
Although people can get liver disease from many of the listed reasons, most of the time,
chronic liver disease stems from alcoholism. It usually takes at least 8 years of heavy
drinking for someone to develop chronic liver disease, although the exact timeline can be
more or less. The doctor must diagnose the patient’s liver disease with a blood test or a
liver biopsy, as liver disease has few symptoms initially. In diagnosing the patient, the
doctor can determine the severity of the liver disease. There are 4 different stages of
alcohol-related liver disease, producing different results:
• Initial stages/ mild fibrosis

• Alcoholic hepatitis/moderate inflammation
• Cirrhosis
• End stage liver disease
Initial Stages/Mild Fibrosis
The initial stages of liver disease include mild fibrosis of the liver disease through scarring of
the liver. This is often caused by alcohol, although other health conditions can produce liver
disease. As a result, the liver malfunctions, and the person experiences discomfort.
Alcoholic Hepatitis
In the second stage, called “the alcoholic hepatitis” phase, the person suffers inflammation of
the liver. The cells of the liver are destroyed by the heavy amounts of alcohol the person has
consumed over time. Roughly 35% of heavy drinkers go through this phase of liver disease,
and also develop:
• Jaundice
• Vomiting
• Nausea
• Fever
• Abdominal pain
Liver scarring/fibrosis
40
Cirrhosis
Cirrhosis is a condition of scarring on the liver, which can worsen over time. This
condition can occur from type 2 diabetes, in men, people older than 50, and
alcohol abusers. There are 200,000 annual cases of cirrhosis in the U.S.
Percentage-wise, 10% to 20% of heavy drinkers eventually get cirrhosis.
Cirrhosis is characterized by scarring of the liver. Consequently, the liver fails to

work properly. Fibrosis begins to form in the liver. Portal hypertension, another
complication from cirrhosis, is scar tissue blocking the flow of blood in the liver;
hence the onset of high blood pressure in the portal vein
End Stage Liver Disease
Cirrhosis can be life threatening if not treated, and can increase the risk of
infection from other potentially fatal conditions. Most prominently, cirrhosis can
lead to liver failure and liver cancer. Liver cancer results from the spreading of
unhealthy cells in the liver. Liver failure denotes lack of liver functions. The
individuals suffering this may experience fatigue, diarrhea, confusion, excess
bleeding, and death. If someone is enduring the pain of liver failure, don’t hesitate
to get medical care.
41
Symptoms:
. Fatigue
. Muscle cramps
. Weight loss
. Nausea
. Vomiting
. Upper abdominal pain
Other symptoms include:
. Easy bruising and bleeding

. Jaundice
. Swelling of legs
. Reduction in breast size
. Irregular periods in women
Complications:
If untreated for a prolonged period it may lead to

Portal hypertension - High blood pressure in veins which brings blood to the liver from
intestine and spleen.
Swelling of legs & abdomen - portal hypertension causes fluid accumulation in
legs and abdomen (ascites). It could also be due to inability of the liver to
synthesize albumin. Splenomegaly- enlarged spleen.
Bleeding - Portal hypertension leads the blood to be redirected to smaller
veins which in turn increase in size and become dilated. Strained by extra
42
load, these smaller veins can burst and cause bleeding in esophagus or
stomach. Further, the inability of liver to produce enough clotting factors
could also contribute to bleeding.
Other complications could include:

. Hepatic encephalopathy
. Increased risk of liver cancer
. Acute or chronic liver failure
Prevention:
. Limit alcohol consumption

. Exercise regularly
. Have a healthy diet and maintain the right bodyweight
. Get vaccination against Hepatitis A & B
43
CASE STUDY 2
PATIENT PROFILE:
Patient name: XXXXX

Age: 68
Gender: male
Height: 157cms
Weight: 50kgs
BMI: 20 kg/m²
IBW: 57 Kgs
Food habits: no vegetarian
Occupation: Farmer
Life style: moderate
Admission no: ARH1.0001261143

Medical Diagnosis: Decompensated chronic liver disease Past medical history:
HTN, CAD, SOB
Present problem: Chronic liver disease
Consultant doctor: Sri Karan uddesh [general medicine]
44
BIOCHEMICAL PARAMETERS
Parameter At time of At time of Normal ranges

s admission discharge
analysis
Hb 13.4 14.8 13.0-17.0 gm%
RBC 2.2 4.5 4.5-5.5 millions

/cumm
WBC 3,11 4.1 4000-11000
cells /cumm
PCV 44; 3.9 40.0- 50 vol%
Platelets 228 3.12 1.5-4.5

lakhs/cumm
albumin 1.89 4.6 3.5-5.5 gm/dl
Urea 23 28 15- 38 mg/dl
Creatinine 0.8 0.8 0.51-0.95 mg/dl
Sodium 137 138 135-146mmol/L
Potassium 3.0 3.5 3.5-5.1 mmol/L
Chlorides 100 106 98-107 mmol/L
45
1. Tab.Ecospin 150mg helps prevent heart attacks,

strokes, and angina
2. Tab.Aztor 40mg It is used to lower
cholesterol and to reduce the
risk of heart diseases
3. Tab. Sobinex 50mg used in the treatment of
indigestion, metabolic acidosis
and used as an alkalinizing
agent
4. Tab.Ketocheck 10mg used in the treatment of
chronic kidney disease.
5. Tab.clopilet 75mg used to reduce blood clot
formation in the blood vessels.
6. Tab,baclofen 5 mg To help relax Muscle in the
body
7. Tab.vernicline 0.5 mg To help people stop smoking
8. Syp.duphalac 30 ml To help relieve constipation
DIETARY MANAGMENT:
OBJECTIVE OF DIETARY MANAGMENT:
✞ High protein
✞ Low fat
✞ Low salt
Iron rich
✞ Fluid up to 1.5 liters/day
46
MODIFIED RDA:
NUTREINTS CALICULATED
ENERGY 1425k.cal
PROTEIN 50gms
FAT 30 gms
CHO 178 gms
PRESCRIBED DIET IN HOSPITAL:
Date Prescribed diet Reason
1/5/2024 Low salt diet HTN
2/5/2024 Low salt diet HTN
3/5/2024 low salt diet HTN
47
MENU PLAN:
Timings Menu
Early morning SkimmMilk

Eggwhite
Breakfast Idli
Samber
Mid-morning Grape
Lunch Rice
Milkmaker
Carrot
Cucumber
Curd
Evening Apple
Almonds
Walnuts
Dinner chapati
Rice
Chiken curry
Bed time Buttermilk
NUTRITIVE VALUE AND CALCULATION:
Timing Menu Ingredients Quantity energy CHO Protein Fat

[ gm./ml] [Kcal] [gms] s [gms] [gms]
Early Skimmilk Skim Milk 100 13.1 13.1 0.6 0.3

morning(6:30am) 70 52 0.7 11 0.3
48
Breakfast (8 Am) Idli semolina 30
Samber redgram 30
onion 20
toamto 20
oil 1.2
Mid-Morning (11 :00Am) Fruit Grape 100
Lunch (1:00 Pm) rice rice 60

milkmaker milkmaker 50
salads oinon 20
carrot 20
cucumber 20
curd curd 1.2
Evening (4:00 Pm) fruit apple 100

almonds 5
walnuts 5
Dinner (8:00 Pm) chapati wheatflour 60

rice rice 60
curry chikencurry 50
tomato 20
onion 20
oil 1.5
Bedtime(9:00pm) Buttermilk Curd 100
TOTAL
RDA
49
FOODS FOODS AVOIDED
INCLUDED
Ginger garlic Meat, fried or fatty foods pasta, white
vegetables Pulses rice, white bread, sugary drinks
beans Cereal porridge,
bread, rice
Skimmed milk, egg Oily foods , salty foods, saturated fat
chiken Fish
All types of berries Spicy foods refined carbohydrates
fruits nuts
Jaggery, honey. Papad, chutney, alcohol smoking
carbonated beverages
DIET COUNSELLING:
• Balance your body’s minerals like salt and potassium

• Balance your body fluids
• Make hormones that affect the way other organs work
DIETARY MANAGEMENT:
* High calories
* High carbohydrates
* High protein
* Restricted or low fat
* High fat soluble vitamins
DISCHARGE ADVICE:
• Soft high protein with low chili, low fat and low cholesterol diet is prescribed by Dietician. • Medications
as prescribed by consultant doctor
CONCLUSION:
• Patient admitted with above-mentioned complaints. Necessary investigation done and reports enclosed.
• Patient was discharged in stable condition
• Patient is allowed to take healthy diet without any restrictions for one month after that Patient is advised to
take low fat, high protein, high vitamin and mineral and antioxidant rich diet
50
CASE STUDY - 3
FEMUR FRACTURE
The femur is the thigh bone, the largest and strongest bone in the human body.1 It supports the
weight of the body and helps you move. Reaching from the hip to the knee, the femur is extremely hard
and not easy to break. A broken thigh bone is one of the few simple fractures that can be considered life-
threatening because it can cause
significant internal bleeding.
51
Anatomy:
There are four types of bones in your body: long bones, short bones, flat bones, and irregular
bones. The femur—the only bone in the upper leg—is a long bone. Longer than they are wide,
this type of bone has spongy bone tissue at both ends and a cavity filled with bone marrow in the
shaft.3
Femur is Latin for thigh, and the bone is commonly referred to as the "thigh bone." The end of
the thigh bone closest to the heart (proximal end) is called the femoral head. This is the ball part
of the ball-and-socket hip joint.
Below the head of the femur is the neck and the greater trochanter. The greater trochanter attaches to
tendons that connect to the gluteus minimus and the gluteus medius muscles. These muscles pull the leg to
help with walking and running.
Below the greater trochanter is the lesser trochanter, situated at the base of the neck of the
femur. The lesser trochanter is the part of the femur attached to a pair of muscles that help flex
the thigh to lift the leg forward.
Below the lesser trochanter is the gluteal tuberosity, which is where the gluteus maximus is
attached.
The main shaft of the femur is known as the body. The distal end of the femur (the end
furthest from the heart) is where it connects with the patella (knee cap) and the bones of the
lower leg (the tibia and fibula).
This end of the femur has a saddle that rests on the top of the tibia. It has rounded edges on
either side of the knee joint, known as the condyles. The depression between the condyles is
called the patellar groove.
Inside the body of the femur is the medullary cavity, which contains bone marrow. At the ends
of the femur are areas of compact bone, which is solid and does not contain marrow.
Surrounding the compact bone is spongy bone, which has lots of small cavities dispersed
throughout it. The neck and head of the femur are made up of spongy bone.
52
Function:
The femur supports the weight of the body on the leg. All other leg bones are attached to the
bottom portion of the femur.
But the femur isn't just for moving the body. There is both yellow and red bone marrow in the
shaft of the femur, and they play a critical role in producing blood cells and storing fat.4
Blood flow in the femur is hard to measure. It is a significant amount, so much so that a
needle inserted into the spongy bone can be used to infuse enough fluid into the bloodstream
to offset shock or dehydration.
Types of Femoral Shaft Fractures:
Femur fractures vary greatly, depending on the force that causes the break. The pieces of
bone may line up correctly (stable fracture) or be out of alignment (displaced fracture).
The skin around the fracture may be intact (closed fracture) or the bone may puncture the
skin (open fracture).
Doctors describe fractures to each other using classification systems. Femur fractures
are classified depending on:
● The location of the fracture (the femoral shaft is divided into thirds: distal, middle,
proximal)
● The pattern of the fracture (for example, the bone can break in different directions, such as
crosswise, lengthwise, or in the middle)
● Whether the skin and muscle over the bone is torn by the injury
The most common types of femoral shaft fractures include:
53
Transverse fracture: In this type of fracture, the break is a straight horizontal line
going across the femoral shaft.
Oblique fracture. This type of fracture has an angled line across the shaft.
Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane.
A twisting force to the thigh causes this type of fracture.
Comminuted fracture. In this type of fracture, the bone has broken into three or
more pieces. In most cases, the number of bone fragments corresponds with the amount
of force needed to break the bone.
Open fracture. If a bone breaks in such a way that bone fragments stick out through the
skin or a wound penetrates down to the broken bone, the fracture is called an open or
compound fracture. Open fractures often involve much more damage to the surrounding
muscles, tendons, and ligaments. They have a higher risk for complications—especially
infections—and take a longer time to heal.
54
Cause
Femoral shaft fractures in young people are frequently due to some type of high-energy
collision. The most common cause of femoral shaft fracture is a motor vehicle or motorcycle
crash. Being hit by a car while walking is another common cause, as are falls from heights and
gunshot wounds.
A lower-force incident, such as a fall from standing, may cause a femoral shaft fracture
in an older person who has weaker bones.
Symptoms
A femoral shaft fracture usually causes immediate, severe pain. You will not be able to put
weight on the injured leg, and it may look deformed—shorter than the other leg and no longer
straight.
Doctor Examination:
Medical History and Physical Examination:
It is important that your doctor know the specifics of how you hurt your leg. For example, if
you were in a car accident, it would help your doctor to know how fast you were going,
whether you were the driver or a passenger, whether you were wearing your seat belt, and if
the airbags went off. This information will help your doctor determine how you were hurt and
whether you may be hurt somewhere else.
It is also important for your doctor to know if you have any other health conditions, such as
high blood pressure, diabetes, asthma, or allergies. Your doctor will also ask you if you use
tobacco products or are taking any medications.
After discussing your injury and medical history, your doctor will do a careful examination.
He or she will assess your overall condition, and then focus on your leg. Your doctor will look
for:
● An obvious deformity of the thigh/leg (an unusual angle, twisting, or shortening of the leg)
● Breaks in the skin
● Bruises
● Bony pieces that may be pushing on the skin
After the visual inspection, your doctor will feel along your thigh, leg, and foot looking for
abnormalities and checking the tightness of the skin and muscles around your thigh. He or
she will also feel for pulses. If you are awake, your doctor will test for sensation and
movement in your leg and foot.
55
Imaging Tests:
Imaging tests will provide your doctor with more information about your injury.
X-rays. The most common way to evaluate a fracture is with x-rays, which provide clear
images of bone. X-rays can show whether a bone is intact or broken. They can also show the
type of fracture and where it is located within the femur.
Computerized tomography (CT) scans. If your doctor still needs more

information after reviewing your x-rays, he or she may order a CT scan. A CT
scan shows a cross-sectional image of your limb. It can provide your doctor with
valuable information about the severity of the fracture. For example, sometimes
the fracture lines can be very thin and hard to see on an x-ray. A CT scan can
help your doctor see the lines more clearly.
56
Nonsurgical Treatment:
Most femoral shaft fractures require surgery to heal. It is unusual for femoral shaft fractures
to be treated without surgery. Very young children are sometimes treated with a cast. For
more information on that, see Thighbone (Femur) Fractures in Children.
Surgical Treatment:
Timing of surgery. Most femur fractures are fixed within 24 to 48 hours. On occasion, fixation
will be delayed until other life-threatening injuries or unstable medical conditions are
stabilized. To reduce the risk of infection, open fractures are treated with antibiotics as soon
as you arrive at the hospital. The open wound, tissues, and bone will be cleaned during
surgery.
For the time between initial emergency care and your surgery, your doctor may place your
leg either in a long-leg splint or in traction. This is to keep your broken bones as aligned as
possible and to maintain the length of your leg.
Skeletal traction is a pulley system of weights and counterweights that holds the broken
pieces of bone together. It keeps your leg straight and often helps to relieve pain.
External fixation. In this type of operation, metal pins or screws are placed into the bone
above and below the fracture site. The pins and screws are attached to a bar outside the
skin. This device is a stabilizing frame that holds the bones in the proper position.
External fixation is usually a temporary treatment for femur fractures. Because they are
easily applied, external fixators are often put on when a patient has multiple injuries and
is not yet ready for a longer surgery to fix the fracture. An external fixator provides good,
temporary stability until the patient is healthy enough for the final surgery. In some cases,
an external fixator is left on until the femur is fully healed, but this is not common.
57
External fixation is often used to hold the bones together temporarily when the skin and
muscles have been injured.
Intramedullary nailing. Currently, the method most surgeons use for treating femoral shaft fractures is
intramedullary nailing. During this procedure, a specially designed metal rod is inserted into the canal of
58
Intramedullary nailing provides strong, stable, full-length fixation.
An intramedullary nail can be inserted into the canal either at the hip or the knee.
Screws are placed above and below the fracture to hold the leg in correct alignment while the
bone heals.
Intramedullary nails are usually made of titanium. They come in various lengths and
diameters to fit most femur bones.
59
(Left) This x-ray, taken from the side, shows a transverse fracture of the femur. (Right) In this front
view x-ray, the fracture has been treated with intramedullary nailing.
Plates and screws. During this operation, the bone fragments are first
repositioned (reduced) into their normal alignment. They are held together with screws
and metal plates attached to the outer surface of the bone.
Plates and screws are often used when intramedullary nailing may not be possible, such as
for fractures that extend into either the hip or knee joints.
Recovery
Most femoral shaft fractures take 3 to 6 months to completely heal. Some take even longer,
especially if the fracture was open or broken into several pieces or if the patient uses tobacco
products.
60
Pain Management
Pain after an injury or surgery is a natural part of the healing process. Your doctor and
nurses will work to reduce your pain, which can help you recover faster.
Medications are often prescribed for short-term pain relief after surgery or an injury. Many
types of medications are available to help manage pain. These include acetaminophen,
nonsteroidal anti- inflammatory drugs (NSAIDs), gabapentinoids, muscle relaxants, opioids,
and topical pain medications. Your doctor may use a combination of these medications to
improve pain relief, as well as minimize the need for opioids. Some pain medications may
have side effects that can impact your ability to drive and do other activities. Your doctor will
talk to you about the side effects of your pain medications.
Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and
can be addictive. Opioid dependency and overdose has become a critical public health issue in the
U.S. It
is important to use opioids only as directed by your doctor. As soon as your pain begins to
improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve
within a few days of your treatment.
Weightbearing
Many doctors encourage leg motion early on in the recovery period. It is very important to
follow your doctor's instructions for putting weight on your injured leg to avoid problems.
In some cases, doctors will allow patients to put as much weight as possible on the leg right
after surgery. However, you may not be able to put full weight on your leg until the fracture
has started to heal. Be sure to follow your doctor's instructions carefully.
When you begin walking, you will probably need to use crutches or a walker for support.
61
Physical Therapy
Because you will most likely lose muscle strength in the injured area, exercises during the
healing process are important. Physical therapy will help to restore normal muscle strength,
joint motion, and flexibility. It can also help you manage your pain after surgery.
A physical therapist will most likely begin teaching you specific exercises while you are
still in the hospital. The therapist will also help you learn how to use crutches or a walker.
Complications:
Complications from Femoral Shaft Fractures

Femoral shaft fractures can cause further injury and complications.
● The ends of broken bones are often sharp and can cut or tear surrounding blood vessels or
nerves, though this is very rare.
● Acute compartment syndrome may develop. This is a painful condition that occurs when pressure
within the muscles builds to dangerous levels. This pressure can decrease blood flow, which
prevents nourishment and oxygen from reaching nerve and muscle cells. Unless the pressure is
relieved quickly, permanent disability may result. This is a surgical emergency. During the
procedure, your surgeon makes incisions in your skin and the muscle coverings to relieve the
pressure.
● Open fractures expose the bone to the outside environment. Even with good surgical cleaning of the
bone and muscle, the bone can become infected. Bone infection is difficult to treat and often requires
multiple surgeries and long-term antibiotics.
● Occasionally, the ligaments around the knee can be injured during a femoral shaft fracture. If you have
knee pain after surgery, tell your doctor.
∙
Complications from Surgery:
In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia,
complications of surgery may include:
● Infection
● Injury to nerves and blood vessels
● Blood clots
● Fat embolism (bone marrow enters the blood stream and can travel to the lungs; this can also
happen from the fracture itself without surgery)
● Malalignment or the inability to correctly position the broken bone fragments
● Delayed union or nonunion (when the fracture heals slower than usual or not at all)
62
CASE STUDY 3
PATIENT PROFILE:
◊ Patient name: XXXXX
◊ Age: 84 years
◊ Gender: male
◊ Height:154CM
◊ Weight:
65kgs
◊ BMI: 27 kg/m
◊ IBW: 54 kgs
◊ Food habits: nonvegetarian
◊ Life style: sedentary
◊ Date of admission: 24/05/2024
◊ Admission no: ARHIP65303
◊ Duration of stayed: 6
days
◊ Date of discharge:
29/05/2024
◊ Medical Diagnosis: Left IT femur fracture
◊ Present problem: left hip pain
BIOCHEMICAL PARAMETERS
Parameters At time At time of Normal ranges
analysis of discharge
admission
Hb 12.3 13.3 13.0-17.0 gm%
Platelets 2.5 2.5 1.5-4.5

lakhs/cumm
albumin 1.89 4.6 3.5-5.5 gm/dl
Creatinine 1.0 1.2 0.51-0.95 mg/dl
Sodium 145 138 135-146mmol/L
Potassium 3.5 3.5 3.5-5.1 mmol/L
63
1. INJ. Rantac 150ml It is used to treat stomach-related

problems, especially acid reflux
2. INJ. Monocef 1 gm It is also used during surgical

procedures to prevent future
infections. This medicine contains
ceftriaxone as its active ingredient
3. INJ. dynapar 1 mg BD Used to realieve extreme and
serious pain.
4. ING. amikacior 5 mg BD Used to treat serious bacterial
infections in many different
parts of the body
5. INJ. metrogyl 1 mg BD Used to treat bacterial
infections, that may occur
during the surgery
6. IV fluids 200 mg Used to prevent the
dehydrations
DIETARY MANAGMENT:
⮚ High protein
Moderate calories
⮚ Low fat
⮚ Low salt
⮚ High fibre
⮚ Iron rich
⮚ Moderate carbohydrates
MODIFIED RDA FOR THE PATIENT:
Energy: 1400 kcal

Protein: 65g
Carbohydrates: 227.5 g
Fat: 30 g
64
24/05/2024 Normal diet Femur fracture
27/05/2024 NBM Surgery
28/05/2024 NBM followed by soft diet P.op
65
24 HOUR RECALL:
Timings Menu
Early morning Milk
Breakfast Idli, samber
Mid-morning Waltermelon
Lunch Chapati
rice
Bittergoud
Evening Milk
Dinner Rice
Samb
er
Curd
Bed time Water
DIET PLAN AND CALCULATION:
TIME MENU
Early morning(6:30am) Milk
Breakfast (8 Am) Idli

Samber
Egg
Mid-morning pomegranate
(11 :00Am) Walnuts
Lunch (1:00 Pm) rice Fish
curry
Spinach
curry
66
Evening (4:00 Pm) Apple , Almonds
Dinner (8:00 Pm) Pulkha
Paneer
Bedtime(9:00pm) milk
PRO
MEAL PLAN MEAL ITEM INGREDIENTS QTY ENE TEI FAT CAR
RGY N B
Early morning Moringa Moringa Leaves 100 59 0.2 0.5 13.4
Leaves Juice 10 655 20.8 58.9 10.5
Breakfast Ragi Java Beeroot 50 0.5 43 1 0.1
Lunch Rice, Rice, 60 0.6 346 6.4 0.4

Fish Fish, 70 0.7 59 8.9 1.1
Tomato 30 0.3 50 1 0.1
oil 900 100
Evening (4:00 Pm) Fruit Apple 100 59 0.2 0.5 13.4

Dry fruit Almonds 10 655 20.8 58.9 10.5
Dinner (8:00 Pm) chapati wheat flour 60 348 11 0.9 73.9

paneer panner 50 321 25 25 3.57
onion 50 50 1 0.1 11.1
tomato 50 20 2.9 0.2 3.6
oil 1 900 100
67
Bedtime(9:00pm) milk milk 100ml 67 3.2 4.1 4.4
TOTAL 135 62. 34.6 228.

4.0 9g 05g 82
9 ms ms g
kca
ls m
s
RDA 140 65 30 213.
0 gm gm 82
kca s s g
ls
m
s
DIET COUNSELLING
Foods to be included:
Eat foods high in vitamin C to help absorb the iron that comes from plants such as spinach. For instance,
drink a glass of orange juice with an iron-fortified cereal. Good sources of vitamin C are oranges,
broccoli, tomatoes, kiwi, strawberries, peppers, potatoes and cabbage.
Summary. Eating nourishing foods after surgery can help your body recover, your wound heal, and
prevent constipation. Stick to whole foods with plenty of fiber, lean protein, whole grains, and fresh
fruits and vegetables. Be aware of foods that can cause constipation and avoid them.
Foods to be avoided:
But you must make sure your calories are obtained from complex carbohydrate such as whole grains,
starchy vegetables, and legumes. Avoid simple carbohydrates found in foods such as pastries, desserts,
cookies, candy, soda, and ice cream.
Eat up to 8 hours before surgery your scheduled arrival time. Eat light meals such as oatmeal or toast.
Do not eat foods that are heavy or high in fat such as meat or fried foods.
CONCLUSION
A 84 yrs old male patient came with femure fracture admitted on 24/05/2024 for further
management .Patient later responded with the given treatment and being discharge on 4/05/2024
in stable condition with the following advice.
Patient is advised to take healthy food as healthy diet .
68
CASE STUDY: 4
THROMBOCYTOPENIA
Thrombocytopenia is a condition in which you have a low blood platelet count. Platelets
(thrombocytes) are colorless blood cells that help blood clot. Platelets stop bleeding by clumping and
forming plugs in blood vessel injuries.
Thrombocytopenia might occur as a result of a bone marrow disorder such as

leukemia or an immune system problem. Or it can be a side effect of taking certain medications. It
affects both children and adults.
Thrombocytopenia can be mild and cause few signs or symptoms. In rare cases, the
number of platelets can be so low that dangerous internal bleeding occurs. Treatment options are
available.
Symptoms
69
Thrombocytopenia signs and symptoms may include:
● Easy or excessive bruising (purpura)

● Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots
(petechiae), usually on the lower legs
● Prolonged bleeding from cuts
● Bleeding from your gums or nose
● Blood in urine or stools
● Unusually heavy menstrual flows
● Fatigue
● Enlarged spleen
When to see a doctor:
Make an appointment with your doctor if you have signs of thrombocytopenia that worry you.
Bleeding that won't stop is a medical emergency. Seek immediate help for bleeding that can't be controlled by
the usual first-aid techniques, such as applying pressure to the area.
Causes:
Thrombocytopenia means you have fewer than 150,000 platelets per microliter of circulating blood. Because
each platelet lives only about 10 days, your body normally renews your platelet supply continually by
producing new platelets in your bone marrow.
70
Thrombocytopenia rarely is inherited; or it can be caused by a number of medications or
conditions. Whatever the cause, circulating platelets are reduced by one or more of the following
processes: trapping of platelets in the spleen, decreased platelet production or increased destruction of
platelets.
Trapped platelets:
The spleen is a small organ about the size of your fist situated just below your rib cage on the left
side of your abdomen. Normally, your spleen works to fight infection and filter unwanted material from
your blood. An enlarged spleen — which can be caused by a number of disorders — can harbor too many
platelets, which decreases the number of platelets in circulation.
Decreased production of platelets:
Platelets are produced in your bone marrow. Factors that can decrease platelet production include:
● Leukemia and other cancers
● Some types of anemia
● Viral infections, such as hepatitis C or HIV
● Chemotherapy drugs and radiation therapy
● Heavy alcohol consumption
Increased breakdown of platelets:

Some conditions can cause your body to use up or destroy platelets faster than they're produced,
leading to a shortage of platelets in your bloodstream. Examples of such conditions include:
● Pregnancy. Thrombocytopenia caused by pregnancy is usually mild and improves soon after
childbirth.
● Immune thrombocytopenia. Autoimmune diseases, such as lupus and rheumatoid arthritis, cause this
type. The body's immune system mistakenly attacks and destroys platelets. If the exact cause of this
condition isn't known, it's called idiopathic thrombocytopenic purpura. This type more often affects
children.
● Bacteria in the blood. Severe bacterial infections involving the blood (bacteremia) can destroy
platelets.
● Thrombotic thrombocytopenic purpura. This is a rare condition that occurs when small blood clots
suddenly form throughout your body, using up large numbers of platelets.
● Hemolytic uremic syndrome. This rare disorder causes a sharp drop in platelets, destruction of red
blood cells and impairs kidney function.
● Medications. Certain medications can reduce the number of platelets in your blood. Sometimes a drug
confuses the immune system and causes it to destroy platelets. Examples include heparin, quinine, sulfa-
containing antibiotics and anticonvulsants.
Complications:
Dangerous internal bleeding can occur when your platelet count falls below 10,000 platelets per
microliter. Though rare, severe thrombocytopenia can cause bleeding into the brain, which can be
fatal
71
CASE STUDY:04
PATIENT PROFILE:
Patient name: XXXX
Age: 87years
Gender: Male
Height: 152cm
Weight: 60kgs
BMI: 25 kg/m
IBW: 52kgs
Food habits: non vegetarian

Style: Moderate

Admission no:ARHIP65297

Diagnosis: Thromibcytopenia
Present problem: Thrombocytonopia, HTN
72
TESTS .AT THE TIME OFAT
ADMISSION
THE TIME. OF NORMAL
DISCHARGE RANGES
NORMAL
RANGES
Hemoglobin 5.4gm 8.3 12.0 -15.0 gm
PCV 31vol% 34vol% 36 -54 vol%
Platelet count 1.97 3.02 1.5 – 4.5 l/c
creatinine 1.3mg/dl 1.2mg/dl 0.5 to 1.2mg/dl
sodium 134mmol/l 133mmol/l 135-148 mmol/l
potassium 4.5mmol 4.5mmol 3.5 -5.1 mmol
chloride 103mmol 102mmol 98-107 mmol

1. Inj.stay pime 1.5g Used to treat bacterial infection
2. Inj.Rantop 40mg It is used for treating acid-

related diseases of the
stomach and intestine such
as acid reflux, peptic ulcer
disease.
3. Inj. pan 40mg Used treat peptic ulcers,
gastroesophageal reflux disease
4. Ing.lofer 4mg BD Used to prevent
vomitings andn
ausea
5. fluids ns 100m/m Treatment of dehydration
73
6. Tab. doxt 150mg Used to treat different infections
of the bacteria
7. Tab.sedarnat Used to treat nutritional
deficiencies,iron
deficiency,anaemia,vit c
deficiency,improve immunity.
DIETARY MANAGMENT:
High protein
high calories
high carbohydrates
Moderate fat
High fibers
MODIFIED RDA FOR THE PATIENT:
● Energy: 1475 kcal
● Protein: 50 g
● Carbohydrates: 341g
● Fat: 20 g
74
24/05/2024 Normal diet Thrombocytonopia
75
24 HOUR RECALL:
TIME MENU
Early moning [6:30Am] Milk

almonds
Breakfast [8:00Am] Idly
sambar
Mid-morning [11Am] Beetroot
Lunch [1:00Pm] Rice Phulka

spinach
Dal
buttermilk
Evening [4:00pm] Blackgrape
Dinner [8:00pm] Rice

Phulka
cluster
beans
Curd
Bed time[9:00] Ragi java
76
DIET PLAN AND CALCULATION:
TIME MENU
Early morning(6:30am) Moring

a leaves
juice
Breakfast (8 Am) Ragi
Java
Mid-morning Beetroot carrot

(11 :00Am) Milk
Lunch (1:00 Pm) rice
Phulka
fish
curry
Evening (4:00 Pm) Sesame laddu
Dinner (8:00 Pm) Rice

Spinac
h
Redgra
m
Bedtime(9:00pm) milk
Boiled egg
77
Timing items ingredi Quanti Ener prot Fats CH

ent s ty[ gy ei [grms] O
gm/ml] [kcal ns [grms]
s]
[gr
ms]
Early Moringa leaves Moringa 100 92 6.7 1.7 12.5
morning(6:30a juice leaves
m)
Breakfast (8 Am) Ragi,Java Ragiflour 50 328 7.3 1.3 72
Mid- Juice beetro 50 43 1 0.1 8.8

morning ot 50 43 0.9 0.2 8.8
(11 carrot 50 67 3.2 4.1 4.4
:00Am) milk
Lunch (1:00 Pm) Rice rice 60 346 6.4 0.4 7

Fish fish 70 59 8.9 1.1 3.3
toamto 30 20 0.9 0.2 3.6
onion 30 50 1 0.1 11.1
oil 1.2 900 100
Vegetable cucumber 30 13 0.4 0.1 2.5

salad
Evening (4:00 Pm) Laddu sesa 30 73 18 50 23
me 70 319 0.3 0 79.5
jagge 1.2 900 100
ry
Juice 100 65 1.6 0.1 14.5
ghee
prom
ogran
ate
78
Dinner (8:00 Pm) phulka wheatf 30 348 11 0.9 73.9
rice lo 30 346 6.4 0.4 7
curry rice 50 26 2 0.7 3.8
spinac 30 335 22.3 1.7 57.6
h 20 20 0.9 0.2 3.6
red 20 50 1 0.1 11.1
gram
1.2 900 100
Tomat
o
onion
Oil
Bedtime(9:00pm) milk milk 100ml 67 3.2 4.1 4.2

Egg Boiled 50 173 13.3 13.3 0
egg white
TOTAL 1438.1 54.01 33.44 200.0
kcals g gms 1
ms gms
RDA 1400 60 30g 210
kcals gms m gms

A day’s diet was planned for a patient with fever and thrombocytopenia
• High calorie, high protein, high carbohydrates, low fat, high fluid, low fibre and bland diet is
suggested for typhoid fever.
• High calorie was met by including aloo paratha chapatti and ragi porridge and watermelon was
given.
• High protein was met by adding milk and curd.
• More amount pf fluid was suggested as the body gets dehydrates during fever.
DIETARY GUIDELINES: -
• As soon as the fever comes down, bland, low firer, soft diet, which is easily digested and
absorbed should be given to the patient.
• Well cooked, well mashed, sieved, bland, semisolid foods like khichdi, rice with curd, kheers
and custard may be given, bland, readily digested food affords physiologically rest to the
alimentary tract.
• In the beginning, small quantities of food at 2-3 hours interval will provide adequate nutrition
without overtaxing the digestive system at any one time.
• Have small frequent meals.
• High intake of carbohydrates which are easily digestible like soft rice, porridge and fruit
79
custard. Sufficient fluids like coconut water, lassi, fruit juices and glucose water.
• Light biscuits, breads and jams. thin vegetables soups and thin dhals can be had.
• Avoid spicy, fried foods, meats, butter and ghee.
• Avoid high fibre diet and whole grains.
CONCLUSION:
Patients with above complaint got admitted in the hospital under the care of physician. Patient treated with
viral pyrexia with thromobocytopenia other supportive treatments.
80
CASE STUDY: 05
CORONARY ARTERY DISEASE

● Coronary artery disease is caused by plaque buildup in the wall of the arteries that supply
blood to the heart (called coronary arteries).
● Plaque is made up of cholesterol deposits. Plaque buildup causes the inside of the
arteries to narrow over time. This process is called atherosclerosis.
81
● Plaque is made up of deposits of cholesterol and other substances in the artery. Plaque
buildup causes the inside of the arteries to narrow over time, which can partially or totally
block the blood flow.
● Coronary artery disease (CAD) is a narrowing or blockage of your coronary arteries,
usually due to plaque buildup.
● Your coronary arteries supply oxygen-rich blood to your heart. Plaque buildup in these
arteries limits how much blood can reach your heart.
● Picture two traffic lanes that merge into one due to construction. Traffic keeps flowing, just
more slowly.
● With CAD, you might not notice anything is wrong until the plaque triggers a blood clot.
The blood clot is like a concrete barrier in the middle of the road. Traffic stops. Similarly,
blood can’t reach your heart, and this causes a heart attack.
● You might have CAD for many years and not have any symptoms until you experience a
heart attack. That’s why CAD is a “silent killer.”
● Other names for CAD include coronary heart disease (CHD) and ischemic heart disease.
It’s also what most people mean when they use the general term “heart disease.”
SYMPTOMS:
Symptoms of chronic CAD include:
● Stable angina: This is the most common symptom. Stable angina is temporary chest pain
or discomfort that comes and goes in a predictable pattern. You’ll usually notice it during
physical activity or emotional distress. It goes away when you rest or take nitroglycerin
(medicine that treats angina).
Shortness of breath (dyspnea): Some people feel short of breath during light physical
activity. Sometimes, the first symptom of CAD is a heart attack. Symptoms of a heart
attack include:
● Chest pain or discomfort (angina): Angina can range from mild discomfort to severe pain.
It may feel like heaviness, tightness, pressure, aching, burning, numbness, fullness,
squeezing or a dull ache. The discomfort may spread to your shoulder, arm, neck, back or
jaw.
● Shortness of breath or trouble breathing.
● Feeling dizzy or lightheaded.
82
Heart palpitations.
● Feeling tired.
● Nausea, stomach discomfort or vomiting. This may feel like indigestion.
Weakness:
CAUSES
● Atherosclerosis causes coronary artery disease. Atherosclerosis is the gradual buildup of

plaque in arteries throughout your body. When the plaque affects blood flow in your
coronary arteries, you have coronary artery disease.
● Plaque consists of cholesterol, waste products, calcium and fibrin (a substance that helps
your blood clot). As plaque continues to collect along your artery walls, your arteries
become narrow and stiff.
Plaque can clog or damage your arteries, which limits or stops blood flow to a certain
part of your body.
● When plaque builds up in your coronary arteries, your heart muscle can’t receive enough
blood. So, your heart can’t get the oxygen and nutrients it needs to work properly.
● This condition is called myocardial ischemia. It leads to chest discomfort (angina) and puts
you at risk for a heart attack.
MEDICAL TESTS:
● Blood tests: Check for substances that harm your arteries or increase your risk of CAD.
● Cardiac catheterization: Inserts tubes into your coronary arteries to evaluate or confirm
CAD. This test is the gold standard for diagnosing CAD.
● Computed tomography (CT) coronary angiogram: Uses CT and contrast dye to view 3D
pictures of your heart as it moves. Detects blockages in your coronary arteries.
● Coronary calcium scan: Measures the amount of calcium in the walls of your coronary
arteries (a sign of atherosclerosis). This doesn’t determine if you have significant blockages,
but it does help determine your risk for CAD.
83
● Echocardiogram (echo): Uses sound waves to evaluate your heart’s structure and function.
● Electrocardiogram (EKG/ECG): Records your heart’s electrical activity. Can detect
old or current heart attacks, ischemia and heart rhythm issues.
● Exercise stress test: Checks how your heart responds when it’s working very hard. Can
detect angina and blockages in your coronary arteries.
84
TREATMENT:
Some people need a procedure or surgery to manage coronary artery disease, including:
● Percutaneous coronary intervention (PCI): Another name for this procedure is coronary
angioplasty. It’s minimally invasive. Your provider uses a small balloon to reopen your
blocked artery and help blood flow through it better. Your provider may also insert a stent
to help your artery stay open.
85
● Coronary artery bypass grafting (CABG): This surgery creates a new path for your blood
to flow around blockages. This “detour” restores blood flow to your heart. CABG helps
people who have severe blockages in several coronary arteries.
PROCEDURE:
● Coronary artery bypass surgery is major surgery that’s done in a hospital. Doctors trained in
heart surgery, called cardiovascular surgeons, do the surgery. Heart doctors, called
cardiologists, and a team of other providers help care for you.
● Before you go into the operating room, a health care provider inserts an IV into your
forearm or hand and gives you medicine called a sedative to help you relax.
When you are in the operating room, you can expect these things:
● Heart-lung machine: During surgery, a heart-lung machine keeps blood and oxygen
flowing through your body. This is called on-pump coronary bypass.
● Coronary artery bypass surgery usually takes about 3 to 6 hours. How long surgery takes
depends on how many arteries are blocked.
86
● A surgeon typically makes a long cut down the center of the chest along the breastbone.
The surgeon spreads open the rib cage to show the heart. After the chest is opened, the heart
is temporarily stopped with medicine. The heart-lung machine is turned on.
● The surgeon removes a section of healthy blood vessel, often from inside the chest wall or from
the lower leg. This piece of healthy tissue is called a graft. The surgeon attaches the ends of the
graft below the blocked heart artery. This creates a new pathway for blood to flow around a
blockage. More than one graft may be used during coronary artery bypass.
RISK FACTORS:
● Coronary artery bypass surgery is open-heart surgery. All surgeries have some risks.
Possible complications of coronary artery bypass surgery include:
● Bleeding.
● Death.
● Heart attack due to a blood clot after surgery.
● Infection at the site of the chest wound.
● Long-term need for a breathing machine.
● Irregular heart rhythms, called arrhythmias.
● Kidney problems.
● Memory loss or trouble thinking clearly, which often is temporary.
● Stroke
87
MEDICATION:
Medications can help you manage your risk factors plus treat symptoms of
coronary arterydisease. Your provider may prescribe one or more of the
medications listed below.
● Medications to lower your blood pressure.
● Medications to lower your cholesterol.
● Medications to manage stable angina these include nitroglycerin and ranolazine.
● Medications to reduce your risk of blood clots.
88
CASE STUDY-05
PATIENT PROFILE:
PATIENT NAME : XXXXX
AGE : 55 years
GENDER : Male
HEIGHT : 157cm
WEIGHT : 60 kg
BMI : 2.46kg/m2
IBW : 57kg
FOOD HABITS : Non Vegetarian
LIFESTYLE : Sedentary
ADMISSION NO. :ARHI65226
DATE OF ADMISSION : 19/05/2024
DURATION OF STAY : 5 days
DATE OF DISCHARGE : 23/05/2024
MEDICAL DIAGNOSIS :CADIWMI
PLAN OF CARE : CAG-SVG ,PTCA to
RCS PAST
MEDICAL HISTORY : HTN
FOOD ALLERGIES : No known food allergies.
PATIENT ORIENTED MEDICAL RECORD: Complaint of chest pain since 2
days and shortness of Breath.
89
BIOCHEMICAL PARAMETER
PARAMETERS AT AT TIME NORMAL

ANALYSIS TIME DISCHARGES RANGES
ADMISSION
HAEMOGLOBIN 13.8g/dl 13.9g/dl 13.0-18.0
RCC 3.8million/ul 3.4 million/ul 4.2-6.5
SODIUM 141 135 135-145
POTASSIUM 3.2 3.6 3.6-5.2
CHLORIDES 112 46 107

PLATELETS 4.86mm3 4.62mm3 140-440
UREA 154 76 8-24
CREATININE 1.1 1.2mg/dL 0.8-1.3
F.B. S 99 95 <100
MANAGEMENT AND TREATMENT

DETAILS: DRUG ADVICE AFTER
DISCHARGE:
S.NO Drug name Dosage Usage
It’s used in the diagnosis and treatment of

1 T.ECOSPRIN 150mg
headache,migraine and fever.
It is used to prevent blood clot formation

2 T.CLOPITAB 75mg in the hardened blood vessels, thus
reducing the risk of heart attack, stroke
and heart-related chest pain
It's used to lower cholesterol and other
3 T.ATORVAS 80mg harmful types of cholesterol in the body
3000uni Used for the decreasing the Clotting ability
4 Inj.HEPARIN
ts of blood
Helps in to treat peptic ulcers,
gastroesophageal reflux disease (GERD)
5 Inj. PAN 40mg or reflux esophagitis and its associated
symptoms such as acidity, heartburn, acid
reflux and pain in swallowing.
6 T.TIMZID-MR 30mg Used to treating heart related chest pain
90
DIETARY MANAGEMENT:
OBJECTIVE OF DIETARY MANAGEMENT:
● High calorie diet.

● High protein diet.
● Moderate CHO
● Low fat diet.
MODIFIED RDA:
● ENERGY:1400kcals
● PROTEINS:55g
● CARBOHYDRATES:200g
● FATS:30
DIET DURING HOSPITAL STAY:
DATE DIET PRESCRIBED

19/5/2024 NBM
20/5/2024 liquids
21/5/2024 Soft diet
22/5/2024 Soft diet
23/5/2024 Soft diet
24 HOURS DIETARY RECALL:
MEAL TIMINGS MEAL TIMINGS
Early morning Skimmilk
idli
Breakfast coconut chutney
Mid-morning roasted chana

Rice
Lunch Brinjal curry
Tea
Evening snacks Biscuits
roti
Dinner Tomato curry
91
MENU PLAN:
Meal timings Menu Ingredients
Early Ginger water
morning Ginger
Idli semolina
blackgram dal
ground nut
Groundnut red gram dal
Breakfast chutney onion
Samber
tomato
drumstick
oil
Mid-morning fruit promogranate

dry fruit Almond
rice
Rice cheakpea
Lunch
cheakpea curry oinon
tomato
oil
Evening fruit papaya

seeds
Snacks sunflow
er
phulka wheatflour
Currry Chiken curry
Dinner
onion
tomato
oil
92
Bedtime milk Milk
NUTRITIVE VALUE CALCULATIONS:

Meal Quanti Energy Carbohydrat Protein Fat(g)
ty es
timings Menu Ingredient (kcals) (g)
s (g) (g)
Early Ginger 100 66 12.3 2.3 0.9
water
morning Ginger
Breakfast idly semolina 30 348 74.8 10.4 0.8

blackgram 15 347 59.6 24 1.4
groundnut dal 20 567 25 25.3 40.1
samber ground nut 30 335 57.6 22.3 1.7
red gram dal 20 50 11.1 1 0.1
onion 20 20 3.6 0.9 0.2
tomato 20 26 3.6 2.5 0.1
drumstick 1.2 900 100
oil
Mid- Fruits Promograna 100 65 14.5 1.6 0.1

Dry fruits te 10 655 10.5 20.8 58.9
morning Almonds
Lunch Rice rice 60 346 79 0.05 6.4

cheakpea cheakpea 50 210 35 10.7
curry oinon 20 50 11.1 1
tomato 20 20 3.6 0.9
oil 1.2 900
Evening fruit papaya 100 32 7.2 0.6 0.1

seeds sunflower 20 620 17.9 19.8 52.1
Dinner phulka Whetflour 50 239 76 27 14

Curry chiken 30 26 3.8 2 0.7
curry 20 50 11.1 1 0.1
Tomato 20 20 3.6 0.9 0.2
onion 1.2 900 100
oil
93
Bedtime Milk Milk 100 2.6 4.6 2.5 0.1
TOTAL 1350.35 194.64 59.74 33.52
RDA 1400 200 60 30
DIET COUNSELLING:
DIETARY MANAGEMENT:
● High protein, low fat, low, low carbohydrate with high minerals and vitamins are
suggested. High fiber diet with increased number of antioxidants is also
recommended.
● Good nutrition is important during recovery from coronary artery disease.
● Keep your weight within the normal range for your age and body frame.
● Reduce your salt intake to prevent fluid retention that may overload your heart and
cause it to work inefficiently.
DIETARY GUIDELINES:
● After the ptca the patient should know the energy requirement to maintain the healthy
body weight.
● The patient should eat a variety of foods rich in low fat, low saturated fat and low cholesterol.
● The trans-fat should be avoided.
● Vegetable oil rich in poly unsaturated fatty acid like sunflower and safflower oil can be
included with combination.
● Inclusion of fish in the diet is beneficial as they contain omega -3 fatty acids.
● Patient should take skimmed milk or low-fat milk. Whole grains, fruits and vegetables increase the antioxidant
content in the diet.
● Coffee and tea can be taken in moderate quantity; excess of caffeine can increase the heart
rate.
● Constipation should be prevented, so plenty of water and fiber rich foods are included in the
diet.
94
o Egg whites can be given 3-4 in number per day as they contain proteins in it. Egg
yolks contain cholesterol so egg yolks should be restricted to 2-3 per week.
o Five servings of fruits and vegetables should be included in the diet not only to meet
the requirements but also, they are rich in antioxidants and fiber.
o If the patient has hypertension, then sodium should be restricted.
o Patients should avoid tasking preserved foods.
o Concentrated foods like sweets, chocolates, cakes, pastries, ice creams, fried foods
and pickles should be avoided.
• Heavy meals should be avoided, and small and frequent meals should be taken.
• Outside food should be avoided as they are high in fats and calories.
• "ALONG WITH DIET PROPER MEDICATION AND
EXERCISE SHOULD BE TAKEN CARE OF.
CONCLUSION:
● A 20-year-old male patient presented to hospital with c/o chest pain on exertion and
SOB. All necessary investigations were done and diagnosed as CHRONIC
RHEUMATIC HEART DISEASE/ MITRAL STENOSIS Patient underwent surgery of
MITRAL VALVE REPLACEMENT/ AROTIC VALVE REPLACEMNT. The post
operative period was uneventful. Now the patient is being discharged in
hemodynamically stable condition with following medication and advice.
TLC-TENDER LOVING CARE

We provide special food to show them our care, love and service beyond medication and treatment
***** THE END*****
95

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APOLLO REACH HOSPITAL

CORONARY ARTERY BYPASS GRAFTING [CABG]

5. MICU (Medical intensive care

9. SICU (Surgical intensive care

AIMS & OBJECTIVES OF INTERNSHIP

• To Study the various diets associated with the diseases.

• Review the patient record

• Explain the diet and its dietary guidelines

• Provide accurate information

• Verify that patient is understanding via feedback

➢ Calculation of daily calorie and other nutrient intake

➢ Important focus stressed on their physical activity like walking, exercises,

➢ Advice is given in terms of cooked foods and volumetric measurements in

➢ To introduce variety and flexibility in diet prescription, provision of exchange

• Scrutinize compile daily diet indents.

• Supervision of food preparation and ensuring proper food distribution.

• Check food wastage at different levels.

• Planning and distributing area

• Breakfast preparation area

• Patient foods preparation area

• Cutting and storing area

• Room service cabin (for patients)

• Cold storage area

• Storeroom for daily vegetables

DEPARTMENT OF FOOD & BEVERAGE

• Equipment used in trolleys, standardized cups for serving

4. Clear fluid diet

5. Full fluid diet

6. Semi solid diet

9. Low salt diet

10. High fiber diet

11. Bland diet

D. LOWFAT/LOW CHOLESTEROL DIET:

➢ Pectin (apple, guava) lowers the level of serum cholesterol.

➢ Legumes, vegetables & fruits lower the serum cholesterol.

➢ Turmeric, Bengal gram, onion, fenugreek seeds, soya beans& Garlic

E. SODIUM&POTASSIUM RESTRICTED DIET:

o Indications for gastrostomy include stroke, motor neuron disease, Parkinson’s

PEJ TUBES: [percutaneous endoscopic jejnostomy]

• Standard enteral feeds:

 Percutaneous gastrostomy or jejunostomy tubes:

GASTRO- ESOPHEGEAL REFLUX AND ASPIRATION:

• Short bowel syndrome

• Ischemic bowel disease

• Fast weight gains or weight loss

• Muscle twitching, weakness, or cramps

• Stomach pain and vomiting

• Swelling of your hands, feet, or legs

• Tingling in your hands or feet.

ADMINISTRATION OF PARENTERAL NUTRITION:

Catheter-related sepsis occurs in probably ≥ 50% of patients.

❖ For nasogastric introduction of nutrition and aspiration of intestinal

❖ Four lateral eyes.

❖ Soft, frosted and kink resistance PVC tubing.

❖ Color coded funnel end connector for easy identification of size.

❖ Length: 105cms. ▪ Sizes: 6 FG to 24 FG.

1. When food consumption is interfered.

2. When absorption is interfered.

3. When storage is interfered.