SURGERY

1. A leading center of excellence in clinical nutrition
specialist program in 2025
Clinical Nutrition Specialist Program will provide a
comprehensive clinical training program that embodies
the following characteristic:
1. Uphold scientific and medical profession ethic
2. Meet national & international standard of clinical
competence
3. Implement research in contribution towards basic and
clinical nutrition science
4. Provide high quality clinical nutrition service

2. CLINICAL NUTRITION CONFERENCE
Surgery Ward, November 17th 2022
dr. Indrawaty Alimuddin
dr. Tien Muliawati
dr. Ruwiyatul Aliyah*
dr. Christine Rogahang
dr. Utami Handayani
dr. Kaslan
dr. Meylisa

3. Patient Identity
.
999473
MR number
July 1st , 1999
Date of birth
November 12th , 2022
Admission Date
Consultation Date November 14th , 2022
Mr. F, 23 y.o. (Female)
Medical diagnosis
Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition (SGA Score C)
Orthopedic Diagnosis : Low Back Pain due to destruction lumbal III due to suspect infection
process + paravertebral abscess as level as lumbal III – lumbal V + Anemia + Primary Soft Tissue
Right Knee Suspect Benign
Pulmonology Diagnosis : Pleural effusion dexta et sinistra ec suspect infection dd malignancy

4. Main Complaint
Weight loss
Fever and Seizure
There was fever since 2 days ago and no seizure
Nausea & Vomiting
Cough and Shortness of Breath
There was cough since 10 days ago with white
phlegm. There was shortness of breath sometimes
fixed without modalities
Subjective
(History taking)
Swallowing Disorders
History taking
No History
Headache
No History
since 5 months ago because of intermittent low back
pain accompanied with lump on right knee that bigger
over time. worsened in the last 2 months because of
the worsened pain and difficulty walking
There were history of nausea and vomiting since 4
days ago
No History
Decreased of oral intake
There was unintentional weight loss since 4 months
ago ± 6 kg from Initial Body Weight 45 kg (13.3%)
Epigastric and Abdominal Pain

5. Defecation
Last defecation this morning, solid
consistency, yellowish
Via diapers, changed 2 times/ day.
Seems full
Urination
Subjective
(History taking)

6. Patient Family
No history
Cerebrovascular disease
No history
Cardiovascular disease, DM
No History
Kidney and urinary disease
No History
Cerebrovascular disease
Cardiovascular disease, DM
No history
Kidney and urinary disease
No history
Hyperuricemia, hypercholesterolemia
Others Malignancy
No history
No History
lump in right knee since 5 months ago
No history
Hyperuricemia, hypercholesterolemia

7. History of PRESENT Illness
patient complain that
there is mass at right
knee. Patient underwent
a biopsy suergry at Wajo
Hospital, but the family
did not bring the tissue to
be checked
4 months
ago
patient start to control at
orthopaedic polyclinic of
UNHAS Hospital. Diagnosis:
low back pain due to
destruction on Lumbal III due
to suspect infection process
+ soft tissue tumor right knee
susp benign. Patient
complained that the pain was
getting worse. Patient was
then brought to the
emergency room of Unhas
Hospital and being
hospitalized for 2 days
2 days
ago
patient had intermittent
low back pain. There is
mass reappear at right
knee accompanied with
pain. Patient was
hospitalized at
Lamadukelleng
Hospital for 3 days and
then underoing
outpatient treatment at
polyclinic. Patient then
was referred to
Polyclinic of UNHAS
Hospital for further
treatment.
1 week ago
3 months
ago
patient was referred to
RSWS and being
hospitalized at
Orthopaedic Ward
(Lontara) until now.
Patient was planned
for decompression and
posterior stabilization
surgery + culture
biopsy but still wait for
schedule from
orthopedic surgeon

8. 01
02
03
Occupation and Habit
Psychosocial history
Smoking
Drugs and alcohol
No history
She is a student
No History

9. Dietary History
Typical intake and usual amount of food: (before admitted to the hospital)
Intake:
Via oral
Quantity:
She eats regularly 3 times/day, 1 cups of white rice with 1 medium chunck of varied of animal side
dishes,and 1 small bowl of vegetables,1 portion of fruit
Quality:
She likes almost every food
 4 months ago, she ate 3 times/day, 1/2 serving of white rice, 1/2 serving of side dishes of animal origin and 1/2
serving of side dishes of plant origin and 1/2 small bowl of vegetables
 3 months ago, she ate 3 times/day, 1/2 serving of porridge , 1/2 serving of side dishes of animal origin and 1/2
serving of side dishes of plant origin
 1 week ago, she ate 3 times/day, 1/4 serving of porridge , 1/4 serving of side dishes of animal origin and 1/4
serving of side dishes of plant origin, 1/4 small bowl of vegetables and fruit
 4 days ago, she ate 3 times/day, 1/4 serving of porridge , 1/4 serving of side dishes of animal origin and 1/4
serving of side dishes of plant origin, 1/4 small bowl of vegetables and fruit
 Neither food allergies nor lactose intolerance

10. Intake & Fluid Analysis
Last intake Energy (kcal) Protein (g) Carbohydrate(g) Fat (g)
Intake before sick 1837 66.72 339.50 22.56
4 Months Ago 343.75 24.5 68 7.5
3 Months Ago 306.24 23 60.5 7.7
1 Week Ago 271.875 12.25 23 3.75
24 hours food recall 391.75 (20.61%) 14.50 (14.81%) 72.10 (73.62%) 4.83 (11.08%)
10
• Input : Intravenous and Medication 1850 cc
• Output : urine + IWL ( 1400 +390)
• Fluid Balance : 60 cc/24 hours

11. GCS E4M6V5
Body Lenght : 162 cm
IBW : 55.8 kg
MUAC : 18 cm
Estimated MUAC BW : 39 kg
Abdominal circumference : 64 cm
Anthropometry
Blood pressure : 120/70 mmHg
Pulse : 110 beats/minute
Respiratory rate : 23 times/minute
Temperature : 36.1°C
MAP : 86.6 mmHg
Vital signs
01 02
OBJECTIVE
MODERATE ILLNESS
Handgrip Strength: 3.2 kg
Functional Status :
ECOG Score III
03

12. Physical examination
HEAD AND NECK
Conjunctivawas anemic,Sclerawas noticteric.
Therewas noenlargementoflymphnodesand thyroid gland
CHEST
Inspection :Symmetric ,there was loss of subcutaneous fat.
Palpation :No tenderness
Percussion :Sonor
Auscultation : Vesicular breathing sound. No Rhonchi and wheezing, regular heart sounds
and no murmurs
ABDOMEN
Inspection :concave appearance
Auscultation :Normal Bowel Sound
Palpation :No tenderness
Percussion :Tympanic

13. Physical examination
EXTREMITY
There was wasting at all extremities and there was edema
at lower extremities (there is a 4x4 cm mass in the right knee, painful and fixed)

14. MEDICATION FROM OTHER DIVISION
16
Orthopedic (November 14th, 2022)
 PRC transfusion 2 bags/day
 Paracetamol 500mg/Oral (When fever)
 Ranitidin 50 mg/ 12 hours / Intravenous
 Ketorolac 30 mg/24 hours/ Intravenous
Pulmonologist (November 14th, 2022)
 Oxygen 5lpm via nasal cannule
 Ambroxol 30mg/8 hours / Oral

15. LABORATORY FINDINGS
Laboratory
November
12th, 2022
November
13th, 2022
Normal Value
WBC 9.400 4,0 - 10,0 x 103/μL
TLC 1870.6 1.5 - 4 x 103/μL
PLT 63.00 150-400 x 103 /μL
HGB 6.6 12.0 -16.0 gr/dl
MCV 78 80 – 100 μm3
MCH 26 27.0 – 32.0 pg
MCHC 34 32.0-36.0 g/dl
Neutrofil 66.6 52.0-75.0%
Lymfosit 19.9 20.0-40.0%
Random Plasma
Glucose
117 < 200 mg/dl
Urea 16 10- 50 mg/dl
Creatinine 0.46 M:(<1.3) ; F:(<1.1)
mg/dL
Sodium 134 135 – 145 mmol/L
Potassium 4.6 3.5 – 5.0 mmol/L
Chloride 98 97 – 111 mmol/L
NLR 3.3 < 3.13

16. LABORATORY FINDINGS
Laboratory
November
12th, 2022
November
13th, 2022
Normal Value
Procalcitonin 0.42 <0.05ng/ml
AST 80 <38 U/L
ALT 18 <41 U/L
Total Protein 5.6 6.6-8.7 g/dl
Albumin 3.1 3.5-5g/dl
Globulin 2.5 1.5-5g/dl
HbsAg Non-Reactive <0.13 (non-Reactive)
PT 10.8 10-14 second
INR 1.00 0.8-1.1 second
APTT 19.6 22-30 Second

17. Thorax Photo PA/AP (November 12th 2022)
- Right pleural effusion
- Normal cardio
Lumbosacral Photo AP Lateral (November 12th 2022 )
- Lumbosacral lordotic curve extends (Muscle spasm)
- Intak bones
Genu Photo AP Lateral Dextra (November 12th 2022 )
- No radiological abnormalities appear in the genu joint dextra
MRI Lumbosacral (November 8th 2022 )
- Paravertebrae masses of L2-L4 and L5 extending to intradural and subarachnoid space L3, posterior
elements of bilateral musculus psoas vertebrae, bilateral quadratus lumborum musculus accompanied by
bone marrow edema suspect DD abscess/metastasis.
- Solid mass of left adneksa
- Ascites
RADIOLOGIC FINDINGS

18. November 12th, 2022
• Mild hyponatremia 134
November 13th , 2022
• Hypochrome Microcytic Anemia 6.6
• Thrombocytopenia 63.000
• Mild hypoalbuminemia 3.1
• Increased Procalcitonin 0.42
• Increased of NLR 3.3
Metabolical status
Functional
GI- Tract status
Functional Status ECOG SCORE III
HYDRATION STATUS Normovolemic
Assesment

19. Diagnosis & Prognosis
Prognosis
Vitam: Dubia ad bonam
Functionam: Dubia ad bonam
Sanactionam: Dubia ad bonam
22
Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition (SGA Score C)
Orthopedic Diagnosis : Low Back Pain due to destruction lumbal III due to suspect infection
process + paravertebral abscess as level as lumbal III – lumbal V + Anemia + Primary Soft Tissue
Right Knee Suspect Benign
Pulmonology Diagnosis : Pleural effusion dexta et sinistra ec suspect infection dd malignancy

20. Basal Energy Expenditure : 1220 Kcal
Total Energy Expenditure : 1900 Kcal
Macronutrient Composition:
• Protein 1.5 g/kgIBW/day : 83.7 g (17.6%)
• Carbohydrate 50% : 237.5 g
• Fat 32.4% : 68.6 g
Medical Nutrition Therapy is given according to the management of refeeding syndrome 15
Kcal/kgBW/day = 585 Kcal (Equivalent to 30% TEE) via enteral:
- Blenderized food 246 Kcal
- ONS Peptisol 250 Kcal
- VCO 80 Kcal
Fluid requirements 1200 - 1400 cc/24 hours
Correction of hyponatremia by sodium intake (Deficit 117 + 78 = 195 mEq)
correction of hypoalbuminemia with protein intake of 1.5 g/kgBW
Planning
23

21. • Supplementation via enteral :
 B. Complex 2 tabs/8 hours
 Zinc 20mg/ 24 hours
 Curcuma 400mg/8 hours
 Thiamin 100mg/8 hours
• Monitoring and evaluation
 Haemodynamic
 Daily intake
 Gastrointestinal tolerance
• Nutritional education:
 Follow the meal according to the schedule
 Insert NGT when there are no contraindications
• Lab : UUN, Magnecium, Calcium, Phosphat
• Agree to join multidisciplinary care
Planning
24

22. FOLLOW UP

23. LABORATORY FINDINGS
Laboratory
November
13th, 2022
November
14th, 2022
Normal Value
Lactat 1.8 0.5-2.2 mmol
Sodium 137 135 – 145 mmol/L
Potassium 3.9 3.5 – 5.0 mmol/L
Chloride 103 97 – 111 mmol/L
CRP 59.2 <5mg/l
PT 10.3 10-14 second
INR 0.95 0.8-1.1 second
APTT 20.2 22-30 Second

24. Subjective Objective Assessment Planning
Intake via oral, There
was no nausea and
Vomiting. There was
low back pain
Defecation was
yesterday, seem to
be normal
Urination : Via diapers,
3 times change
1st day
Follow Up
(November 15th,
2022)
General Condition :MODERATE ILLNESS GCS E4M6V5
Vital sign :
Blood pressure : 120/60 mmHg
Pulse : 109 beats/minute
Respiratory rate : 23 times/minute
Temperature : 37.1°C
Anhtropometry
Body Length : 162 cm
Actual Body Weight : 44 kg
Ideal Body Weight : 55.8 kg
Estimated MUAC BW : 39 kg
MUAC : 18 cm
Food Recall 24 hours via Oral
Energy : 287.5 Kcal (15%)
Protein : 13.75 gr (19.1%)
Carbohydrate : 49 gr (68.2%)
Fat : 3.75 gr (11.7%)
Physical Examination:
HEAD AND NECK
Conjunctiva was anemic, Sclera was not icteric
Oxygen was not supported
Nasogastric tube was not inserted
There was no enlargement of lymph nodes and thyroid gland
CHEST
Inspection : Symmetric, There was loss of subcutaneous fat
Palpation : No tenderness
Percussion : Sonor
Auscultation : Vesicular breathing sound.There was no rhonchi and
wheezing, regular heart sounds and no murmurs
ABDOMEN
Inspection : Concave Appearance
Auscultation : Normal Bowel Sound
Palpation : Liver and spleen was not pappable
Percussion : Tympanic
EXTREMITY
There was wasting in all extremities and there was edema
At lower extremities (there is a 4 x4 cm mass in the right knee, painful and
fixed)
November 14th , 2022
• Increased CRP 59.2
• Improve of sodium 137 134
November 13th , 2022
• Hypochrome Microcytic
Anemia 6.6
• Thrombocytopenia 63.000
• Mild hypoalbuminemia 3.1
• Increased Procalcitonin 0.42
• Increased of NLR 3.3
Medical Nutrition Diagnosis:
Severe Protein Energy
Malnutrition (SGA Score C)
Orthopedic Diagnosis : Low
Back Pain due to destruction
lumbal III due to suspect
infection process +
paravertebral abscess as level
as lumbal III – lumbal V +
Anemia + Primary Soft Tissue
Right Knee Suspect Benign
Pulmonology Diagnosis :
Pleural effusion dexta et sinistra
ec suspect infection dd
malignancy
BEE : 1220 Kcal
TEE : 1900 Kcal (1.2/1.3)
Macronutrient Composition:
Protein 1.7 g/kgIBW/day : 95.2 g (20.0%)
Carbohydrate 45% : 214 g
Fat 35% : 74 g
Medical Nutrition Therapy is given according to the
management of refeeding syndrome 15 Kcal/kgBW/day
= 585 Kcal (Equivalent to 30% TEE) via enteral:
- Blenderized food 246.7 Kcal
- ONS Peptisol 250 Kcal
- Egg white 37.5 Kcal
- VCO 120 Kcal
Fluid requirements 1600 cc/24 hours
correction of hypoalbuminemia with protein intake of 1.7
g/kgBW
Supplementation via Enteral :
-Zinc 20mg/24jam/oral
- B comp 2 tab/8 hours
-Curcuma 400mg/8 hours
-Thiamin 100mg/8 hours
-Antasida Syrup 10ml/8 hours
Monitoring and evaluation
-Haemodynamic
-Daily intake
-Gastrointestinal tolerance
Nutritional education:
Follow the meal according to the schedule
Insert NGT
Lab : Waiting for Magnecium, Calcium, Phosphat and UUN

25. SGA

26. Thank you