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A
(3 pts)

Pulmonary Case Study

S

Pt. is a 10-year-old Hispanic male. Pt. is experiencing clubbing of fingers and toes,
appears extremely thin and pale, and flatus is very foul smelling. Parents restrict the
amount of fat in pt.s diet due to the smell it causes in his stool.
BMI: 21.4
IBW: 90lbs
Weight: 22.75 kg
Height: 131.0cm
TSF: 4.5 mm
Arm circumference: 16.70 cm
REE: 22.7 x 22.75kg + 495 = 1,011.425 kcals
TEE: 1,011.425(1.7 + 0.3) = 2,022.85 kcals
DER: 2,022(0.93/0.85) = 2,212.99 kcals
Protein: 34.58g
Fluid: 910ml
Activity level: Active
Family hx: pt. had a sister who died shortly after birth, who was also diagnosed with
CF.
CC: cystic fibrosis (diet education request) and upper respiratory tract infection
Pt. comments:
I have been having a lot of cramps lately
I usually have really bad diarrhea in the afternoon at school
I also have a huge one if I eat chips and cheese at night instead of pretzels
I only urinate a lot if I drink a lot
Home Medications: Pancrease, 4 caps with meals; 1 cap with snacks; Bronchodilators
with respiratory treatments.
Hospital Medications: Pancrease, 4 caps with meals; 1 cap with snacks;
Bronchodilators with respiratory treatments. Tobramycin administered via IV. Tylenol
PRN po.

O
Lab Values:
Serum Albumin = 2.3 g/dL
Serum Magnesium = 1.4 mEq/L
HbA1C = 7.1%
Transferrin = 190 mg/dL
Prealbumin = 8mg/dL
Coefficient of Fat Absorption 0.85
FEV1, 75%
D

Dx:
____points
Dx:
____points
Dx:

(Each PES
statement is
worth 4
points)

Inadequate energy intake (NI-1.2) related to pathological or physiological causes that

result in increased energy requirements as evidenced by cystic fibrosis diagnosis, CFA
0.85, FEV1 75% and nutrient analysis of 1000kcal per day.
Inadequate fat intake (NI-5.5.1) related to alteration in gastrointestinal tract structure
and/or function as evidenced by cystic fibrosis diagnosis, pt.s parent statement that
they restrict most of the fat in his diet because it gives him diarrhea and make his stool
really stink, and nutrient analysis of 7g per day.
Altered Gastrointestinal (GI) Function (NC-1.4) related to compromised exocrine
function pancreas and liver, as evidenced by cystic fibrosis diagnosis, diarrhea,

____points

cramping and laboratory values: serum albumin- 2.3 g/dL; serum magnesium- 1.4
mEq/L; transferrin- 190 mg/dL and prealbumin: 8mg/dL

I (M/E)
I:

P
Intervention: 6.5 pts

____points
M/E;
2.5 pts)

M/E:
____points

Signature- 1pt

Writing Style

Increased energy diet (ND-1.2.2.1) to 2,200 kcal per day

Increased fat diet (ND-1.2.5.1) to 100g per day
Recommended modifications E-1.5 (diet education in areas for
improvement/understanding)
Total energy intake FH-1.1.1.1
Total fat intake FH-1.5.1.1
Area(s) and level of knowledge/skill FH-4.1.1

Ashley Konich
Overall impression of the note. Writing style, neatness