Vivian Armand (TB & HIV) 

Nutrition Assessment 

Client history: 

- Chief Complaint: Fatigue, cough, fever, night sweats, weight loss.  

- History of Present Illness: Patient presented to the clinic two days ago with complaints 
of fatigue, productive cough and night sweats for the past two months, with fever and 
weight loss for the last month. A PPD was done at that time and produced a positive. 
She is a direct admit to the medical isolation unit today. Patient reports her cough has 
gotten progressively worse over the last two months since arriving back home after a 
medical mission trip to South Africa with her church. Vital signs in the office were Temp 
100.6 F, RR 18, P 82, BP 114/72, Weight 180 lb. A chest x-ray was done at that time 
indicating possible tuberculosis. A sputum specimen was collected and sent for AFB 
smear and culture. Patient was given another sputum container to take home with 
instructions to obtain an early morning sputum specimen the next day and to return it 
to the clinic. She returned the following day with the sputum specimen she collected at 
home and a third sputum specimen was collected. Several days later, the sputum smear 
results were reported as follows: Negative, Positive, Positive. Her last PPD had been 8 
months prior, a repeat PPD was administered. PPD due to be read today. 
- Past Medical History: Psoriasis. Two vaginal deliveries of healthy female infants. 
Hysterectomy at age 32. Mild hypertension for 5 years that she is able to manage with 
diet. 
- Past Surgical History: Hysterectomy. 
- Family History: She reports that her parents are both living, both have hypertension. Her 
mom has hypothyroidism. She has two healthy children with no medical problems. 
There is no family history of lung disease, thromboembolism, diabetes, stroke, or heart 
disease. 
- Social History: The patient lives alone. Her husband passed away one year ago from a 
sudden heart attack. She denies any history of drug use, alcohol abuse, tattoos or blood 
transfusion. There are no pets in the home. She recently traveled to South Africa with 
her church as part of a medical mission trip with other doctors and nurses. The patient 
has been a registered nurse for 16 years and works in the ICU at a local hospital.  
- Medications: OTC Ibuprofen PRN, OTC Benadryl PRN and OTC multivitamin daily. 
- Allergies: No known drug allergies, Pollen. 
- Review of Systems:  
 - Patient has an occasional headache, denies migraines. No pulmonary disease or history 
of pneumonia. No history of palpitations, irregular rhythm or chest pain, has controlled 
mild hypertension. No nausea until a couple of weeks ago with nausea, vomiting and 
decreased appetite. Reports a 22 lb. weight loss in two months. Reports fatigue and 
being weak. No history of sleep disturbances or changes in neurological status. Has 
psoriasis, primarily on her hands. Skin is warm, extremely dry, flaky on her arms and 
legs. All other systems norma 

Biochemical data, medical tests and procedures: 

- Labs: CO2 32, Bilirubin 1.3, Sodium 145, Potassium 3.4, BUN 35, Albumin 5.0, WBC 4, 
ABG shows respiratory acidosis, Cholesterol 240, Triglycerides 192, Urinalysis normal. All 
other blood tests within normal ranges. PPD positive. Rapid HIV positive. 

Anthropometric measurements: 

- 66in, 178lbs (current)  

- BMI: 28.7 

Physical exam finding (nutrition focused): 

- Physical Exam: 
- General: Temp 103.8 F, HR 90, RR 22, BP 120/68, Pulse ox 89% on room air, 94% on 2 L 
oxygen via NC. Wt: 178 lbs, Ht: 66 ins. Well developed, pleasant Caucasian woman in 
mild respiratory distress, mildly tearful, speaking in short sentences, with an occasional 
cough producing a thick brown tinged sputum. 
- HEENT: PERRL, EOMI, the oropharynx is clear with no lesions, the neck is supple, no 
lymphadenopathy, no JVD, no bruits, the trachea was midline, normal carotid upstroke. 
- Heart: Regular rate and rhythm, no murmurs, rubs, or gallops. Normal S1 and S2. PMI 
normal. No heave. 
- Lungs: Bilateral diffuse crackles, decreased breath sounds lower left, no wheeze, no 
dullness to percussion. 
- Abdomen: Soft, nontender, nondistended, bowel sounds hypoactive. No 
hepatosplenomegaly. No rebound or guarding. 
- Genitourinary: Decreased urine output per patient, no pain or urgency with urination.  
 - Extremities: No clubbing, no lower extremity edema or swelling, no palpable cords. 
Negative Homans' sign. 
- Neurological: The patient is alert and oriented times three. Cranial nerves 2-12 intact. 
DTRs 2+ bilaterally and symmetric. Sensation within normal limits, weakness present. 
Cerebellar exam within normal limits. 
- Lymph system: No cervical, axillary, or inguinal lymph nodes enlarged on palpation. 
- Skin: Warm, extremely dry skin. No rashes, no lesions. 
- Musculoskeletal: No synovitis. No joint deformities. Full range of motion bilaterally 
throughout. 

Food and nutrition history: 

- No nutrition history was provided and the patient was not considered at risk so no 
screening was done either  

Comparative standards: 

- Doctor - to assess the patient’s health status and prescribe treatment plans for both 
diagnoses   
- Nurse - to monitor patient’s wellbeing and disease progression and report to other 
healthcare team members if anything changes  
- Respiratory therapist - to provide respiratory care regarding the patient’s TB diagnosis 
and assess their disease progression  
- Pharmacist- to give the correct medications and advise on how/when to take them for 
both new diagnoses  
- Gynecologist - to discuss the HIV diagnosis and how to manage the disease and how to 
take all precautions necessary  

Total energy estimated needs: 

- (10 × w
​ eight​ in kg) + (6.25 × h
​ eight​ in cm) - (5 × age in years) - 161 
- (10 x 81kg) + (6.25 x 167.6) - (5 x 45) - 161 
- 810 + 1,045 - 225 - 161 = 1,469 x ​.10 ​= 147  
- 1,616 x 1.2AF= 1
​ ,939 calories 
- Calories have been increased by 10% because she is asymptomatic, if this changes, she 
may need 20-50% more calories. Will monitor closely.  
Total protein estimated needs: 

- 81kg x .8 = 64.8 x .10 = 6.5 = 71 grams  

Total fluid estimated needs: 

- 2L (based on a 2,000 calorie diet) x .10 = 2,200mL or 2

​ .2L fluids​ ​at least  

Nutrition Diagnosis 

(P) Problem: 

- Increased energy expenditure 

(E) Etiology (r/t): 

- Related to untreated HIV  

(S) S/S (aeb): 

- As evidenced by an unintentional 20 pound weight loss and persistent fever of 102 

degrees. 

Nutrition Intervention 

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

- Regular 2,000 calorie diet consisting of at least 70 grams of protein and 2.2L fluids. 
- Recommended to take a daily multivitamin. 
 - Avoid undercooked meats and unpasteurized products.  

Intervention: 

- Nutrition education on proper diet with new disease diagnosis such as taking a 
multivitamin, avoiding undercooked meat or unpasteurized products. 

Goal: 

- To consume the recommended diet and abide by the health precautions discussed in 
the intervention.  

Nutrition Monitoring and Evaluation 

Indicator: 

- Follow up with patient in 2 weeks to check weight and see how they are feeling with the 
new prescription and diet order.  

Criteria: 

- Patient will maintain weight status and (with the help of medication prescribed to her) 
will lose her fever. 

 
 Ulfat Aftab (Advanced Cancer, Hospice) 

Nutrition Assessment 

Client history: 

- Patient had been treated in Saudi Arabia for colon cancer which was discovered in stage 
II almost a year ago. She refused resection with anastomosis and was treated with 
chemotherapy only. After multiple treatments with rest periods the chemotherapy was 
ended due to patient request. She felt she could not handle the therapy and associated 
side effects any longer. Upon check-up six weeks ago, the cancer was found to have 
spread to her lymph system and then to her liver, lungs, and ovaries. The cancer was 
staged as IV-B colon cancer. She requested a resection and anastomosis at that point, 
but doctors told her nothing more could be done. Palliative treatment was prescribed 
and it was recommended she return to her native home in Pakistan for end of life care. 
She instead decided to join her son in America to seek American medical care. 
- She is fatigued and in moderate pain from the tumors along her spine. She does not 
have any SOB and although she has very little appetite, she is able to eat her preferred 
diet and is still urinating and defecating. She does have some nausea, increased 
abdominal girth, swelling of the feet and jaundice with mild pruritus of the skin. 
- Mrs. Aftab is a widow of four years who is native to Pakistan but would like to live with 
her adult son, who lives in America, for the duration of her life. She has had on-going 
problems with anemia throughout her cancer and previous treatment. The anemia, as is 
often the case with cancer, is unresponsive to first-line treatments. 
- SOCIAL HISTORY: 
- Never smoked. No alcohol use 
- ALLERGIES: ASA 
- MEDICATIONS: 
- In Saudi Arabia nonparenteral narcotics prescriptions are strictly limited and can only be 
prescribed for terminal cancer patients for a maximum of 30 days. She has run out of 
her pain medicine prescription. She believes she was taking pethidine previously. 

Biochemical data, medical tests and procedures: 

- Electrolytes, protein, albumin, hemoglobin, hematocrit, RBC, are all flagged low and 
WBC is high. 
 - Labs show increased bilirubin and very low hemoglobin at 7.4. 
- ** I would request a look at her liver enzymes to assess liver function d/t her ascites and 
the tumor growth on her liver  

Anthropometric measurements:  

- 102lbs, 61 inches, BMI: 19.3 (underweight)  

Physical exam finding (nutrition focused): 

- REVIEW OF SYSTEMS: 
- The patient relates no recent weight gain, but has noticed bloating of the belly along 
with gradual weight loss over the last year. Pt reports frequent headaches and dizziness, 
general fatigue and decreased alertness. Eyes: No change in vision or diplopia. Ears: No 
tinnitus or vertigo. Mouth: No dysphagia. Pulmonary: No chronic cough or shortness of 
breath. Cardiac: No angina or palpitations. GI: Pt reports frequent diarrhea, occasional 
nausea/vomiting, bloating, a swollen belly and loss of appetite. Musculoskeletal: No 
arthritides, myalgias or fractures. Hematopoietic: reports that she bruises easily. Skin: 
No chronic ulcers or persistent itch, pt is very pale. 
- PHYSICAL EXAMINATION: 
- GENERAL: The patient appears malnourished, pale and ill, but in no acute distress. 
- HEENT: Head is normocephalic. Eyes, pupils are equal. Conjunctivae are pink. Sclerae 
are anicteric. 
- NECK: There is no adenopathy. 
- PULMONARY: Respirations are unlabored, but air flow is audibly reduced. 
- HEART: Regular rhythm. 
- ABDOMEN: Liver, spleen, kidney, and bladder are not palpable. Abdomen is rounded 
and ​ascites a
​ ppears to be present. There are no discernible masses. There are no 
peritoneal signs. 
- MUSCULOSKELETAL: The upper and lower extremities are symmetric bilaterally, general 
weakness noted. No pain or loss of range. 
- NEUROLOGIC: There are no gross focal neurological abnormalities. CNs 2-12 grossly 
intact. 

Food and nutrition history: 

 - Reported loss of appetite  

Comparative standards: 

- Hospice nurse - to provide comfort and care to the patient if that is what she continues 
to choose  
- Oncologist - to assess the cancer progression and advise treatment plans based on the 
patient’s best interest  
- Pharmacist- to give the patient correct medication and advice on how to properly take it  
- Nurse- to monitor the patients well being while in the hospital  
- Home care nurse- to care for the patient if her family members cannot and to ensure 
she is eating and taking her medications regularly when she is discharged  

Total energy estimated needs: 

- Women: (10 × ​weight​ in kg) + (6.25 × h

​ eight​ in cm) - (5 × age in years) - 161 
- (10 x 46.4) + (6.25 x 155) - (5 x 59) - 161  
- 464 + 969 - 295 - 161 = 977 x 1.2AF = 1,172 + 500 (wt gain) = 1,672 or 1
​ ,650 calories  

Total protein estimated needs: 

- 46.4 x 1.5g = 69.6 or​ 70 grams  

Total fluid estimated needs: 

- 1.7L fluids​ based on calories but possible need for a fluid and sodium restriction for 
ascites  

Nutrition Diagnosis 

(P) Problem: 

- Moderate chronic disease related malnutrition  

(E) Etiology (r/t): 

- Related to untreated cancer diagnosis  

(S) S/S (aeb): 

- As evidenced by low BMI, malnourished appearance, ascites, and anemia.  

Nutrition Intervention 

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

- Regular diet consisting of 1,650 calories and 70 grams protein with 1.7L fluid and <2 
gram sodium.  
- *possible need for fluid restriction as well  

Intervention: 

- Increased energy diet. 

- Nutrition education on ways to consume more food (or more calorie dense foods) to 
prevent further malnourished status. 

Goal: 

- To gain at least 5 pounds in two weeks and see improvements in ascites and anemia 
status.   

Nutrition Monitoring and Evaluation 

Indicator: 
 - Patient will keep track of weight status and calories consumed (if possible) as well as 
note any decrease in bloat from ascites. Follow up with RDN in one week to ensure 
recommendations are being followed.  

Criteria: 

- Patient will gain five pounds and have a decrease in ascites along with an altered 
anemia status.  
- Also check liver status at next visit.  

Mariana Luna (Breast cancer, initiating 

chemotherapy) 

Nutrition Assessment 

Client history: 

- Mariana Luna is a 50-year-old female recently diagnosed with early stage breast cancer 
here for initial outpatient chemotherapy with Dr. Genevieve Darbonne at the Central 
Clinic outpatient infusion center. 
- Chief Complaint 
- Ms Luna was referred to Dr. Darbonne by PCP Dr. Bradford and today is seen in the 
outpatient infusion center waiting to receive her first chemotherapy regimen (AC) the 
regimen consists of Adriamycin (doxorubicin) and cyclophosphamide. This regimen is to 
be given on day 1 every 14 days for a total of 4 cycles. 
- History of Present Illness 
- Patient is a 50-year-old Hispanic female recently diagnosed with early stage breast 
cancer. She felt a mass in her left breast, which was confirmed via mammogram 
followed by an ultrasound which revealed a 1 cm mass in her left breast. The patient 
underwent a biopsy that showed adenocarcinoma. She consequently had a left breast 
lumpectomy 2 weeks ago. 
- Past Medical History 
 - HTN x 10 years 
- Family History 
- Father died at age 81 from Small Cell lung Cancer (SCLC) 
- Social History 
- The patient came to the United States when she was very young. She speaks fluent 
English and Spanish. She is divorced, lives with her only daughter who is in medical 
school. 
- Tobacco/Alcohol/Substance Use: Denies alcohol use; (-) tobacco or illicit drug use 
- Allergies/Intolerances/Adverse Drug Events: No Known drug allergies (NKDA) 
- Medications (Current): Amlodipine 10mg PO q24h 

Biochemical data, medical tests and procedures: 

- Laboratory Tests: 
- Na 137 mEq/L 
- K 3.6 mEq/L 
- Cl 104 mEq/L 
- CO2 22mEq/L 
- BUN 28mg/dL 
- SCr 0.8 mg/dL 
- Glu 189 mg/dL 
- Ca 8.7 mg/dL 
- Mg 1.8 meq/L 
- Phosphate 3.6 mg/dL 
- WBC 9.4 x 103/mm3 
- Hgb 11.6 g/dL 
- Platelet 213 x 103/mm3 
- Albumin 3.2 g/dL 
- Direct bilirubin 0.8mg/dL 
- AST 35 IU/L 
- ALT 30 IU/L 
- Alk phos 180Iu/L 

Anthropometric measurements: 

- Weight: 138lb 
- Height: 5’ 2’ inches 
 - BMI: 25.2 

Physical exam finding (nutrition focused): 

- Review of Systems: Well-appearing female nervous about receiving chemotherapy 

- Physical Examination 
- General: Well appearing female 
- Vital Signs: Normal 

Food and nutrition history: 

- None provided  

Comparative standards: 

- Psychiatrist/ therapist - to help the patient through the difficult time she is about to 
endure  
- Oncologist - to assess the cancer progression and come up with a treatment plan  
- Radiologist- to provide chemotherapy and assess disease progression  
- Nurse- to provide care during chemotherapy sessions and assess the patient’s wellbeing  
- Pharmacist - to provide the patient with the correct medication dosages and give 
accurate advice on how and when to take them  

Total energy estimated needs: 

- Women: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161. 
- (10 x 62.7) + (6.25 x 157.5) - (5 x 50) - 161 
- 627 + 984 - 250 - 161 
- 1,200 x 1.375 AF =​ 1,650 calories  

Total protein estimated needs: 

- 62.7 x 1.5 = 9
​ 4 grams  
Total fluid estimated needs: 

- 1.7L fluids​ based on calorie recommendation 

Nutrition Diagnosis 

(P) Problem: 

- Food and nutrition related knowledge deficit  

(E) Etiology (r/t): 

- Related to proper food choices for cancer diagnosis and chemotherapy treatment 

(S) S/S (aeb): 

- As evidenced by patient’s lack of knowledge on nutrition through chemotherapy.  

Nutrition Intervention 

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of 
Nutrition Care RC, Population Based Nutrition Action P 

Nutrition prescription: 

- Regular diet consisting of about 1,650 calories, 95 grams of protein, 1.7L fluid and 
increased fruit/vegetable intake.  

Intervention: 

- Nutrition education on proper food choices through chemotherapy and how to achieve 
health related goals through nutrition.  
Goal: 

- To consume proper food choices discussed with RDN within the nutrition prescription 
provided.  

Nutrition Monitoring and Evaluation 

Indicator: 

- Patient will keep a 2 week food log tracking foods consumed and report back to dietitian 
at the end of the 2 weeks to provide evidence of adherence to recommendations.   

Criteria: 

- Patient will be consuming a general healthful diet based on the calorie, protein, and 
fluid recommendations provided for her and will be able to demonstrate understanding 
of this healthful diet through her food log.