General Information

• Patient's initials
• AW
• Age, Height, Weight
• 54 y/o,
• 5’10” (70 in),
• 304.7 lbs,
• 43.7 BMI
• Occupation
• Employer: Licking Heights School, not sure of job
• Family responsibility
• Married
• Date of Admission
• 1/18/21
• Attending Physician
• Frank Boetang M.D.
• Unit
• Med/Surg.
• Unit #: BM00279733
Previous Medical History
• Disease(s) and/or conditions:
• Acute kidney failure, Unspecified N17.9
• Acute Respiratory Failure with Hypoxia J96.01
• Body Mass Index (BMI) 40.0-44.9, Adult Z68.41
• COVID-19 U07.1
• Essential (Primary) Hypertension I10
• Hypo-Osmolality and Hyponatremia E87.1
• Long Term (Current) Use of Hypoglycemic Drugs Z79.84
• Morbid (Severe) Obesity Due To Excess Calories E66.01
• Pneumonia Due to Coronavirus Disease 2019 J12.82
• Type 2 Diabetes Mellitus with Hyperglycemia E11.65
• Hospitalizations
• June 2020 – Lumbar Strain
• March 2020 – Upper Respiratory Infection
• May 2018 – Motor Vehicle Accident
Present Admission

• Diagnosis/Problem List
• Acute kidney failure, Unspecified N17.9
• Acute Respiratory Failure with Hypoxia J96.01
• COVID-19 U07.1
• Hypo-Osmolality and Hyponatremia E87.1
• Pneumonia Due to Coronavirus Disease 2019 J12.82
• Physical examination
• Could not complete NFPE due to COVID-19 dx.
• Other significant data:
• Chest x-ray, but unable to view
 1/18 1/19 1/20 1/20 1/21 1/22 1/23 1/24 1/25 1/25 1/26
0:23 13:02 05:03 20:38

WBC 10.6 H 10.8 H --- --- 13.0 H 10.5 11.6 H 12.3 H 12.6 H --- 13.8 H

Hgb 14.3 14.5 --- --- 13.2 13.1 12.6 L 13.2 13.1 --- 13.3

Neut % 73.0 80.9 H --- --- 78.8 H 68.8 68.3 68.1 66.5 --- 66.3

Lymph % 16.2 L 14.4 L --- --- 11.9 H 17.6 L 16.3 L 17.9 17.6 L --- 19.2

Neut # 7.7 H 8.8 H --- --- 10.3 H 7.2 H 7.9 H 8.3 H 8.4 H --- 9.1 H

Mono # 1.0 .4 --- --- 1.0 1.2 H 1.3 H 1.2 H 1.2 H --- 1.1

Mono % 9.4

Immature Gran 1.2

3.2 L

1.4
---

---
---

---
7.8

1.3
11.2

2.1
11.6

3.5
9.6

4.2 H
9.4

6.1 H
---

---
8.2

5.8 H
PRESENT
ADMISSION
%

Immature Gran .13 .15 --- --- .17 .22 H .40 H .52 H .76 H --- .80 H

C – LABS
#

Sodium 129 L 133 L --- 127 L 128 L 129 L 128 L 132 L 131 L --- 130 L

Potassium 4.5 4.9 --- 5.0 L 4.7 4.7 5.2 H 4.4 4.1 --- 4.1

Chloride 96 L 97 L --- 96 L 95 L 96 L 96 L 95 L 96 L --- 98

Carbon Dioxide 16 L 15 L --- 17 L 20 L 21 L 23 27 22 --- 22

Anion Gap 17.2 L 20.8 H --- 15.1 H 12.8 21 L 9.0 9.5 13.1 --- 9.9

BUN 63.0 H 70.0 H --- 85.0 H 86.0 H 68.0 H 55.0 H 41.0 H 34.0 H --- 29.0 H

Creatinine 2.10 H 2.06 H --- 1.73 H 1.51 H 1.27 H 1.17 1.08 .91 --- .75

Glucose 202 H 388 H --- 421 H 433 H 453 H 409 H 356 H 292 H 487 H 250 H

Calcium 8.3 L 8.6 --- 8.7 8.8 8.7 8.6 8.5 8.8 --- 9.0

Magnesium --- --- 2.4 H --- --- -- --- --- 2.3 --- 2.0

AST 79 H --- --- --- --- -- --- --- --- --- ---

Globulin 3.9 H --- --- --- --- -- --- --- --- --- ---
 Study of Disease
(Brief)
• Definition
• Hypoxia – condition where not enough oxygen makes it to the
cells and tissues in the body
• COVID-19 - Merriam Webster definition: a mild to severe
respiratory illness that is caused by a coronavirus (Severe
acute respiratory syndrome coronavirus 2 of the
genus Betacoronavirus), is transmitted chiefly by contact with
infectious material (such as respiratory droplets) or with objects
or surfaces contaminated by the causative virus.
• CDC definition of COVID-19 symptoms:
• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
 Study of Disease
(Cont.)
• MNT Treatment
• Energy Needs:
• 27 kcal per kg of body weight per day; total energy expenditure
for polymorbid patients aged >65 years.
• 30 kcal per kg body weight per day; total energy expenditure
severely underweight polymorbid patients.
• 30 kcal per kg per day; guiding value for energy intake in older
persons, this value should be individually adjusted with regard to
nutritional status, physical activity level, disease status and
tolerance.
• **The target of 30 kcal/kg body weight in severely underweight
patients should be cautiously and slowly achieved, as this is a
population at high risk for refeeding syndrome.
• Protein Needs:
• 1 g protein per kg body weight a day in older persons; the
amount should be individually adjusted with regard to nutritional
status, physical activity level, disease status, and tolerance.
• >/ 1 g protein per kg body weight a day in polymorbid medical
inpatients in order to prevent body weight loss, reduce the risk of
complications and hospital readmission and improve functional
outcome.
• Complications and related diseases:
• Pneumonia, AKI, Hypoxia, azotemia
 Medical Treatment
• Medications
• Remdesivir 100mg
• Insulin – Levemir, NovoLOG
• Lasix 40 mg
• Lovanox 40 mg
• Mucinex 600 mg
• Norvasc 10 mg
• Decadron 6 mg
• Heparin 5,000 units
• Sodium Chloride
• Tessalon Perlas 100 mg
• Zithromax 500 mg
• Duoneb 6 ml

• General Progress/Physician Progress Summary:

• 1/19/21 Progress Note Chief Complaint: “The patient is overall
feeling better. He notes that his respiratory status is improved from
yesterday.”
• 1/20/21 Progress Note Chief Complaint: “Shortness of breath”
• 1/21/21 Progress Note Chief Complaint: “Shortness of breath,
Patient stated that he feels better, less short of breath, Still requiring
5 L nasal cannula oxygen, with no evidence of respiratory distress,
Continue current measures, reevaluate next a.m., Likely will require
home O2 prior to discharge, once O2 requirements are improving”
• 1/22/21 Progress Note Chief Complaint: “Shortness of breath,
hypoxia”
• 1/23/21 Progress Note Chief Complaint: “Hypoxia, Shortness of
breath”
• 1/24/21 Progress Note Chief Complaint: “Patient is stable on 4 L
oxygen. Denies any worsening short of breath. Vitals stable.”
• 1/25/21 Progress Note Chief Complaint: “Patient is stable on 4 L
oxygen, denies any short of breath.”
• 1/26/21 Discharge in stable condition.
 Medical Nutrition Therapy/Nutrition Care Process
Day 1 Full Assessment
Need for Nutritional Intervention/Alert
Met Criteria
Alert Generated
Nutrition Care Level
Moderate
Home Diet History
3 Meals/Day
Afternoon Snack
Narrative
Pt is a 54 yo male admitted for AKI and hypoxia with COVID-19 pneumonia. PMH of HTN, T2DM, obesity. Nutrition screen this date per MST
score 3- decreased appetite and wt loss. CBW 304.7 lbs (bed scale) reflects obese BMI of 43.7 kg/m^2. EMR wt hx:
• 6/14/20 329 lbs (actual)
• 3/10/20 340 (stated)

CBW reflects wt loss of 35.4 lbs (10.38%) in 10 months, which is not clinically significant per ASPEN malnutrition criteria. However, pt reports
weight loss of 15 lbs (4.7%) x 2 weeks. This report is clinically significant per ASPEN malnutrition criteria. No edema per
nursing documentation. Pt ordered small breakfast this date per CBORD. Spoke with pt via room phone. Pt reports decreased
appetite since COVID-19 dx. Since dx, pt reports eating 2-3 bites of food per day. Prior to dx, pt eating 3 meals per day and snacks on
vegetables with 75% PO intake. Pt PO intake <50% estimated needs for </ 5 days. Pt agreeable to trial chocolate Ensure TID. Pt denies
N/V/C. C/o diarrhea since COVID-19 dx. Taken together, pt meets ASPEN criteria for severe malnutrition in context of acute illness d/t poor
po intake and wt loss.
Self-feeding Ability
Independent
PO Intake in Hospital
See narrative
Usual Weight
319.7 lbs
Religious/Cultural/Ethnic Food Preferences
No
Nausea/Vomiting Presence
None
Bowel Pattern
Diarrhea
Dental Type
Partial- Lower
Medical Nutrition Therapy/Nutrition Care
Process Day 1 Full Assessment
Current Food Consistency Ideal Body Weight (IBW)
Thin Liquid 166.00 lbs
Regular Adjusted Body Weight (ABW)
Current Diet Order 200.68 lbs
Diabetic Percent Ideal Body Weight (%IBW)
Pertinent Medications 184.00 lbs
Insulin - Levemir, NovoLOG Patient Height
Amlodipine 70 in
Remdesivir Body Mass Index
Dexamethasone 43.72
Hx Dysphagia Total Kilocalorie/Energy Requirements
No IBW: 2265-2642.5 kcals
Hx Diabetes Method for Calculating Total
Yes Kilocalorie/Energy Requirement
Hx Renal Disease 30-35 kcal/kg IBW
Yes - AKI Protein Factor Value
Hx Gastrointestinal Disorders .8-1.2 g/ kg IBW
No Total Protein Requirement
Hx Cancer 60.4-90.6
No Total Fluid Requirement
Patient Gender 2265-2642.5 mL
Male Method for Calculating Total Fluid
Patient Age Requirement
54 years 1 mL/kcal
Current Height (inches) Degree of Malnutrition
70.0 inches Severe
Current Weight (pounds) Setting of Malnutrition
304.7 lbs Acute
Patient Weight Diagnosis #1
0 lb 4.875 oz PES: Severe malnutrition related to
304.7 lb acute illness of COVID-19 as
Height/Weight Measurement Method evidenced by suspected po intake </
Built in Bedscale 50% intake of estimated energy
Lab value comments per EMR needs for >/ 5 days and wt loss >2% in
WBC 10.8 H 2 weeks.
BUN 70.0 H
Creatinine 2.06 H
Glucose 388 H
 Medical Nutrition Therapy/Nutrition Care
Process Day 1 Full Assessment
Nutritional Goal
Maintain Current Weight
Pt Will Accept Diet
Meal Intake > 75%
Nutritional Interventions
Provide Diet as Ordered
Reevaluate Pt in 3-5 days
Add Supplement
Monitor Labs & Intake
Monitoring & Evaluation
Diet Order
Medications
Total Energy Intake
Fluid/Beverage Intake
Protein Intake
Carbohydrate Intake
Electrolyte/Renal Profile
GI Profile
Glucose/Endocrine Profile
Nutritional Plan Comments
Nutrition care level is moderate per priority points; scored points for
poor po intake and wt loss.

POC:
1.Pt meets criteria for severe malnutrition in the context of acute
illness.
2.Will send chocolate Ensure Enlive TID, which provides 350 kcals and 20 g
pro per serving.
3.Will monitor adequacy of PO intake, weight trends, I/O’s, labs, and
supplement acceptance and follow up per protocol.
NPO
No
Diabetic
Consistent Carbohydrate
Medical Nutrition
Therapy/Nutrition Care
Process Day 2
• 1/20/21 – Called to follow up this date. Asked pt
how he was doing and if he liked the Ensure. He
stated that his appetite is not better and the
Ensure gave him bad heartburn. D/t heartburn,
we put in an order for Ensure clear to see if that
would help. He also stated that he got crackers
to eat. He requested jello.
Medical Nutrition
Therapy/Nutrition Care
Process Day 3
• 1/21/21 – Called to follow up this date. Asked pt
how he was doing. He stated that his appetite
was better. He stated that he never got the
Ensure clear or the jello. We sent in another
order to get this for him.
 Medical Nutrition Therapy/Nutrition Care Process
Day 4 LOS Note
Nutrition Care Level
Moderate
Hx Weight Gain
No - No new wts since adm
PO Intake
Poor
Significant abnormal labs
BUN: 68.0 H
Cr: 1.27 H
Glucose from 1/19/21-1/22/21: 421 mg/dL-453 mg/dL
Pertinent Medications
NovoLOG
Levemir
Amlodipine
Dexamethasone
Narrative

Nutrition follow up assessment complete this date. CBW 304.7 lbs (bed scale) reflects obese BMI of 43.7 kg/m^2. No new
wts to assess this adm. Pt is net +1650 ml since adm per I/Os. Pt has edema per nursing documentation. No meal intake %s
since adm. Pt is skipping majority of meals per CBORD. This dietetic intern has been following up with pt daily via phone.
On 1/20/21, pt c/o chocolate Ensure giving him heartburn. Ensure clear was sent to see if that would improve. On 1/21/21,
pt reports appetite improving. Sent pt a tray with jello, chicken noodle soup, crackers, and Ensure clear.
Total Kilocalorie/Energy Requirements
2265-2642.5 kcal IBW
Method for Calculating Total Kilocalorie/Energy Requirement
30-35 kcal/kg IBW
Protein Factor Value
.8-1.2 g/kg
Total Protein Requirement
60.4-90.6 g
Total Fluid Requirement
2265-2642.5 mL
Method for Calculating Total Fluid Requirement
1 mL/ kcal
 Medical Nutrition Therapy/Nutrition Care Process
Day 4 LOS Note
Degree of Malnutrition
Severe
Setting of Malnutrition
Chronic
Diagnosis #1
PES: Severe malnutrition related to acute illness of COVID-19 as evidenced by suspected po intake </ 50% intake of estimated energy
needs for >/ 5 days and wt loss >2% in 2 weeks.
Nutritional Goal
Maintain Current Weight
Follow Diet as Ordered
Meal Intake > 75%
Nutritional Interventions
Provide Diet as Ordered
Reevaluate Pt in 3-5 days
Add Supplement
Monitor Labs & Intake
Monitoring & Evaluation
Diet Order
Medications
Total Energy Intake
Fluid/Beverage Intake
Protein Intake
Carbohydrate Intake
Glucose/Endocrine Profile
Nutritional Plan Comments
Nutrition care level is moderate per priority points; scored points for poor po intake and wt loss.

POC:
1.Pt meets criteria for severe malnutrition in the context of acute illness.
2.No new wts since adm. Obtain new weight measurement if possible.
3.Will send Berry Ensure Clear TID, which provides 240 kcals and 8 g pro per serving.
4.Will monitor and follow up per protocol.
NPO
No
Diabetic
Consistent Carbohydrate
Regular
A Balanced Diet
No Restrictions
Medical Nutrition
Therapy/Nutrition Care
Process Day 5
• 1/25/21 (Monday) – Called to follow up this
date. Asked pt how he was doing. He said his
appetite improved and he only had to
heartburn that one time. He ate most of his
breakfast this date: Eggs, French toast, yogurt,
Ensure, and chocolate milk. Over the weekend,
he had more to eat (still little): cottage cheese,
salmon, Ensure. On this date, 2 meals with 100%
PO intake.
Medical Nutrition
Therapy/Nutrition Care
Process Day 6
• 1/26/21 – Pt discharged this date. Got a consult for
a diabetic diet education. This was completed by
Lindsey.
Prognosis
• Medical – Good prognosis. Stable, discharged
1/26/21.
• Compliance to Nutrition Care Plan – Pt did
comply with trying the chocolate Ensure and
got heartburn. Then tried Ensure clear and
seemed to be drinking it. At the beginning of his
time here, he was not eating. That gradually
improved as his length of stay continued.
• Follow-up Plans – New diabetic, received
diabetic education upon discharge.
• I wish I could have gone into his
room and done an NFPE.
Unfortunately, I could not d/t COVID-
19 dx.
• Wish I would have asked if he
noticed wt loss anywhere in
particular in reference to the sites we
look for on the NFPE’s.
• In addition, I also did not ask if the wt What Would
loss was intentional. D/t his higher
BMI, I think it is reasonable to ask if
the wt loss is intentional. D/t it being
I Have Done
significant within a 2-week span, it
probably wasn’t intentional, but it
Differently?
never hurts to ask. That answer could
have affected his dx.
• Other than that, I think I did well with
the patient. I felt comfortable talking
to him on the phone, asking
appropriate questions, and following
up in his care.
References
Barazzoni, R., Bischoff, S. C., Breda, J., Wickramasinghe, K., Krznaric, Z.,
Nitzan, D., . & Singer, P. (2020). ESPEN expert statements and
practical guidance for nutritional management of individuals with
SARS-CoV-2 infection.
Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation, and
Treatment of Coronavirus. [Updated 2020 Oct 4]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
Covid-19. (n.d.). Retrieved February 03, 2021, from
https://www.merriam-webster.com/dictionary/COVID-19
Symptoms of coronavirus. (n.d.). Retrieved February 03, 2021, from
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-
testing/symptoms.html
QUESTIONS?
C