NUT 4700 MNT I

Case Study 1: Malnutrition and Depression

Review the case and answer the questions at the end. Please type your answers, and turn
in a hard copy in class on the due date as noted on the syllabus. Also submit a copy on
line in the assignment drop box.
Note that there are terms that you may need to look up. In addition, you will need to
identify the information relevant to the nutrition assessment (not all information in
medical records is pertinent to nutrition part of the assessment is judging what the
relevant information is.)
We will review the case study as a group in class. You may make corrections or
comments on your hard copy that you turn in that day. If you turn in your case study late,
2 points per class period will be deducted from your total grade.

Case Presentation

ML is a 75 year old widow who was brought to her primary care physicians office by the
local Older Americans Transportation Service. She had missed her two prior scheduled
office visits because of the recent death of her husband and a subsequent fall, which
resulted in an intertrochanteric fracture of her right hip.

On presentation, ML appeared withdrawn and much frailer than on previous visits. She
answered in a monotone with terse, nonspontaneous speech, and she lacked expression.
When asked about how she has been coping after the loss of her husband, she became
tearful. She admitted that in addition to the loss of companionship, the loss of his pension
has caused tremendous financial hardship.

Past Medical History

ML tripped on the steps in her house 2 months ago and fractured her hip. She underwent
an open reduction/internal fixation surgery to repair the fracture, and the operation went
well. She had no serious operative complications, but she lost approximately 250cc blood
during the procedure (1 unit = 500cc). ML underwent inpatient rehabilitation for 10 days
after discharge from the surgical service and then returned home, where she lives alone.
She ambulates slowing with a cane and can climb stairs only with difficulty.

During her inpatient rehabilitation stay, she was diagnosed with depression and she was
started on an antidepressant. She has no major chronic diseases except for osteoporosis,
discovered at the time of her hip fractures 2 months ago. ML had an appendectomy at age
46 and bilateral cataract surgeries 10 years ago. She has no previous history of
pneumonia, tuberculosis, hepatitis, or urinary tract infection.

Medications
ML currently taking: fluoxetine (Prozac) for depression, iron supplement for anemia
(three times per day), oxycodone for pain as needed. She also self-medicates with over


the counter preparations of ibuprofen (200-400mg three times a day) when she does not
want to take the stronger pain medicine.
She frequently uses over the counter laxatives and glycerin suppositories for her
constipation, which she has had since her surgery. She does not take a multiple vitamin,
calcium or vitamin D. She has no known food allergies.

Social History

ML lives alone in the four-bedroom, two-story home she has occupied since she married
55 years ago. Her son and daughter both live out of state. Although they call her every
few weeks, they have not visited since her husbands death. ML also explains that she
used to attend church and visit the local senior center regularly with her husband but has
not been to either lately. She has no energy to get up and go anymore and she falls
asleep in front of the television most nights. She also reports being constipated and that
her food does not have much taste. She avoids alcohol and tobacco and drinks one cup of
coffee and two cups of tea daily.

Review of Systems

General: Weakness, fatigue, weight loss, and depression.
Mouth: Food lacks taste (hypoguesia); dry, thick-feeling tongue; sores in corners of
mouth.
Gastrointestinal (GI): Poor appetite, constipation.
Extremities: Hip pain when climbing stairs, some tenderness at old incision site, and
chronic low back pain

Physical Examination

Vital Signs

Temperature: 97.0 deg F
Heart rate: 88 BPM
Respiration: 18 BPM
Blood pressure: 130/80 mm Hg
Height: 52
Current weight: 98 lb
Usual weight: 125lb


General: Thin, elderly woman who is appropriately conversant but withdrawn. She is
well groomed, but her clothes are loose fitting, suggesting weight loss.
Skin: Warm to touch, patches of dryness and flaking to elbows and lower extremities
Head, ears, eyes, nose, throat (HEENT): Temporal muscle wasting, no enlargement of
thyroid
Mouth: Ill-fitting dentures, sore beneath bottom plate, cracks/fissures at corners of mouth
(angular cheilitis)


Cardiac: Regular rate at 88 BPM
Abdomen: Well-healed appendectomy site scar, no enlargement of liver or spleen,
diffusely diminished bowel sounds
Extremities: Well-healed hip surgery incisions with slight surrounding erythema, no sores
on feet, trace pretibial edema to both lower extremities
Rectal: Hard stool in vault, stool test for occult blood negative
Neurologic: Alert, good memory, no evidence of sensory loss
Gait: Slightly wide-based with decreased arm swing, antalgic and tentative but with safe,
appropriate use of cane

Laboratory Data

Albumin: 2.5 g/dL (normal 3.5-5.8g/dL)
Hemoglobin: 11.0 g/dL (normal 11.8-15.5 g/dL)
Hematocrit 33.0% (normal 36-46%)

At her physicians request, ML provided the following 24 hour recall, stating that this
represent her usual daily intake:

Breakfast (home)

1 slice white toast
2 tbsp Jelly
1 cup coffee, black

Lunch (home)

2 butter cookies
1 cup chicken and rice soup
6 saltine crackers
2 cups tea

Dinner (home)

1 slice white bread
2 tbsp jelly
2 tbsp peanut putter
2 butter cookies

Total kcals: 1058
Protein: 22 gm/day (8% of kcals)
Fat: 30 gm (26% of kcals)
Carbohydrate: 175 gm (66% of kcals)
Calcium 153mg
Iron 6 mg








Case Study 1 Questions Name_____Jeremy Bartel_____________

1. What medical, environmental, and social factors could lead to nutritional
problems in this patient?
ML fractured her hip 2 months ago and has been taking oxicodone or ibuprofen for pain.
ML has been taking laxatives and glycerine suppositories for constipation. ML has had
an appendectomy and cataract surgery in both eyes. ML lives alone in a four bedroom,
two story home. She has hip pain when climbing stairs. She was going to the senior
center and attending church with her husband, but has not been to either in a while. She
has a son and a daughter, both of which live out of state. Her children call periodically,
but have not visited since her husbands funeral. She eats a lot of food that is processed
and pre-made.

2. Calculations:
a. BMI - pounds/inches
2
x 703 = 98/62
2
x 703 = 98/3844 x 703 = 17.9
b. Ideal body weight = IBW (kg) = height (cm) 100 {[height (cm)
150]/2} = 157.48 - 100 - {[157.48 - 150] / 2} = 57.48 - 3.74 = 53.74 kg or
118.48 lbs.
c. Percent ideal body weight = CBW/IBW = 98/118 x 100 = 83%
d. Percent usual body weight = CBW/UBW = 98/125 x 100 = 78.4%
e. BEE (using Mifflin St Jeor) = 10 x weight (kg) + 6.25 x height (cm) - 5 x
age (y) - 161 = 10 x 44.5 + 6.25 x 157.48 - 5 x 75 - 161 = 893.25 kcal
f. Total energy needs for repletion (weight gain) = 30 x 44.5 = 1335 kcal
g. Protein needs = .8-1 g/kg = 44.5 x .8 = 35.6 g
h. Fluid needs = 25 ml/kg = 44.5 x 25 = 1112.5 ml

3. What do MLs BMI and percent weight change indicate about her nutritional status?
Based on her BMI of 17.9 shes starting to become underweight. Shes also lost
21.6% of her body weight. Thats close to a quarter of what she originally
weighed. She needs to gain some weight.

4. What nutrition-related issues do her lab values indicate?
Her albumin level is low, which can indication protein-energy malnutrition. Her
hemoglobin hematocrit levels are also low, which could indicate anemia.

3. What concerns do you have about her medications effecting nutritional status?
Ibuprofen use can cause serious stomach irritation, which could be part of the
anemic state that ML is in. Oxicodone can cause constipation, which ML is
experiencing.



4. What general conclusions can you draw regarding the adequacy of her current
diet?
I think that ML is eating less then she is reporting. The foods that she is eating
are all processed, like white bread. Shes eating foods that are high in sugar or
starch as part of every meal.

5. How can MLs diet be improved to meet her increased requirements, achieve
weight gain, and relieve her constipation? (suggest alternatives to foods she is
currently consuming)

Breakfast (home)
1 slice whole wheat bread
2 TB sugar-free Almond butter
1 TB no sugar added Jelly
1 C coffee with cream.

Lunch (home)
2 C Chicken and Rice soup
4 whole grain Crackers
1 C tea
1 C milk
1 medium sized Apple

Dinner (home)
4 oz Baked Salmon
1/2 C Brown rice (make a large batch and freeze then thaw as needed)
1/2 C Steamed frozen mixed vegetable (easy to use and nutritionally dense in the
winter)
1/2 C Spinach salad with onions, tomatoes and dressing
2 butter cookies (she needs to enjoy life a bit)


6. What specific recommendations would you offer to improve MLs nutritional
status?
She needs to start including whole grains and nuts into her diet along with more
meat protein. Also, adding dairy and almonds will help with calcium levels. The
salmon will help provide EPA and DHA, which essential amino acids. The
spinach will provide iron, onions will help circulation and tomatoes have licopene
for vision health.

Visiting church and the senior center would help her connect with friends who
can support her through this hard time.