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Student Name: Jessica Roberts

Date: 12/8/13

NTR549 Case Study #2:

Patient History: Mike is a 12-year old white male who presents at doctor’s office today with

stomach pain for > 6 months. Mike is 64.5 inches tall and weighs 130 lbs. One year ago, Mike

was 62 inches tall and 100 lbs. His blood pressure and heart rate are normal for age and height.

Bowel history shows 2 bowel movements per week. Mike’s main concern is stomach pain

although he does show concerns about his weight gain.

Family History: Parents have been divorced for 1 year and Mike is not able to see his dad very

often. Mike and his mother have moved to a new neighborhood due to the recent divorce. Mom

usually works late and does not have time to prepare regular home-cooked meals; therefore, she

frequently purchases fast food for Mikes meals as he is not allowed to cook when mom is not

home. Mom is concerned about Mike’s rapid weight gain but feels new neighborhood is not safe

and does not allow Mike to be outdoors unsupervised.

Mother: newly diagnosed diabetes

Father: hypertension & overweight

Food/Nutrition-related History: Diet history reveals an average intake of 3100 kcal/day (ranges

from 2900-3400). Average protein intake is 90g/day and fat intake is ~ 37% of total kcals.

Average fiber intake is 14g/day, calcium ~1000 mg/day, iron 14 mg/day, and sodium 3800

mg/day from food. Sweetened beverage intake is ~40oz/day. Physical activity history reveals

Mike watches TV/plays video games 3-4 hours every day.

Questions:

1. What is Mike’s current BMI?

[130/(64.52)] x 703 = 22.0

2. What was Mike’s BMI 1 year ago?

[100/(622)] x 703 = 18.3

3. Plot Mike’s current BMI and BMI from one year ago on growth chart, upload to

Moodle.

See Appendix A

4. What is his current BMI percentile and classification?

≈89th

percentile, overweight1

5. What was his BMI percentile and classification 1 year ago?

≈62nd

percentile, normal1

6. How much weight did Mike gain over the past year?

30#

7. What is his percent weight change?

[(130-100)/100]x100 = 30% increase

8. What are Mike’s daily energy & protein needs? (show me which calculation you

choose) 1, 2

Kcal = 113.5 - 61.9 x age(y) + PA x [26.7 x wt (kg) + 903 x ht (m)]

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Age = 12, PA = 1-1.1 (inactive), wt = 59 kg (130/2.2=59), ht = 1.6 m

(64.5x2.54=163.8/100=1.6)

113.5 - 61.9 x 12 + 1 x [26.7 x 59 + 903 x 1.6] = 2390 kcal/d

113.5 - 61.9 x 12 + 1.1 x [26.7 x 59 + 903 x 1.6] = 2693 kcal/d

Kcal = 2390-2693 kcal/d

Pro DRI: .95 g/kg/d

.95x59 = 56 g/d

9. Based on Mike’s Food/Nutrition-related history above, what concerns do you have?

Excessive kcal intake, low calcium intake (1000 cp to 1300), high sodium intake

(3800 cp 1500), low fiber (14 cp 38), excessive intake of sweetened beverages,

inactivity

10. What factors are affecting Mike’s nutrient & physical activity requirements?

Because his mom is working, she doesn’t feel she has time to cooke and regularly

brings home fast food. She also doesn’t want him cooking by himself. She also feels

the new neighborhood isn’t as safe, so he isn’t allowed outside alone which decreases

physical activity. He is watching a lot of TV and playing video games. This leads to

decreased physical activity, and can lead to excessive snacking. He is drinking a

large amount of sweetened beverages (40 oz/d) which increases caloric and sugar

intake.

11. Develop 1-day meal plan to meet Mike’s daily requirements for energy, protein,

fiber, calcium, iron & sodium. Please provide nutrient analysis of menu.

See Appendix B.

12. Complete NCP form. Include 1-2 PES statements. Identify interventions in at least

two domains. Make sure your goals and monitoring & evaluation relate back to your

original nutrition diagnoses

See Appendix C.

13. Record oral case presentation using screencast-o-matic. Orally present the case as if

delivering to medical team. Presentation should be no longer than 5-7 minutes. Tips

& Guidelines regarding case presentations can be found under “project resources” on

Moodle. http://screencast-o-matic.com/watch/cIl1VcVWLJ

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PART II:

One year later, Mike presented to his primary care physician for a well-child visit.

During the appointment, it was observed that the child was pale. Parents gave a history

of easy bruising, which had persisted for the past 2 months. A complete blood count

with differential showed anemia, thrombocytopenia and a white blood cell count of

65,000 thou/µl (normal: 4500-13,500 thou/µl). The family history is negative for cancer.

Pt is currently taking a multivitamin and remains fairly sedentary.

The patient was referred to the hospital for further evaluation. A diagnosis of acute

myelogenous leukemia (AML)-M4 (select marker) was confirmed by bone marrow

biopsy.

During the first round of induction chemotherapy, the patient’s weight decreased to 56

kg just 7 days into treatment. Mike reported decreased appetite and has noticed a

significant decrease in his intake of food. Patient had symptoms of nausea, vomiting and

increased stooling with blood.

New Anthropometrics:

Age: 13 years

Height: 66.5 inches

Weight at diagnosis of cancer: 59 kg

Weight after first round of chemotherapy: 56 kg

14. What is his Stature for Age Percentile?

95th

percentile

15. What is his Weight for Age Percentile at diagnosis of cancer? and post

chemotherapy?

≈89th

percentile; ≈80th

percentile

16. What is his BMI for Age Percentile at diagnosis of cancer? and post chemotherapy?

≈78th

percentile; ≈60th

percentile

17. Calculate his percent weight loss. [(usual – current)/usual * 100]

[(59-56)/59*100]=5.1%

18. Calculate current estimated energy needs (post chemo) per kilogram per day. Utilize

“Pediatric Oncology – additional notes” posted to Moodle Module 10. 3

Kcal= [17.5 x wt(kg) + 651] x 1.4 to 1.6

[17.5 x 56 + 651]x1.4= 2283 kcal/d

[17.5 x 56 + 651]x1.6= 2610 kcal/d

Kcal = 2283-2610 kcal/d

2283/56 = 40.8

2610/56 = 46.6

40.8-46.6 kcal/kg/d

19. Calculate estimated protein needs per kilogram per day3

1.5-2 g/kg/d = 84-112 g/d

20. Write 1 PES statement for his new diagnosis/symptoms.

Inadequate oral intake related to decreased appetite as evidenced by a 5% weight

loss in 7 days.

21. Write 1 Intervention (include domain) and patient goal for the PES statement

written in question #17.

Food and/or nutrient delivery (ND) – ND 3.1.3: Modified Beverage

Initiate modified beverage to supplement energy and protein intake.

Goal: Prevent significant weight loss (1-2% in 1 week, 5% in one month)

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References

1. Leonberg BL. Pocket guide to pediatric nutrition assessment, 2e. Chicago: Academy of

Nutrition and Dietetics; 2013.

2. Academy of Nutrition and Dietetics. Oncology: General Guidance. Pediatric Nutrition

Care Manual. http://nutritioncaremanual.org . Accessed December 2, 2013.

3. Klinman RE, eds. Pediatric Nutrition Handbook 6e. Elk Grove Village, IL: American

Academy of Pediatrics; 2009.

4. International Dietetics and Nutrition Terminology (IDNT) Reference Manual:

Standardized Language for the Nutrition Care Process 4e. Chicago, IL: Academy of

Nutrition and Dietetics; 2013.

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Appendix A

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Appendix B: One Day Diet and Nutrition Analysis

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Item

Serving

Size Kcal

Pro

(g)

Fiber

(g)

Ca (% of

1300 mg)

Na

(mg)

Iron (% of

8 mg)

Breakfast

Cheerios 1 1/2 c 150 5 5 15% 210 68%

1% milk 3/4 c 75 6 0 19% 94 0

banana whole 108 0 2 0 0 2%

sugar 2 Tbsp 90 0 0 0 0 0

Lunch

PBJ

Sandwich 370 22 10 0 390 4%

Chips Cheetos 150 2 0 0 250 2%

Applesauce 1 cup 100 0 4 0 40 0

Cookie

6 circus

cookies 140 1 0 0 55 0

1 % milk 8 oz 100 8 0 25% 125 0%

Snack

grapes 1 cup 164 0 1 1% 0 2%

Dinner

Meatloaf 1 slice 155 12 0 5% 100 10%

Baked

Potato (with

sour cream

and chives) 1 230 5 3 8% 273 3%

1 % milk 8 oz 100 8 0 25% 125 0%

Roll 100 3 2 1% 131 7%

corn 1/2 c 60 2 3 0% 360 2%

strawberries 1 c 76 2 3 3% 1 3%

Snack

popcorn 2 1/2 c 116 4 6 0% 362 5%

cheddar

cheese 1 oz 114 7 0 20% 176 1%

Kcal

Pro

(g)

Fiber

(g)

Ca (% of

1300 mg)

Na

(mg)

Iron (% of

8 mg)

Total: 2398 87 39 122% 2692 109%

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Appendix C: NCP Form

Patient: Mike Referred for: Stomach Pains

NUTRITION ASSESSMENT

Food and Nutrition Related History: Diet history reveals an average intake of 3100 kcal/day (ranges from 2900-3400). Average protein intake is 90g/day and fat

intake is ~ 37% of total kcals. Average fiber intake is 14g/day, calcium ~1000 mg/day, iron 14 mg/day, and sodium 3800

mg/day from food. Sweetened beverage intake is ~40oz/day. Physical activity history reveals Mike watches TV/plays video

games 3-4 hours every day. Anthropometric Measurements

Age: 12 Gender: Male Ht: 64.5” Wt: 130# Wt Hx: 100# 1 year ago % Wt change: 30% weight gain

BMI: 22, overweight

Biomedical Data, Medical Tests & Procedures None available

Labs/Date Albumin Glucose HbA1C BUN Creat Na+ K+ Hgb Hct MCV Other

Medical Record

Medical Diagnosis/PMH/Relevant Conditions:

Pertinent Medications N/A

Skin status: x Intact □ Pressure Ulcer/Non-healing wound; Comments:

Medical Record

Physical Assessment:

Estimated Nutritional Needs Based on Comparative Standards:

Calories: 2390-2693 kcal/d (40.5-45.6kcal/kg/d)

Protein: 56 g/d (.95 g/kg/d)

Fluid: 2390-2693 mL/d (1 mL/kcal)

Diet Order Medical Record (orders)

Feeding Ability

x Independent

□ Limited Assistance □ Extensive/Total Assistance

□ N/A

Oral Problems

□ Chewing Problem

□ Swallowing Problem

□ Mouth Pain

x None of the Above

Intake

x Good (> 75%)

□ Fair (approx. 50%)

□ Poor (<50%)

□ Minimal – (<25%)

□ NPO Medical Record

□ No Nutritional Diagnosis at this time x Proceed to Nutrition Diagnosis Below

NUTRITION DIAGNOSIS

P (problem) INTAKE (NI-1.3) Excessive energy intake related to:

E (Etiology) Limited healthful food choices as evidenced by:

S (Signs & Symptoms) Weight gain of 30# (30%) over 1 year.

P (problem) PHYSICAL ACTIVITY (NB-2.1) Physical inactivity related to:

E (Etiology) Limited access to safe exercise environment and lack of support as evidenced by:

S (Signs & Symptoms) Reported screen time of 3-4 hours a day.

INTERVENTION

Nutrition Prescription: diet providing 2390-2693 kcal/d

Food or Nutrient Delivery: decreased fast-food intake and provide healthful diet (ND 1.1)

Nutrition education: educate client and mother of importance of exercise as well as educate on simple, healthy dinners that can be prepared (E 1.5)

Nutrition Counseling:

Coordination of Care (refer to): PCP(primary care physician) (RC 1.5)

Goal(s): weight maintenance or weight gain of less than 10 pounds during the next year. Increased physical activity time to minimum of 90 minutes a week. Decrease in sweetened beverage intake to 16 oz or less per day.

MONITORING & EVALUATION Indicators: Weight change over the next year

Criteria: Weight maintenance or weight gain less than 10 pounds