Written Case Study. iii. Caloric density: 1.5kcals/mL (350kcals/240mL or one bottle); 0.05g protein/ml (13g protein/240ml or one bottle)

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1 Written Case Study Patient: RG DOB: 6/1/1987 Diagnosis: Malignant fibrous histiocytoma distal right femur; s/p limb salvage (1/12) Subjective: 1. Physical Appearance: Pt appeared thin but not wasted with a lower than expected amount of lean body mass and muscle for his age. 2. Diet History prior to admission: Pt s diet PTA was most likely not adequately meeting kcal and protein needs as pt was only consuming two meals and one snack per day. He usually eats breakfast around 11:00am and dinner at 5:00pm with a snack before going to bed around 12:00am. Pt s diet differs drastically when his mother is in town and able to cook and shop for his groceries. Mother cooks healthy, well-balanced meals with fresh fruits and vegetables and fish while pt relies on take-out and fast food when he cooks for himself. Pt states he likes to eat man food referring to red meat and beer. Pt was not consuming any nutrition supplements at home because he disliked how they taste. Pt generally does not consume an adequate number of servings of dairy per day. a. Feeding History: Pt has always consumed a PO diet has never had a feeding tube or TPN. b. Method of feeding: PO intake c. Oral/Enteral Intake: i. Specific formula: Ensure plus while inpatient ii. Mixing procedures: n/a iii. Caloric density: 1.5kcals/mL (350kcals/240mL or one bottle); 0.05g protein/ml (13g protein/240ml or one bottle) iv. Schedule: TID v. Fluid flushes: n/a vi. WIC: n/a vii. 24 hour recall or typical day: PTA pt consumed two bowls of Rice Krispie s cereal with berries and a fruit platter for breakfast. He did not eat lunch. His mother cooked him a steak dinner with rice, green beans, and beets, of which he had two plates. In the evening he ate a snack of corn chips and guacamole and popsicles. Throughout the day he consumed water, Gatorade, and iced tea. I would estimate his current intake is meeting roughly 50% of his estimated kcal and protein needs. viii. Tolerance issues (nausea/vomiting/diarrhea/constipation): Experienced some nausea with chemotherapy.

2 PES: ix. Any other relevant information: Pt led a very active lifestyle prior to diagnosis; he played ice hockey in college. Also of note, he and three other students living in the same dormitory at the same time in college have been diagnosed with cancer relatively close to the same time. Their cancer diagnoses are not the same and the dormitory has since been demolished. d. Vitamin or Mineral Supplements: Pt was consuming 5000IU of Vitamin D3 at home. Recommended decreasing dosage to 800IU as recent Vitamin D3 labs were within normal limits 3/8/12 it was 31 nanograms/ml. e. Food Allergies: none 1. Nutrition-related diagnosis: Involuntary weight loss (NC-3.2) related to inadequate energy intake with increased energy needs during treatment (pt consuming only two meals/day with one snack and no supplements) as evidenced by a 17% weight loss in 6 months (severe weight loss). a. Justify nutritional significance: Weight loss is a side effect of chemotherapy treatment. Chemo causes nausea/vomiting and poor appetite which leads to weight loss. It is also related to an imbalance of calories, or too few calories for weight maintenance. It can also be related to malabsorption or maldigestion. Pt weight loss is associated with poorer outcomes of treatment, longer hospital stays, and increased rates of complications in cancer patients. i. Pt weight loss may also be related to initial stage cancer cachexia, which is characterized by anorexia, early satiety, severe weight loss, weakness, and anemia (Fearon, 2006). b. Give brief natural history of the diagnosis: Pt s weight has been decreasing steadily with some instances of small weight gains in the past five months related to chemotherapy treatment. 2. Diet order: high calorie/high protein 3. Age: 24 years a. Corrected Age: n/a b. Justify use of corrected age: Pt is too old to justify the use of corrected age. 4. Weight: 80kg (176lbs) a. Percentile: Pt s age is outside the range of the growth charts. b. Corrected weight percentile: n/a c. Weight age: n/a 5. Height: 183cm (6 )

3 a. Percentile: Pt s age is outside the range of the growth charts. b. Corrected height percentile: n/a c. Height age: n/a 6. Head Circumference: Pt s age is outside the range of the head circumference charts. a. Percentile: n/a b. Corrected head circumference percentile: n/a c. Head circumference age: n/a 7. Weight/Height Percentile: Pt s age is outside the range of the growth charts. a. Justify rationale for use of this number: n/a 8. Body Mass Index/percentile: 23.9 normal, however, pt s BMI has been consistently decreasing relative to his weight loss. His BMI prior to treatment and surgery five months ago was 27, which is considered overweight. However, the pt had much more lean body mass prior to treatment. A greater amount of lean body mass can skew BMI up, thus classifying the pt as overweight when he actually had a higher ratio of muscle to fat and was not overweight. However, the pt also reported binge drinking in college and says he gained weight from that, which was all fat. 9. Plot patient on growth chart: Pt is an adult and has finished growing. a. Justify choice of growth chart: n/a b. Evaluate patient s growth: n/a 10. Estimated Requirements: a. Kcals/kg: 39kcals/kg b. Grams Protein/kg: 2.3g/kg c. ml/day to meet maintenance fluid needs: 2600mL/day d. Justify how you determined these numbers: i. Kcal needs were calculated using the Harris Benedict Equation X 1.6 activity factor. The activity factor was deemed appropriate because although he has lost weight his current body weight is considered normal and is what we would like him to maintain. 1. BEE = [66 + (13.7 X IBW of 84kg) + (5 X 183cm) (6.8 X 24)] X 1.6 = kcals/day / 80kg = 39kcals/kg 3. Same equation is used to determine pediatric oncology patient s kcal needs.

4 ii. Protein needs were based on recommendations from the Adult Nutrition Care Manual standards for patients receiving treatment and with muscle wasting ( g/kg). We decided to go with a protein value in the higher end of the range because he is a young male who had ample lean body mass before and to spare more protein from his muscles from being broken down and used as energy. 1. Pediatric oncology patient protein needs are between for children and for adolescents. iii. We based his fluid needs on the Adult Nutrition Care Manual standard of 30-35mL/kg and chose 32.5mL/kg which is in the middle of the range. His fluid balance has been fluctuating between positive and negative fluid balance mL X 80kg = 2600mL/day 11. Nutrition related Medications Reviewed: 2. Pediatric fluid needs are based on maintenance fluid estimations using a chart from The Harriet Lane Handbook. Using this chart, at 80kg RG would require 2700mL/day of fluids, which is very near the above estimation. a. Dexamethasone steroid that prevents the release of substances in the body that cause inflammation i. Causes fluid retention, sodium retention, and hypokalemia. It can also cause weight gain (due to fluid retention) and nausea/vomiting. ii. IV, 10mg, 2.5mL daily (5 doses total) b. Etoposide chemotherapy cancer medicine that interferes with the growth of cancer cells and slows their growth and spread in the body i. Can cause nausea/vomiting and loss of appetite. ii. IV, 200mg, 10mL daily (5 doses total) c. Gabapentin used to treat nerve pain RG is experiencing from reflexive sympathetic dystrophy, which is an unknown pain along with tingling and swelling in his right foot i. Interacts with antacids; can cause stomach pain, loss of appetite, and nausea/vomiting. ii. PO, 300mg q 8hrs d. Ifosfamide chemotherapy cancer (antineoplastic) medication that interferes with the growth of cancer cells and slows their growth and spread in the body i. Can cause nausea/vomiting, diarrhea, and mouth sores. ii. IV, 5600mg daily (5 doses total)

5 e. Methadone opioid pain reliever RG is taking due to pain associated with his surgery and reflexive sympathetic dystrophy i. Can cause nausea/vomiting, constipation, and pt s should not eat grapefruit or drink grapefruit juice while taking this medication (increases serum levels of it). ii. PO, 5mg BID f. Zofran anti-nausea medication i. Can cause constipation or diarrhea. ii. IV, 8mg, 4mL q 6hrs g. Bactrim antibiotic RG is taking to prevent any infections from occurring during his chemotherapy cycle, as his immune system is greatly diminished during treatment i. Can cause nausea/vomiting, diarrhea, and appetite loss. ii. PO, 160mg BID 12. Pertinent Labs Reviewed: Assessment: a. Include labs available when assessing this patient: Labs from initial assessment on 3/28 i. Glucose 141H (ref. range ) ii. Ca 8.2L (ref. range ) 1. Adjusted Ca (4-4)* = 8.2 iii. Mag 1.5L (ref. range ) b. Note labs deemed to be nutritionally significant and justify why: i. The high glucose lab is probably due to the steroid medication he is taking. He currently is not taking any insulin or following any dietary intervention to control his blood glucose. Diabetes management education is not a main concern at this point as his blood sugar levels would have to be consistently >150 for DM education and dietary intervention. ii. Calcium and adjusted Ca are low, which could also be related to the steroid medication he is taking, or related to the patient s low daily consumption of dairy products. It could also be affected by his fluid status; he is receiving more fluid than is required for maintenance, which would make the lab value read low. He may require nutrition intervention, including a Ca supplement or diet education on consuming dairy products. iii. His Magnesium is low, which also could be related to medication interactions. He is currently receiving Mag in his IV fluids, so the lab value should be monitored to make sure it normalizes but doesn t go too high.

6 1. Nutrition risk level: High a. Justify choice of risk level: The pt is at high nutrition risk because he lost 17% of his body weight in 6 months, which is considered a severe weight loss. He is also having inadequate oral intake related to chemotherapy treatment causing poor appetite as evidenced by only consuming two meals/day and one snack. His current dietary habits are not providing sufficient calories and protein to prevent weight loss and deterioration of lean body mass, posing a nutrition risk. 2. Pertinent Lab values: iv. Glucose 141H (ref. range ) v. Ca 8.2L (ref. range ) vi. Mag 1.5L (ref. range ) a. Justify their relationship to nutrition/hydration status: i. The high glucose lab is probably due to the steroid medication he is taking. He currently is not taking any insulin or following any dietary intervention to control his blood glucose. Diabetes management education is not a main concern at this point. ii. Calcium and adjusted Ca are low, which could also be related to the steroid medication he is taking, or related to the patient s low daily consumption of dairy products. It could also be affected by his fluid status; he is receiving more fluid than is required for maintenance, which would make the lab value read low. He may require nutrition intervention, including a Ca supplement or diet education on consuming dairy products. iii. His Magnesium is low, which also could be related to medication interactions. He is currently receiving Mag in his IV fluids, so the lab value should be monitored to make sure it normalizes but doesn t go too high. 3. IV fluids: 250mL/hr of NaCl 45% + Magnesium Sulfate 500mg X 13 hours (3250mL total IV fluid) when chemo is not running. 4. Growth: a. Justify their relationship to nutrition/hydration status: The patient is receiving more fluid than is required for maintenance because of all the IV chemotherapy medications he is receiving, which could alter his lab values, including the lab value for Ca. Furthermore, the pt is receiving Magnesium in the IV fluids, so his Mag lab values should be closely monitored to ensure it does not go too high. a. Rate of weight change: 17% weight loss in 6 months. b. Appropriateness of growth: n/a c. Justify your assessment: The pt is an adult and is finished growing, so growth is not a necessary parameter to assess.

7 5. Diet prior to admission: a. Adequacy of macro and micronutrients: It s likely he had inadequate macronutrient/energy intake PTA because of his habit of not consuming three meals per day with two or more snacks. This is corroborated by his severe weight loss. It s also likely he had inadequate intake of micronutrients, especially calcium PTA because he says he does not consume dairy products regularly and his blood Ca lab value was low. The pt does not take a multivitamin at home. It may prudent for him to initiate a daily multivitamin. He was not taking a multivitamin in the past due to being on methotrexate, which can interact with folate. However, methotrexate is currently not being used with his treatment regimen because he cleared it too slowly from his system which prevented the continuation of his chemotherapy treatment. b. Adequacy of fluid: Probably adequate. The patient reports drinking water, Gatorade, and iced tea regularly at home. He did not report any feelings of thirst. c. Appropriateness of supplements: Pt could have benefitted from a nutrition supplement at home, but was not consuming any supplements because he disliked the taste. He was taking 5000IU of Vitamin D3 at home. The RD recommended taking 2000IU of Vitamin D3 due to low lab values of 25-hydroxy-vitamin D, but the pt s mother opted for a higher dosage. The RD recommended decreasing the dosage to 800IU as recent Vitamin D3 labs were within normal limits. d. Contribution of supplements to overall intake: n/a e. Justify your assessment: The patient offered a detailed diet history and 24-hour recall, and the pt s mother was there to verify everything, so I am confident that this assessment is accurate. My assessments of his macro and micronutrient status are justified because of his 17% weight loss in the past 6 months, and his low lab value of Ca. 6. Diet order: High calorie/high protein diet with chocolate Ensure plus TID. a. Adequacy of macro and micronutrients: Inadequate because of poor PO intake. The patient reported decreased appetite related to apathy and chemo treatment. We observed an intake of 0% of his breakfast. At that time he had finished one Ensure plus. b. Adequacy of fluid: Adequate. The pt was taking a normal amount of fluid PO, but was also getting abundant amounts of fluid IV. His fluid balance fluctuated between positive and negative. c. Appropriateness of supplements: He is taking 800IUs of Vitamin D3, which is appropriate to maintain adequate levels of D3 and also because he doesn t regularly consume dairy products. He is also supposed to take Ensure plus TID to supplement his diet due to poor intake, and also to provide extra calories and protein to prevent more weight loss and loss of lean body mass. However, he does not like the supplements, he tolerates them, and so he may not be able to finish three per day. Ideally, in order to meet about 45% of his needs he would have to consume four Ensure plus supplements per day.

8 d. Contribution of supplements to overall intake: Depending on how many he is finishing per day, the Ensure plus is contributing less than 50% of his total daily estimated kcal needs. i. Ensure plus = 350kcals; 350kcals * TID = 1050kcals 1. 13kcals/kg = ~30% of estimated kcal needs ii. Ensure plus = 13g protein; 13g * TID = 39g protein g/kg = ~21% of estimated protein needs e. Appropriateness of administration: Encouraging PO intake of his regular diet and Ensure plus supplements is appropriate administration at this point. If he has continued weight loss a feeding tube may be justified in order to run nightly feeds to help him meet estimated kcal and PRO needs. f. Justify your assessment: The RD discussed with him the progression of nutrition intervention: supplements, then appetite stimulant, then feeding tube. At this point he is still in the first stage of progression and he will need to show better PO intake of meals and supplements in order to prevent progressing to the next stage of nutrition intervention. 7. Accuracy of data available: The data collected is based on subjective information collected by the medical team and objective data collected by the RD and myself from our observations and from information provided by the patient. The subjective data is mostly accurate, but some parameters, including weight and lab values, could be altered by fluid status. Objective data is also mostly accurate, but could be affected by patient misreporting of information. Plan/Goals: 1. Oral nutrition: Continue on a regular diet with chocolate Ensure plus TID. Encourage and monitor PO intake to assess nutritional adequacy. Pt and family were provided with diet education on strategies to increase kcals and protein in his diet and the use of nutrition supplements. 2. Enteral nutrition: May be indicated in the future if the pt s PO intake of meals and supplements continues to be poor and after initiation of an appetite stimulant. If the pt is still losing weight after initiation of these interventions, a feeding tube with an overnight feed is indicated to prevent further weight loss. 3. Parenteral nutrition: Not indicated as the pt has a functioning GI tract that is working properly. 4. Labs/Studies: Monitor glucose and maintain glycemic control. Monitor Vitamin D3 and Ca lab values and prescribe/adjust supplementation as necessary. 5. Growth: Obtain weight daily. Goal is to prevent any additional weight loss during admission. 6. Additional information needed: None. 7. Follow up: Determine weight status and current PO intake of meals and supplements. Goal is for pt to maintain current weight and have a PO intake of >85% of all meals and supplements.

9 8. Justify your plan/goals: I am giving the pt the chance to improve their PO intake before initiating an appetite stimulant, which is something he and his family were not excited about taking. The RD and I educated the pt and his family on ways to increase kcals and protein in his diet and gave them tools to improve his weight and nutrition status on their own. We will wait to see during his next visit if these have improved, and if not the next stage of nutrition intervention can be initiated by starting an appetite stimulant or recommending a feeding tube. References Abbott Nutrition. Adult Nutrition Care Manual. Children s National Medical Center standards of care and CNMC Registered Dietitian guidance Fearon, K., Voss, A., & Hustead, D. (2006). Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. American Journal of Clinical Nutrition. Fearon, K. (1992). The mechanisms and treatment of weight loss in cancer. Proceedings of the Nutrition Society.