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ONE HOSPITALS
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INDEX

S.NO CONTENT

1. HOSPITAL INTRODUCTION

 ABOUT THE HOSPITAL

 AIMS AND OBJECTIVES OF INTERNSHIP

 FLOOR PLANNING

 DIETARY DEPARTMENT OF HOSPITAL

 RSPONISIBILITIES OF DIETICIAN

 ROLE OF DIETICIAN

 ROLE OF DIETICIAN IN KITCHEN

 OUT PATIENT DIET COUNSELLING

 THERAPEUTIC DIET IN THE HOSPITAL

 FOOD TASTING

 ENTERAL AND PARENTAL NUTRITION

 MODIFICATION OF NORMAL DIET

2. CASE STUDIES

 OSTEOARTHRITIS– (TKR)

 LEFT HIP HEMIARTHROPLASTY

 IC BLEED (INTRACEREBRAL HEMORRHAGE)

 UMBILICAL HERNIA

3.  BIBLIOGRAPHY

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HOSPITAL INTRODUCTION

ABOUT HOSPITAL

One Hospital, located in the heart of Karimnagar, is a state-of-the-art multi-speciality hospital

dedicated to providing comprehensive and compassionate healthcare services to the
community. Founded by Chairman Mahesh Reddy in 2010, our hospital is committed to
delivering exceptional patient care and outcomes through cutting-edge technology, innovative
treatments, and a team of highly skilled medical professionals.
With a wide range of specialities and services, One Hospital is equipped to handle complex
medical cases and provide personalized attention to each patient. Our mission is to improve the
health and well-being of our patients and their families, and to be the trusted healthcare partner
in the region.
*Specialities:*

- Cardiology
- Neurology

- Oncology

- Orthopaedics’

- Gastroenterology

- Nephrology

- Urology

- General Surgery
- Pediatrics

- Obstetrics and Genecology

*Facilities:*

- 24/7 Emergency Services

- Advanced Diagnostic Labs

- Modular Operation Theatres

- Comfortable Patient Rooms

- Pharmacy
*Vision:*
To be the leading healthcare provider in the region, known for our excellence in patient care,
innovation, and compassion.

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AIMS & OBJECTIVES OF INTERNSHIP

Hospital dietary internship is to gain knowledge and practical experience, the treatment of
various diseases with diet.

OBJECTIVES:

• To Study the various diets associated with the diseases.

• To know the administration pattern and the functioning of dietary department.
• To understand the role and duties of dietician and other staff members in the dietary
department.

• To acquire the dietary skills in the diet counselling.

• To get expertise in various practices of kitchen layout in the hospital.
• To study the cases with the menu plans for various diseases to acquire clarity.
DIETARY DEPARTMENT OF HOSPITAL:

The dietary department is the central point of the diet service in the hospital. It is located in
the outpatient department on the ground floor.

The dietician has to assess the patients and fill in a Nutritional Assessment Form which
depicts the nutritional status of the patient.

This assessment form includes the following criteria

1. Nutritional status based on BMI.

2. Likes and dislikes.

3. Appetite/Food intake/Food tolerance

4. Weight loss/Gain

5. Type of diet
A few signs and symptoms are also kept in mind while assessing the patients which help in
better understanding of the patient's condition.
§ Nausea

§ Vomiting

§ Constipation

§ Diarrhea

§ Edema,Ascites
§ Based on the diagnosis, medical history and present illness the diet of the
patient is decided by the dietician, who then informs to the F&B department.

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ROLE OF A DIETICIAN

Dieticians are the health professionals, ideally trained to implement and change dietary habits
of an individual or population. One who plans and supervises the preparation of therapeutic or
other diets for individuals or groups in hospitals, institutions, other establishments and for
workers in particular sectors, gives instructions in selection and proper preparation of food
according to dietary principles, performs duties related to nutrition programs and may be
responsible for food purchasing on behalf of an organization or establishment.

RESPONSIBILITIES OF A DIETICIAN :

Ø Collecting, organizing and assessing data relating to the health and nutritional status of
individual groups and populations.

Ø Interpreting scientific information and communicating information, advice, education and

professional opinion to individuals, groups and communities.
Ø Managing client centered nutrition care for individuals by planning appropriate diets and
menus and educating people on their individual nutritional needs and ways of assessing

and preparing their food.

Ø Planning implementing and evaluating nutrition program with groups. Communities or

population as a part of team. This may be in a community health, public health or food

industries setting.

Ø Managing food service systems to provide safe and nutritious food by designing
nutritionally appropriate menus and designing and implementing nutritional policies. •
Undertaking food and nutrition research and evaluating practice.

PATIENT COUNSELLING:

Patient counseling is a broad team which describes the process through which health care

professionals attempt to increase patient knowledge of health issues. The process providers for
the exchange of information between the patient and health practitioner. The information
gathered is needed to assess the patient’s medical condition to further design, select, implement,
evaluate, and modify health interventions.

The structure of patient counseling is divided into four groups.

➢ Ø Introduction
➢ Ø Counseling contents
➢ Ø Counseling process
➢ Ø Conclusion

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INTRODUCTION:

• Review the patient record

• Conduct an appropriate patient counseling introduction by self and patient
• Obtain the initial information of patient medical condition
• Assess actual problem of the patient
COUNSELLING CONTENT:

• Explain the diet and its dietary guidelines

• Suggest the patient which foods have to intake or which foods that must avoid
• As per diseased condition diet should suggest to the patient
• The dietician should know diet plays a major role in the prognosis of disease and that
should be strictly follow the guidelines of diet therapy
• Encourage the patient to follow up the programme in order to remain in sound health
COUNSELLING PROCESS:

• Provide accurate information

• Use language that the patient likely to understand
• Use the appropriate counseling aids to support counseling
• Present the fact and order in logical order
• Maintain control and direction of the counseling session
• Probes for additional information
• Use open-ended questions
• Display effective non-verbal behaviors
CONCLUSION

• Verify that patient is understanding via feedback

• Summaries by acknowledging or emphasizing the key points of information
• Provide an opportunity for final concerns or questions and help them to follow.

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DIET PRESCRIPTION:

The formulation is the most important nutritional therapy for each patient.
Requirement is
considered with that of initial metabolic, biochemical and anthropometric data
obtained by
nutritional assessment of the patient.

➢ The dietary prescription is made on the basics of the patient’s age, activity
pattern, BMI, and type of treatments he /she is undergoing
.
➢ Estimation of body weight and its comparison with desirable body weight.

➢ Calculation of daily calorie and other nutrient intake

➢ Giving a written diet chart along with their calorie for a day, their ideal
body weight, timings of the meals and snacks and guidelines to be followed. A
diet sheet was given to every patient counselled which has the requirement of
calories and the necessary modifications in the diet.

➢ Important focus stressed on their physical activity like walking, exercises,

cycling, outdoors games etc.… as per patient’s choice

➢ Advice is given in terms of cooked foods and volumetric measurements in

order to achieve better competence

➢ To introduce variety and flexibility in diet prescription, provision of

exchange list proves to be good.

The patient is made to know about the approximate quantities and calorie given by the
common foods usually taken. Distribution of calories is done in the diet chart
throughout the day per every meal. The foods to be restricted and allows liberally are
also included in the sheet.

ROLE OF DIETICIAN IN KITCHEN:

· Scrutinize compile daily diet indents.

· Supervision of food preparation and ensuring proper food distribution.

· Check food wastage at different levels.

· Establishes and maintains standard of food production and services and sanitation.

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KITCHEN

The kitchen is divided into various sections starting with:

· Planning and distributing area

· Breakfast preparation area

· Patient foods preparation area

· Grinding area

· Cutting and storing area

· Room service cabin (for patients)

· Washing area

· Cold storage area

· Storeroom for daily vegetables

FOOD TASTING:

TASTING is a special feature present at the Apollo hospital which enables a check on
the food prepared in the kitchen, served to the patient. The food should be cooked well
to its exact texture/consistency. It should be cooked properly, appealing, appetizing, and
colorful so that it is accepted gracefully by the patient.

Tasting is done twice a day for lunch and for dinner. This duty of tasting is assigned to dietician.
A Special book is maintained in which tasting register is entered in the food is categorized as
very good, good and satisfactory, not satisfactory. Column for extra comment is also provided.
The date along with time is mentioned to ensure regular checking of food. The supervisor is
posted along with dietician; the remarks are noted and advised to rectify it. If any possible
changes can be made, it is done. Also, it is checked that these mistakes are not repeated to
create any inconvenience to the patient.

DEPARTMENT OF FOOD & BEVERAGE

The hospitals mainly cater food to the patient. It also caters food services to
doctors and staff.
The kitchen provides a variety of diets that is normal diet, soft diet, liquid diet,
sodium restricted diet, low potassium diet, high protein diet and low-calorie diet.
Production includes large stoves, evaporation hooks and gas pipelines.
• Equipment used in trolleys, standardized cups for serving 15

• Kitchen staff includes head cook, assistant cook, helpers. They have separate

dress code with head scarf. They wear polythene gloves while proportioning
food

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• Preparation area located decides the staff dining room. The cooking area well
equipped with cutting and peeling machine. A dough maker, tawa, dal maker, rice
steamer and wet grinder

• Dish wash area is provided for washing big utensils. Free flow of hot water is provided

• Storeroom is located in the basement. There is facility for both dry and cold
storage. The dry store contains all the non-perishable and semi=perishable items. There
is a cold storage room where perishable fruits and vegetables are stored.

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KITCHEN LAYOUT

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GENERAL HOSPITAL DIETS:

The Diets given to the patient have been generalized under the following
headings:
1. Normal diet
2. Diabetic diet
3. Therapeutic diet
4. Clear fluid diet
5. Full fluid diet
6. Semi solid diet
7. Soft diet
8. Renal diet
9. Low salt diet
10. High fiber diet
11. Bland diet

1.NORMAL DIET

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2. DIABETIC DIET:

Dietary measures are an essential part of the treatment of a diabetic patient

who requires a treatment & a sulphonyl urea drugs & insulin. The diet for a diabetic
patient is prescribed in terms of exchange list. It is a high protein, low fats &a high
complex carbohydrate diet.

3. THERAPEUTIC DIET:

Diet therapy relates to modification of normal diet to meet the needs of the sick
individuals. The normal diet may be modified to provide change in consistency as in
fluid & soft diets to increase or decrease the energy value, to include greater of lesser
amount of one or more nutrients, for example, high protein, low sodium etc., to increase
or decrease bulk high &low fiber diets, to provide foods bland in flavor.
The planning of therapeutic diet implies the ability to adopt the principles of
normal nutrition to the various regimens for adequacy, correctness, economy &
palatability. It requires recognition of the need for dietary supplements such as vitamins
&mineral concentrates when the nature of the diet itself imposes severe restrictions, the
patient’s appetite is poor, or absorption & utilization are impaired so that the diet cannot
meet the need of optimum nutrition.
4. DIABETIC DIET:

Dietary measures are an essential part of the treatment of a diabetic patient who requires
a treatment & a sulphonyl urea drugs & insulin. The diet for a diabetic patient is
prescribed in terms of exchange list. It is a high protein, low fats &a high complex
carbohydrate diet.

5. THERAPEUTIC DIET:

Diet therapy relates to modification of normal diet to meet the needs of the sick
individuals. The normal diet may be modified to provide change in consistency as in
fluid & soft diets to increase or decrease the energy value, to include greater of lesser
amount of one or more nutrients, for example, high protein, low sodium etc., to increase
or decrease bulk high &low fiber diets, to provide foods bland in flavor.

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The planning of therapeutic diet implies the ability to adopt the principles of normal
nutrition to the various regimens for adequacy, correctness, economy & palatability. It requires
recognition of the need for dietary supplements such as vitamins &mineral concentrates when
the nature of the diet itself imposes severe restrictions, the patient’s appetite is poor, or
absorption & utilization are impaired so that the diet cannot meet the need of optimum
nutrition.

Therapeutic diet begins with normal diet which is modified.

TYPES OF THERAPEUTIC DIETS:

A. CLEAR LIQUID DIET:

Clear liquid diet is usually used for 1-2 days after surgery
&only clear fluid are given. This diet gives kcals with electrolytes & no
proteins. It does
not leave any residue.
B. LIQUID DIET:
It is included wherever a patient is unable to chew, swallow solid foods. In
conditions like
After surgery myocardial infraction(first 24 hours),burns and gastroenteritis. It
includes all the foods that are liquid at room temperature.

Therapeutic diet begins with normal diet which is modified.

CLEAR LIQUID DIET LIQUID DIET

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C.SOFT DIET:

This diet is one of the most frequently used routine diets. Many hospital patients are placed on
this until a diagnosis is done. It may be used in acute infection, following patients who are
unable to chew. It is made up of simple easily digested food & contains no harsh fiber& no rich
highly seasoned foods. Patients with dental problems are given mechanically soft diet. It is
often further modified for certain pathogenic conditions as bland diet or low residue diet which
includes refined cereals & simple like bread, egg, chicken, potato, strained fruit juices.

D.LOWFAT/LOW CHOLESTEROL DIET:

This diet is generally prescribed for obese, fatty liver, gallstones& heart patients. A low calorie,
low fat particularly low saturated fat, low cholesterol. High PUFA, carbohydrate &normal
protein, minerals &vitamins are suggested. High fiber diet is also recommended.

E.LOWFAT/LOW CHOLESTEROL DIET:

This diet is generally prescribed for obese, fatty liver, gallstones& heart patients. A low calorie,
low fat particularly low saturated fat, low cholesterol. High PUFA, carbohydrate &normal
protein, minerals &vitamins are suggested. High fiber diet is also recommended.

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FOODS HAVING CHOLESTEROL LOWERING EFFECTS:

➢ Pectin (apple, guava) lowers the level of serum cholesterol.

➢ Guar gum (extracted from the leaves of cluster beans) has hypo

cholesterol emic effect.

➢ Legumes, vegetables & fruits lower the serum cholesterol.

➢ Turmeric, Bengal gram, onion, fenugreek seeds, soya beans&

Garlic have cholesterol lowering effects.Addition of rice bran oil enhances

the excretion of bile acids &neutral sterol in the faeces.

SODIUM&POTASSIUM RESTRICTED DIET:

This diet is generally prescribed for hypertensive &renal patients. Adequate protein (high

biological value) should be given unless there is oliguria develops. A high carbohydrate,
sodium &potassium restricted diet is given. The fluid intake will be adjusted to output
including losses in vomiting & diarrhoea.

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ENTERAL NUTRITION:

Enteral feeding refers to the delivery of a nutritionally complete feed, containing protein,
carbohydrate, fat, water, minerals, and vitamins, directly into the stomach, duodenum or
jejunum.

Gastro enteric tube feeding plays a major role in the management of patients with poor
voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction and in
patients who are critically ill.

Supplemental parenteral nutrition is used in step –up approach when full enteral support is
contra–indicated or fails to reach the required intake targets

PATIENT SELECTION:

The use of home enteral feeding is increasing worldwide. Multi- disciplinary primary care
teams focused on home enteral nutrition can provide cost –effective care.
Enteral feeding should be considered for malnourished patients or

In those at risk of malnutrition who have a functional gastrointestinal tract but are unable to
maintain an adequate or safe oral intake.

Enteral nutrition is often used for children as well as for adults. Children may require enteral
feeding for a wide range of underlying condition, such as for malnutrition, for increased
energy requirement (e.g., cystic fibrosis), for metabolic disorders and also for children with
neuromuscular disorders.

Although it is often a life –saving man oeuvre, the patient’s quality of life may be adversely
affected.

ENTERAL FEEDING IS BENEFICIAL FOR:

• Critically ill patients, in whom enteral feeding promotes gut barrier integrity and
reduced rates of infection and mortality.
• Postoperative patient with limited oral intake. The complication rate and duration of
hospital stay are reduced by early enteral feeding after:

Elective gastrointestinal surgery / gastrointestinal cancer surgery

Early post-pyloric feeding (duodenal or jejunal) is useful as, although gastric and colonic
function is impaired postoperatively, small bowel function is often normal. Feeding is usually
introduced after 1 to 5 days.
Patients with severe pancreatitis without pseudo cyst or fistula complication. Enteral feeding
promotes the resolution of inflammation and reduces the incidence of infection.

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Low –flow enteral feeding may also be useful in combination with parenteral nutrition to
maintain gut function and reduce the likelihood of cholestasis.

ACCESS:

Short-term access is usually achieved using nasogastric (NG) or Naso jejunal (NJ) tubes at an
initial continuous feeding rate of 3mls per hour. Percutaneous endoscopic gastronomy (PEG)
or jejunostomy placement should be considered if feeding is planned for longer than one month.

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NG TUBES:

• These are the most used delivery routes but depend on adequate gastric emptying.
• They allow the use of hypertonic feeds, high feeding rates and bolus feeding into the stomach
reservoir.
• Tubes are simple to insert but easily displaced.

NJ TUBES: [NASTRO-JEJUNUM]

• These reduce the incidence of gastro-oesophageal reflux and are useful in the presence of delayed
gastric emptying.
• Post –pyloric placement can be difficult but may be aided by intravenous
PEG TUBES: [percutaneous endoscopic gastrostomy]

• Indications for gastrostomy include stroke, motor neuron disease, Parkinson’s disease and esophageal
cancer
• Relative contraindications include reflux, previous gastric surgery, gastric ulceration or malignancy
and gastric outlet obstruction.
• They are inserted directly through the stomach wall endoscopically or surgically, under antibiotic
cover.

PEJ TUBES: [percutaneous endoscopic jejnostomy]

They permit early postoperative feeding and are useful in patients at risks of reflux. They are inserted through
the stomach into jejunum the, using a surgical or endoscopic technique.

This can be difficult and has more complications.

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FEED PREPARATIONS:

Various nutritionally complete pre-packaged feeds are available:

• Standard enteral feeds:

These contain all the carbohydrate, protein, fat, water, electrolytes, micronutrients (vitamins and trace elements)
and fiber required by a stable patient.

• Pre-digested feeds:
These contain nitrogen as short peptides or free amino acids and aim to improve nutrient absorption in the
presence of pancreatic insufficiency or inflammatory bowel disease.

The fiber content of feeds is variable, and some are supplemented with vitamin K, which may interact with other
medications.

Nutrients such as glutamine, arginine and essential omega-3 fatty acids can modulate immune function. Enteral
immune nutrition may decrease major infectious complications and length of hospital stay in surgical some
critically ill patients. Further research is ongoing.
COMPLICATIONS OF ENTERAL FEEDING:

General Complications of feeding:

Tube complications:

• NG tube:
This may cause nasopharyngeal discomfort and later nasal erosions, abscesses and sinusitis.

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Fine –bore tubes should be used and replaced in the alternate nostril each month. Large stiff tubes are particularly
unsafe in the presence of varices and insertion of any tube should be avoided for three days following acute
varicella bleed.

• Percutaneous gastrostomy or jejunostomy tubes:

These can lead to complications related to endoscopy plus bowel perforation and abdominal wall or
intraperitoneal bleeding.

Post –insertion complications include stoma site infections, peritonitis, septicemia, peristomal leaks,
dislodgement and gastro colic fistula formation.

All feeding tubes should be flushed with water before and after use, as they block easily. Blockage can
sometimes be removed by flushing with warm water or an enzymes solution, but some tubes may need to be
replaced.

INFECTION:

Bacterial contamination of enteral feed can cause serious infection. Administration sets and feed containers
should be discarded every 24 hours to minimize the risk of infection. Feeds should never be decanted, and
equipment should not be handled.

GASTRO- ESOPHEGEAL REFLUX AND ASPIRATION:

Reflux occurs frequently with enteral feeding, particularly in patients with impaired consciousness, poor gag
reflex and when fed in the supine position. Patients should be propped up by at least 30ₒ whilst feeding and
should remain in that position further 30 minutes to minimize the risk of aspiration. Post –pyloric tubes should
be used in unconscious patients who need to be nursed flat.

Reflux is more likely with accumulation of gastric residues. Gastric aspirates should be measured regularly,
and the feeding regimen altered or prokinetics added to reduce gastric pooling.

GASTROINTESTINAL SYMPTOMS:

• Gut motility and absorption are promoted by hormones released during mastication, with coordinated
stomach emptying and the in presence of intraluminal nutrients.
• As the usual physiological mechanisms are bypassed during enteral feeding, gastrointestinal symptoms
such as abdominal bloating, cramps, nausea, diarrhea and constipation are common.
• Symptoms may respond to reduced feed administration rates, continuous rather than bolus feeding,
alternative feed preparation or the addition of prokinetic agent.

PARENTERAL NUTRITION

Parental nutrition, or intravenous feeding, is a method of getting nutrition into your body through your veins.
Depending on which vein is used, this procedure is often referred to as either total parenteral nutrition (TPN)
or peripheral parenteral nutrition (PPN nutrition delivers nutrients such as sugar, carbohydrates, proteins,
lipids, electrolytes, and trace element to These Nutrients are vital in maintaining high energy, hydration and
strength levels. Some people only need to get certain types of nutrition intravenously.

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The most common side effects of parenteral nutrition are mouth sores, poor night vision, and skin changes.
You should speak with your doctor if these conditions don’t this form of nutrition is used to help people who
can’t or shouldn’t get their core nutrients from food. It’s often used for people with:

• Chronis disease
• Cancer
• Short bowel syndrome
• Ischemic bowel disease
It also can help people with conditions that results from low blood flow to their bowels.

SIDE EFFECTS:

• Other less common side effects include:

• Changes in heartbeat
• Confusion
• Convulsions or seizures
• Difficulty breathing
• Fast weight gains or weight loss
• Fatigue
• Fever or chills
• Increased urination
• Jumpy reflexes
• Memory loss
• Muscle twitching, weakness, or cramps
• Stomach pain and vomiting
• Swelling of your hands, feet, or legs
• Thirst
• Tingling in your hands or feet.

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ADMINISTRATION OF PARENTERAL
NUTRITION:
Parenteral nutrition is administered from a bag containing the nutrients you need through tubing attached to a
needle or catheter.

With TPN, your healthcare provider places the catheter in a large vein, called the superior vena cava that goes
to your heart. Your healthcare provider may also place a port, such as a needleless access port, which makes
intravenous feeding easier.
For temporary nutritional needs, your doctor may suggest PPN. This type of intravenous feeding uses a
regular peripheral intravenous line instead of a central line threaded into your superior vena cava.
You’ll most likely complete intravenous feedings yourself at home. It usually takes 10 to 12 hours, and you’ll
repeat this procedure five to seven times a week. Your healthcare provider will provide detailed instructions
for this procedure. In general, you first need to check your nutrient bags for floating particles and
discoloration.

RISKS OF PARENTERAL NUTRITION:

The most common risk of using parenteral nutrition is developing catheter infection. Other risks include:

• Blood clots.
• Liver disease.
• Bone disease.
It’s essential to maintain clean tubing, needleless access ports, catheters, and other equipment to minimize these
risks.

COMPLICATIONS:

About 5 to 10% of patients have complications related to central venous access.

Catheter-related sepsis occurs in probably ≥ 50% of patients.

Glucose abnormalities or liver dysfunction occurs in >90% of patients.

Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose often,
adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed. Hypoglycemia can
be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on the
degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more prolonged
hypoglycemia may require infusion of 5 or 10% dextrose for 24h before resuming TPN via the central venous
catheter.
Hepatic complications

Include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can develop at any age but are
most common among infants, particularly premature ones (whose liver is immature).

Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline phosphatize;
it commonly occurs when TPN is started. Delayed or persistent elevations may result from excess amino acids.
Pathogenesis is unknown, but cholestasis and inflammation may contribute. Progressive fibrosis occasionally
develops. Reducing protein delivery may help.

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Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized seizures. Arginine
supplementation at 0.5 to 1.0 mol/kg/day can correct it. If infants develop any hepatic complication, limiting
amino acids to 1.0 g/kg/day may be necessary.

Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusions
or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Vitamin and mineral
deficiencies are rare when solutions are given correctly. Elevated BUN may reflect dehydration, which can be
corrected by giving free water as 5% dextrose via a peripheral vein.
Volume overload (suggested by > 1kg/day weight gain) may occur when patients have high daily energy
requirements and thus require large fluid volumes.
Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients
given TPN for>3mo.The mechanism is unknown. Advanced disease can cause severe periarticular, lower-
extremity, and back pain.

Adverse reactions to lipid emulsions (e.g., dyspnea, cutaneous allergic reactions, nausea, headache, back
pain, sweating, and dizziness) are uncommon but may occur early, particularly if lipids are given at>1.0
kcal/kg/h. Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure; treatment
usually is not required. Delayed adverse reaction to lipid emulsions include hepatomegaly, mild elevation of
liver enzymes, splenomegaly, thrombocytopenia, and leukopenia and especially in premature infants with
respiratory distress syndrome, pulmonary function abnormalities.

Gall bladder complications include cholelithiasis, gall bladder sludge, and cholecystitis. These complications
can be caused or worsened by prolonged gall bladder stasis. Stimulating contraction by providing about 20 to
30% of calories as fat and stopping glucose infusion several hours a day is helpful. Oral or enteral intake also
helps. Treatment with metronidazole, ursodeoxycholic acid, Phenobarbital, or cholecystokinin helps some
patients with cholestasis.

RYLES TUBE FEEDING:

❖ For nasogastric introduction of nutrition and aspiration of intestinal secretion.
❖ Close distal and coned with radio opaque material for accurate placement.
❖ Four lateral eyes.
❖ Tube with radio- opaque line, marked at 50- 70 cms from the tip for accurate placement.
❖ Soft, frosted and kink resistance PVC tubing.
❖ Color coded funnel end connector for easy identification of size.
❖ Length: 105cms. ▪ Sizes: 6

RE- FEEDING SYNDROME:

• This occurs in previously malnourished patients who are fed with high carbohydrate load
• Carbohydrates (e.g., glucose) in the feed can cause a large increase in the circulating insulin
level. This results in a rapid and dramatic fall in phosphate potassium and magnesium –with an
increasing extracellular fluid (ECF) volume.
• As the body tries to switch from catabolic (starvation mode) to using exogenous fuel sources,
there is an increase in oxygen consumption, increased respiratory and cardiac workload (may
precipitate acute heart failure and tachypnoea and make weaning from a ventilator difficult).
Demand for nutrients and oxygen may outstrip supply.

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Both above can lead to multiple organ failure, respiratory and/ or cardiac failure, arrhythmias,
rhabdomyolysis, seizures or coma, red cell and /or leukocyte dysfunction.
The gut may have undergone some atrophy with starvation, and, with the return of enteral feeding,
there may be intolerance to the feed, with nausea and diarrhea. Feeds should be start slowly and the
electrolytes closely monitored and adequately replaced to avoid these problems developing.

MODIFICATION OF NORMAL DIET:

The nutritional needs of a normal person in his life span are modified according to the demands of
growth and developmental different stages of life.
Diet Therapy can protect the individual from further attack of the disease and restore normal health.
NEED FOR DIET MODIFICATION:
1. When food consumption is interfered.
2. When absorption is interfered.
3. When storage is interfered.
4. When functioning of the tissues impaired or when tissues destroyed.
5. When there is increased excretion of nutrients
6. Increasing nutrient requirement.

NORMAL DIET CAN BE FOLLOWED IN A FOLLOWING WAY:

1. The nutrient content of the diet.

2. Increase/Decrease energy value of the diet.
3. Increase/Decrease bulk of the diet.
4. Including/Excluding specific foods.
5. Consistency.
6. Method of Feeding.

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 CASE STUDY-1

OSTEOARTHRITIS– (TKR)
INTRODUCTION: Arthritis refers to biomechanical changes within a joint. Osteoarthritis is
the most common kind of arthritis, also known as degenerativejoint disease (DJD).
Osteoarthritis is more likely to develop as people age. The changes in Osteoarthritis usually
occur slowly over many years. Inflammation and injury to the joint cause bone changes,
deterioration of tendons and ligaments and a breakdown of cartilage, resulting in pain,
swelling and deformity of the joint. It occurs when the protective cartilage that cushions the
ends of the bones wears down over time.

Ø There are two main types of Osteoarthritis:

a) PRIMARY: most common, generalized, primarily affects the fingers, thumb, spine,
hips, knee and the great toe.
b) SECONDARY: occurs with a pre-existing joint abnormality, including injury or
trauma, inflammatory arthritis, infectious arthritis, genetic joint disorder.

PATHOPHYSIOLOGY:

OA causes inflammation, changes in bone shape, and cartilage deterioration. It is primarily a

disease affecting the cartilage.

OA occurs due to a combination of factors, including:

• physical stress on the body, such as general wear and tear

• physical changes that affect joint function, which may be present from birth or may
develop due to excess weight placing pressure on the joint or an injury
• other risk factors, such as aging or genetics

25
People with the condition have higher levels of pro-inflammatory markers, which indicate
inflammation, and proteases, which are enzymes that break down protein. These eventually
cause joint deterioration.In most cases, the first changes that occur in the body due to OA
affect the articular cartilage. This is the cartilage covering the ends of the bones where they
meet at the joint.

The articular cartilage may erode or become irregular, split, or frayed. If there are erosions in
the cartilage, these may gradually expand down to bone level and affect more of the joint
surface.

Cartilage consists of water and the matrix, which is a gel-like substance containing different
types of protein:

• collagen
• proteoglycans
• non-collagenous proteins
Ø Articular cartilage contains a group of cells called chondrocytes, which produce and
maintain the matrix.
Ø Injury or damage to the cartilage can cause damage to the matrix, resulting in
chondrocytes multiplying and forming clusters. This causes bony lumps to form
called bone spurs.
Ø Damage to the matrix can also cause thickening of the bone underneath the cartilage
and may sometimes cause fluid-filled areas in the bone called bone cysts.
Ø Alongside these changes to the cartilage, there may be inflammation of the joint’s
synovium.Thesechanges can occur gradually, and people may slowly start to
experience symptoms of OA, such as pain, stiffness, and limited range of motion.

26
*SYMPTOMS: Osteoarthritis symptoms often develop slowly and worsen over time.
Signs and symptoms include:

• PAIN: affected joints might hurt during or after movement.

• STIFFNESS: Joint stiffness might be most noticeable upon awakening or before
inactive.
• TENDERNESS: Joint might feel tender when light pressure is applied.
• LOSS OF FLEXIBILITY: not be able to move joint through its full range of motion.
• GRATING SENSATION: might feel a grating sensation, and might hear crackling
sound.
• BONE SPURS: These are extra bits of bone which feel like hard lumps, forms around
the affected joints.
• SWELLING: Might be caused by soft tissue inflammation around the joint.

*CAUSES:Osteoarthritis has often been referred to as a wear and tear disease, but besides
the breakdown of cartilage, it affects the entire joint.

There are several factors that increase a person’s chances of developing osteoarthritis, these
include:

• Obesity: Knee and hip joints are particularly vulnerable in overweight individuals.
Excess weight puts stress on the knee, hip, ankle, and foot joints, as well as the lower
spine. Increased leptin levels, more common in overweight individuals, may also
accelerate joint damage.
• Age: The incidence and prevalence of OA increase with age.
• Gender: Hand and knee OA is more common in females.
• Occupation: Certain occupations, such as construction work, carpentry, and
hairdressing increase the risk for osteoarthritis of the hands, hips, and knees.

27
 • Genetics: Twin studies indicate that up to 40% of OA risk may be due to genetic
factors. The increased risk, however, does not seem to follow typical patterns of
Mendelian inheritance and is probably related to alterations in gene expression.
• Trauma: Posttraumatic OA is common after a significant joint injury, such as knee
meniscal or anterior cruciate ligament tear. Repetitive joint trauma presents a
cumulative risk.
• Congenital or acquired anatomical joint abnormality: Laxity of the knees or of
other joints (i.e., being “double-jointed”), poor proprioception, and quadriceps
weakness increase the risk of osteoarthritis of the knee. Osteoarthritis may also be
more common in the context of some dysplasias (i.e., abnormal growths of bone and
cartilage) and Paget’s disease.

*DIAGNOSIS: Medical history, a physical examination and lab test help to make up the
Osteoarthritis diagnosis.

• X-rays: Cartilage doesn't show up on X-ray images, but cartilage loss is revealed by a
narrowing of the space between the bones in the joint. An X-ray can also show bone
spurs around a joint.
• Magnetic resonance imaging (MRI): An MRI uses radio waves and a strong magnetic
field to produce detailed images of bone and soft tissues, including cartilage. An MRI
isn't commonly needed to diagnose osteoarthritis but can help provide more
information in complex cases.

*TREATMENT:There is no cure for Osteoarthritis but medication, assistive devices and

other therapies can help to ease pain. As a last resort, a damaged joint may be surgically
fused or replaced with combination of metal, plastic or ceramic.

Medical treatments and recommendations include:

Medications (topical pain medicines and oral analgesics including nonsteroidal anti-
inflammatory medications, NSAIDs).

• Exercise (land- and water-based).

• Intermittent hot and cold packs (local modalities).
• Physical, occupational, and exercise therapy.

28
 • Weight loss (if overweight).
• Healthy eating, managing diabetes and cholesterol.
• Supportive devices such as braces, orthotics, shoe inserts, cane, or walker.
• Intra-articular injection therapies (steroid, hyaluronic acid “gel”).
• Complementary and alternative medicine strategies, including vitamins and
supplements.

Surgery may be helpful to relieve pain and restore function when other medical treatments
are ineffective or have been exhausted, especially with advanced OA.

The goals of treatment are to:

ü Decrease joint pain and stiffness and delay further progression.

ü Improve mobility and function.
ü Increase patients' quality of life.

The type of treatment regimen prescribed depends on many factors, including the patient's
age, overall health, activities, occupation, and severity of the condition.

*NUTRITION INTERVENTION:The person affected with Osteoarthritis should take

care of their diet which requires to include certain food items in the diet which can help them
to cure and to exclude other food items that might cause harm and ill-effects to the diet.

Ø The osteoarthritis diet should include antioxidant food items like fruits and
vegetables, ginger in the form of ginger tea, turmeric is a solution to various health
problems and can be considered for this as well.

29
Ø Maintaining a healthy weight: For every 5 kg of weight gained over a body mass
index (BMI) of 25, the risk for developing OA of the knee increases by 36%.
Although OA is usually associated with aging, the link between being overweight and
developing knee OA starts early, at around 11 years of age in girls and 20 years of age
in men. Losing as little as 5 kg significantly decreases a woman’s chances of
developing symptomatic knee OA.
Ø Maintaining adequate vitamin D status: Low blood levels of vitamin D are associated
with OA and cartilage loss (evidenced as joint space narrowing and changes in
cartilage volume), though there has been no reported benefit for vitamin D
supplementation and progression of knee OA.
Ø Ginger may provide significant pain relief for osteoarthritis patients by acting as an
inhibitor of inflammation in synovicytes.
Ø Replacing animal products with a plant-based diet. Animal products typically contain
significant amounts of saturated fat and advancedglycation end
product(AGEs).Individuals consuming the most saturated fat had a 60% greater risk
for OA progression when compared with those eating the lowest amount. AGEs
increase stiffness and brittleness in articular cartilage, making it more prone to
mechanical damage.

Ø Cereals & cereal products: Ragi, bajra, whole wheat flour. Pulses & Legumes: Lentils,
peas, kidney beans, chickpeas, toor dal, soy beans.
Ø Fruits & Vegetables: Custard apples, chiku, apple, white jamun, grapes, lemons,
oranges, raw mangoes, carrots, beetroots, bottle gourd, bitter gourds, spinach, Indian

30
 spinach, colocasia, drumsticks, yam, taro, tapioca, coriander leaves, celery, spring
onions, garlic, ginger.
Ø Milk & milk products: Milk liquid, curd, cottage cheese, ghee, lassi, custard.
Ø Meat, Fish & Poultry: Sweet and salt water fishes (especially beneficial if taken with
bones), eggs, Chicken (lean and/or fowl).
Ø Nuts & Oils: Almonds, raisins, pista, walnuts, vegetable oil, mustard oil.
Ø Fortified breakfast cereals, juices, milk products and yoghurt.

TOTAL KNEE REPLACEMENT: (TKR)

Knee joint replacement is a surgery to replace a knee joint with a man-made artificial
joint. The artificial joint is called a prosthesis.

Knee replacement surgery replaces parts of injured or worn-out knee joints. The
surgery can help ease pain and make the knee work better. During the surgery, damaged bone
and cartilage are replaced with parts made of metal and plastic.

The most common indication for a primary knee replacement, TKA, is osteoarthritis.
Osteoarthritis causes the cartilage of the joint to become damaged and no longer able to
absorb shock. Risk factors for knee osteoarthritis include gender, increased body mass index,
history of a knee injury and comorbidities.Pain is typically the main complaint of patients
with knee osteoarthritis. Pain is subjective, and involves peripheral and central neural
mechanisms that are modulated by neurochemical, environmental, psychological and genetic
factors.Total knee arthroplasty is more commonly performed on women and individuals of
older ages.

31
There are four basic steps to a knee replacement procedure:

Ø Prepare the bone. The damaged cartilage surfaces at the ends of the femur and tibia
are removed along with a small amount of underlying bone.
Ø Position the metal implants. The removed cartilage and bone is replaced with metal
components that recreate the surface of the joint. These metal parts may be cemented
or "press-fit" into the bone.
Ø Resurface the patella. The undersurface of the patella (kneecap) is cut and
resurfaced with a plastic button. Some surgeons do not resurface the patella,
depending upon the case.
Ø Insert a spacer. A medical-grade plastic spacer is inserted between the metal
components to create a smooth gliding surface.

Eating foods rich in the following nutrients are important for the recovery.After
surgery, the focus is on healing and recovery and diet plays an important role in this process.
Foods that help regain strength and aid the recovery process are obvious choices.

ü Protein:Protein helps repair and build healthy tissue.

ü Iron:Iron works in each of your body’s cells to help make energy.
ü Vitamin C: Vitamin C helps body repair damaged tissues, keeps the bones and teeth
strong, and helps body absorb iron.
ü Calcium: Calcium helps build and maintain bones, muscles move, blood clot
andnerves send messages.
ü Fiber: Fiber helps body produce regular bowel movements.

32
NUTRITIONAL SCREENING:
Date of Assessment: 03/12/2024

PATIENT PROFILE:

PATIENT NAME: XYZ

AGE: 58Years

GENDER: Female

COMMUNITY: Hindu

OCCUPATION: Housewife

ECONOMIC STATUS: Average

NUMBER OF FAMILY MEMBERS: 04

FOOD ALLERGIES: Nothing significant

FOOD PREFERENCE: Non-Vegetarian

PERSONAL HABIT: Nil

UHID: 4507485

DATE OF ADMISSION: 01/12/2024

DATE OF DISCHARGE: 07/12/2024

DIAGNOSIS: B/L Grade4 Osteoarthritis of Knee / TKR (Total Knee Replacement).

ANTHROPOMETRIC MEASUREMENTS:

HEIGHT:166 cm

WEIGHT:67kg

BMI:26.17

BMI CLASSIFICATION: Overweight

IBW:66kg

WAIST CIRCUMFERENCE:86cm

HIP CIRCUMFERENCE:98cm
BMR: Using Thumb rule: Estimated calories= 1600Kcal
Protein= 70g

33
PHYSICAL ACTIVITY: Sedentary

CLINICAL DATA:

PAST HISTORY: Hypertension (from 10years)

CHIEF COMPLAINTS: ℅ pain in the bilateral knee joint since2-3 months. Pain got
aggravated since1 month. ℅ difficulty in walking.

CURRENT SYMPTOMS: Pain in the knee, Vomiting and Difficult walking.

FAMILY HISTORY: Nil

PHYSICAL EXAMINATION:

a. Temperature:97℉
b. Pulse rate: 78/MIN
c. Blood Pressure: 130/80mmHg
d. SpO2: 96%
e. GRBS: 101mg/dL

HAEMATOLOGY: BLOOD GROUP:B

Rh: POSITIVE

BIOCHEMICAL PARAMETERS:

PARAMETERS UNIT 23/12/2022 NORMALVALUES

Hemoglobin g/dL 10.0 12.0-15.0

Hematocrit % 31.3 36-46

Creatinine mg/dL 0.60 0.50-0.90

Potassium, Serum mmol/L 4.4 3.6-5.0

Sodium, Serum mmol/L 137 137-145

34
MEDICATIONS:

MEDICATIONS DOSAGE MECHANISM OF ACTION

INJ.SUPACEF 1.5GM It works by inhibiting the cell wall synthesis of bacteria,

which ultimately results in the death of bacteria.
Supacef 1.5gm Powder for injection is used to treat
various types of bacterial infections such as infection of
the respiratory tract, soft tissue, urinary tract, ears, nose,
and throat.
INJ.EMESET 4MG Emeset Injection 2ml is an antiemetic medication. It
works by blocking the action of a chemical messenger
(serotonin) in the brain that may cause nausea and
vomiting during anti-cancer treatment (chemotherapy)
or after surgery

IVF NS 75/ML/HR Sodium Chloride is source of water and electrolytes. It

is capable of inducing diuresis depending on the clinical
condition of the patient. It is a crystalloid given
intravenously in case of shock, dehydration, and
diarrhoea to increase the plasma volume.

INJ.PAN 40MG This drug acts to decrease gastric acid secretion, which
reduces stomach acidity. Pantoprazole administration
leads to long-lasting inhibition of gastric acid secretion.

INJ.DYNAPAR 75MG Dynapar AQ Injection 1ml belongs to a group of

medicines called nonsteroidal anti-inflammatory drugs
(NSAIDs). It is used for short-term relief of pain,
inflammation, and swelling in conditions that affect
joints and muscles. It works by blocking chemical
messengers in the brain that tell us we have pain.
INJ.TRAMADOL 50MG (+)-Tramadol inhibits serotonin reuptake and (-)-
tramadol inhibits norepinephrine reuptake, enhancing
inhibitory effects on pain transmission in the spinal
cord. The complementary and synergistic actions of the
two enantiomers improve the analgesic efficacy and
tolerability profile of the racemate.
INJ.CLEXANE 40MG The Clexane®/antithrombin complex inhibits activated
clotting factors. Clexane® forms a complex with
antithrombin. This complex undergoes a conformational
change; in its altered conformation, the complex inhibits
FXa, which is the primary mechanism of action

35
 TAB.NERVIJEN -NP Nervijen Np Tablet works by binding a certain region of
the brain and reduces the pain signals sent out by the
damaged nerves of the body. It also prevents
megaloblastic or pernicious anaemia that lead to
weakness, fatigue, numbness of fingers, toes and
problems in thinking.
TAB.SPORLAC DS - Sporlac-DS Tablet 20's works by restoring good bacteria
in the intestines. Thereby, prevents diarrhoea and loss of
beneficial bacteria due to prolonged intake of antibiotics
or due to infections in the intestine.

24 HOUR DIETARY RECALL:

MENU:

EARLY MORNING: Milk

BREAKFAST: Vegetable Pulav

LUNCH: Rice and Dal Rasam

EVENING: Coffee

DINNER: Chapati + Chutney

DETAILED MENU PLAN:

TIMINGS MENU INGREDIENTS QUANTITY ENERGY PROTEIN CHO FATS

(Kcal) (g) (g) (g)
EARLY Milk Milk 100ml 72.89 3.26 4.94 4.48
MORNING
(7AM)
BREAKFAST Pulav Rice 40g 142.53 3.17 31.29 0.04
(10AM)
Carrot 20g 6.6 0.2 1.1 0.09
Beans 20g 6.2 0.4 1.4 0.04
Potato 20g 13.95 0.30 2.97 0.04
Tomato 20g 3.91 0.18 0.54 0.09
Chilly 10g 4.5 0.26 0.63 0.073
Onion 10g 4.8 0.15 0.95 0.02
LUNCH Rice Rice 40g 142.53 3.17 31.29 0.04
(2PM)

36
 Dal Toor Dal 30g 98.7 6.46 14.01 1.41
Tomato 20g 3.91 0.18 0.54 0.09
Coriander 10g 3.1 0.35 0.19 0.07
Tamarind 10g 23.9 0.28 6.25 0.06
Red Chilly 5g 17 - 4.0 -
EVENING Coffee Milk 50ml 36.44 1.63 2.47 2.24
(5PM)
Coffee Powder 5g 12.05 0.61 2.05 0.02
DINNER Chapati Wheat Flour 50g 160 5.2 32 0.76
(9PM)
Chutney Coriander 10g 3.1 0.35 0.19 0.071
Garlic 10g 12.38 0.69 12.93 0.016
Groundnut 30g 156 7.09 5.17 11.88
Chilly 5g 2.25 0.13 0.31 0.003
Sugar 10g 90 - - 10
Oil 15ml 135 - - 15
TOTAL 1151.74 34.06g 155.2g 46.53g
Kcal

NUTRITION CALCULATION OF DIETARY RECALL:

ENERGY: 1151.74Kcal

PROTEIN: 34.06g

CARBOHYDRATE: 155.2g

FAT: 46.53g

37
FOOD FREQUENCY TABLE:

FOOD GROUPS NEVER DAILY WEEKLY MONTHLY YEARLY

CEREALS ●
PULSES ●
MILK ●
MILK ●
PRODUCTS
MEAT ●
OIL ●
VEGETABLES ●
FRUITS ●
SUGAR/SWEETS ●
NUTS ●
BEVERAGES ●
● – YES

HOSPITAL DIETARY RECALL:

DAY 1-01/12/2024 – NPO (For Surgery)

DAY 2-02/12/2024–SOFT LOW SALT DIET

DAY 3- 03/12/2024 – SOFT LOW SALT DIET

DAY 4- 04/12/2024 – SOFT LOW SALT DIET

DAY 5- 05/12/2024 – SOFT LOW SALT DIET

DETAILED HOSPITAL DIETARY RECALL:

DAY 1- NPO (NIL PER ORAL)

DAY 2:SOFT LOW SALT DIET

MENU:

BREAKFAST: Dosa + Ginger Chutney

MIDMORNING: Palak Soup

38
 LUNCH: Pongal

SNACKS: Coffee

DINNER: Rice + Radish Sambar + Curd

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENTS QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Hot Water - 100ml - - - -
(7AM)
Breakfast Dosa Rice 40g 142.49 3.17 31.29 0.04
(9AM)
Urad Dal 20g 74.2 5.14 6.8 0.84
Chutney Chilly 5g 2.1 0.13 0.31 0.35
Coriander 10g 3.1 0.35 0.19 0.07
Ginger 5g 2.74 0.11 0.44 0.042
Midmorning Soup Palak 60g 14 1.72 2.18 0.23
(11AM)
Garlic 5g 6.91 0.34 6.46 0.008
Lunch Pongal Moong dal 30g 104 7.16 18.79 0.34
(2PM)
Rice 30g 106.90 2.38 23.47 0.156
Chilly 5g 2.1 0.13 0.31 0.35
Pepper 5g 13 0.55 3.24 0.16
Cumin seeds 5g 19 1.0 2.0 1.0
Garlic 5g 6.91 0.34 6.46 0.008
Evening Coffee Milk 50ml 36.44 1.63 2.47 2.24
(5PM)
Coffee powder 5g 12.05 0.61 2.05 0.025
Dinner Rice Rice 50g 178.17 3.97 39.12 0.26
(8:30PM)
Sambar Radish 100g 16 0.68 3.4 0.1
Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Garlic 5g 6.19 0.345 6.46 0.008
Ginger 5g 2.74 0.11 0.44 0.042
Coriander 10g 3.1 0.35 0.19 0.07
Curd Curd 50ml 29 1.55 2.35 1.5

39
 Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 904.65 32.24g 165.8 17.96
Kcal 6g g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 904.65Kcal

PROTEIN: 32.24g

CARBOHYDRATE: 165.86g

FAT: 17.96g

DAY 3:SOFT LOW SALT DIET

MENU:

EARLY MORNING: Milk

BREAKFAST: Idli + Vegetable Kurma

MIDMORNING: Fruit Bowl

LUNCH: Soft Rice + Rasam + Curd +Egg

EVENING: Coffee

DINNER: Pongal

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 100ml 72.89 3.26 4.9 4.4
(7AM)
Breakfast Idli Rice 40g 142.49 3.17 31.29 0.04
(9AM)
Urad Dal 20g 74.2 5.14 6.8 0.84
Kurma Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Potato 30g 23.1 0.6 5.52 0.03
Brinjal 20g 54.48 0.352 0.69 0.07

40
 Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Ginger 5g 2.74 0.11 0.44 0.042
Midmorning Fruit Watermelon 50g 15.0 0.3 3.78 0.08
(11AM) Bowl
Papaya 50g 129 2.02 32.48 0.46
Lunch Rice Rice 50g 178.17 3.97 39.12 0.26
(2PM)
Rasam Tamarind 5g 12.0 0.14 3.12 0.03
Toor Dal 20g 65.8 4.33 9.3 1.06
Chilly 5g 2.1 0.13 0.31 0.35
Tomato 20g 3.91 0.18 0.54 0.09
Pepper 1 17 0.7 4.4 0.2
powder tablespoon
Curd Curd 50ml 29 1.55 2.35 1.5
Egg Egg 50g 85 7.0 - 7.0
Evening Coffee Milk 50ml 36.44 1.63 2.47 2.24
(5PM)
Coffee 5g 12.05 0.61 2.05 0.025
powder
Dinner Pongal Moong dal 30g 104 7.16 18.79 0.34
(9PM)
Rice 30g 106.90 2.38 23.47 0.156
Chilly 5g 2.1 0.13 0.31 0.35
Pepper 5g 13 0.55 3.24 0.16
Cumin seeds 5g 19 1.0 2.0 1.0
Garlic 5g 6.91 0.34 6.46 0.008
Sugar 10g 40 - 10 -
Oil 10ml 90 - - 10
TOTAL 1365.9 48.86g 219.7g 31.4g
Kcal
TOTAL NUTRIENTS CONSUMED:

ENERGY: 1365.9Kcal

PROTEIN: 48.86g

CARBOHYDRATE: 219.7g

FAT: 31.4g

41
 DAY 4:SOFT LOW SALT DIET

MENU:

EARLY MORNING: Milk

BREAKFAST: Upma

MIDMORNING: Sweet Corn Soup

LUNCH: Rice + Mangalore Cucumber Sambar+ Wheat Dosa + Chow Chow Palya

EVENING: Coffee

DINNER: Khichdi

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Milk Milk 100ml 72.89 3.26 4.9 4.4
Morning
(7AM)
Breakfast Upma Rava 70g 303.8 5.6 49.28 9.38
(9AM) (Semolina)
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Chilly 5g 2.1 0.13 0.31 0.35
Onion 20g 9.6 0.30 1.9 0.04

Midmorning Soup Sweet Corn 40g 34.0 1.29 7.6 0.47

(11AM)
Ginger 5g 2.74 0.11 0.44 0.042
Garlic 5g 6.19 0.345 6.46 0.008
Lunch Rice Rice 50g 178.1 3.9 39.12 0.26
(2PM)
Sambar Mangalore 100g 15 0.7 3.6 0.1
Cucumber
Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Garlic 5g 6.19 0.345 6.46 0.008
Coconut 20g 71.0 0.67 3.05 6.7
Chilly 5g 2.1 0.13 0.31 0.35
Wheat Wheat Flour 50g 160 5.2 32 0.76
Dosa

42
 Palya Chow Chow 100g 19 0.8 4.5 0.1
Chilly 5g 2.1 0.13 0.31 0.35
Onion 20g 9.6 0.30 1.9 0.04
Evening Coffee Milk 50ml 36.44 1.63 2.47 2.24
(5AM)
Coffee 5g 12.05 0.61 2.05 0.025
powder
Dinner Khichdi Rice 30g 106.90 2.34 23.47 0.15
(9PM)
Toor dal 30g 98.7 6.5 13.95 1.59
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Onion 10g 4.8 0.15 0.95 0.024
Cumin seeds 5g 19 1.0 2.0 1.0
Sugar 10g 40 - 10 -
Oil 15ml 135 - - 15
TOTAL 1391.1 35.2g 226.4g 43.8g
Kcal

TOTAL NUTRIENTS CONSUMED:

ENERGY: 1391.1Kcal

PROTEIN: 35.2g

CARBOHYDRATE: 226.4g

FAT: 43.8g

DAY 5:NORMAL LOW SALT DIET

MENU:

EARLY MORNING: Coffee

BREAKFAST: Rava Idli+ Chutney

MIDMORNING: Fruits

LUNCH: Rice + Drumstick Sambar+ Wheat Dosa + Cabbage Palya+ Curd

EVENING: Discharge

43
TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT
(Kcal) (g) (g) (g)
Early Morning Coffee Milk 50ml 36.44 1.63 2.47 2.24
(7AM)
Coffee powder 5g 12.05 0.61 2.05 0.025
Breakfast Rava Rava 100g 360 12.68 72.83 1.05
(10AM) idli (Semolina)
Curd 100ml 58 3.1 4.7 3.0
Carrot 20g 6.64 0.19 1.1 0.09
Onion 10g 4.8 0.15 0.95 0.024
Chutney Red Chilly 5g 17 - 3.75 0.2
Groundnut 20g 113 5.16 3.23 9.85
Coriander 10g 3.1 0.35 0.19 0.07
Garlic 5g 6.19 0.345 6.46 0.008
Midmorning Fruits Pineapple 50g 18.55 0.26 4.71 0.08
(11AM)
Watermelon 50g 15.0 0.3 3.78 0.08
Lunch Rice Rice 50g 178.1 3.9 39.12 0.26
(2PM)
Sambar Drumstick 100g 64 9.4 8.2 1.4
Potato 30g 23.1 0.6 5.52 0.03
Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Coriander 10g 3.1 0.35 0.19 0.07
Wheat Wheat Flour 50g 160 5.2 32 0.76
Dosa
Palya Cabbage 100g 24 1.4 5.8 0.12
Onion 20g 9.6 0.30 1.9 0.04
Chilly 5g 2.1 0.13 0.31 0.35
Curd Curd 50ml 29 1.55 2.35 1.5
Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 1267.2 48g 209g 31.3g
Kcal

44
TOTAL NUTRIENTS CONSUMED:

ENERGY: 1267.2Kcal

PROTEIN: 48g

CARBOHYDRATE: 209g

FAT: 31.3g

DISCHARGE DIET GIVEN AT THE HOSPITAL:

HIGH PROTEIN DIET

GUIDELINES:

Post-op nutrition goals make it possible for a speedier recovery. Maintaining a proper post-op
diet is essential.

Some people lose their appetite after surgery and while taking pain medications. However,
surgery increases the body’s need for calories, and need more calories to heal.

• Eat smaller meals more often if your appetite has decreased.

• Include fiber: Add fiber at each meal and snack from fruits, vegetables, cooked beans,
and whole grains. Fiber helps maintain normal bowel movements.
• Eat enough protein: Have protein at each meal for your muscles and bones. It is found
in meat, fish, eggs, poultry, nuts, dairy products, soy products, and cooked dried
beans.
• Calcium is an important component of bone: Drink milk or calcium-fortified juices,
and eat yogurt or cheese.
• Vitamin C helps the body heal wounds and form bone. Get vitamin C from citrus
fruits, green and red peppers, collard greens, broccoli, spinach, strawberries,
tomatoes, and potatoes.
• Remember to drink plenty of water. To avoid constipation, drink at least six to eight
cups of fluid a day.
• Meat and poultry: beef, chicken, lamb, turkey.
• Seafood: shrimp, crab, salmon, tuna.
• Eggs: whole eggs or egg whites.
• Dairy: cottage cheese, Greek yogurt.
• Legumes: Beans, lentils, peas, and soy.

45
 • Non-starchy vegetables: spinach, cauliflower, broccoli, mushrooms.

SAMPLE MENU:

According to Harris Benedict Equation:

BMR: 447.5 + (9.2*Weight) + (3.0*Height) – (4.3*Age)

=447.5+ (9.2*66) +(3.0*166) -(4.3*58)

=447.5+ 607.2 + 498- 249.4

BMR = 1303Kcal

ENERGY: 1303* 1.2 =1564Kcal

PROTEIN: 1.2g/kg body weight = 79g

CHO: 1564/400* 60= 234.6g

FAT: 41.7g

EXCHANGE LIST:

FOOD GROUPS PORTION ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Cereals & millets 6 600 18 120 4.2
Pulses 3 300 18 45 2.4
Milk/ Milk products 3 210 9.0 10 9.0
Root & Tubers 2 160 2.6 36 -
Green leafy 1 46 3.6 - 0.4
vegetables
Other Vegetables 2 56 3.4 - 0.4
Fruits 1 40 - 10 -
Sugar 1 20 - 5 -

46
 Oil & Fats 1 45 - - 5
Nuts 1 45 - - 5
Egg 2 170 14 - 14
TOTAL 1650Kcal 69g 226g 41g

MEAL DISTRIBUTION:
FOOD GROUPS PORTION EARLY BREAK- MID- LUNCH EVENING DINNER BEDTIME
MORNING FAST MORNING

Cereals & millets 6 2 2 2

Pulses 3 1 1 1

Milk/ Milk 3 1 1 1
products
Root & Tubers 2 1 0.5
Green leafy 1 1
vegetables
Other Vegetables 2 1 1
Fruits 1 1

Sugar 1 0.5 0.5

Oils & Fats 1 0.5 0.5

Nuts 1 1
Egg 2 1 1

MENU:

EARLY MORNING: Milk + Almonds

BREAKFAST: Rajma Pulao + Egg

MIDMORNING: Guava Juice + Steamed Sweet Potato

LUNCH: Rice + Spinach Dal + Egg + Cucumber Salad

EVENING: Boiled Chickpea Salad

DINNER: Chapati + Paneer Potato Curry

BEDTIME: Milk + Almonds

47
 NUTRIENT CALCULATION:
TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT
(Kcal) (g) (g) (g)
EarlyMorning Milk Milk 100ml 72.89 3.26 4.94 4.48
(7am)
Almonds 10g 58 2.13 1.97 5.06
Breakfast Pulao Rice 50g 178.17 3.97 39.12 0.26
(9AM)
Rajma 60g 76 5.2 13.68 0.3
Peas 50g 40 2.71 7.3 0.2
Beans 30g 9.3 0.6 2.1 0.06
Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Egg 50g 85 7 - 7
Midmorning Juice Guava 100g 68 2.55 14.32 0.95
(11AM)
Sweet Sweet Potato 100g 86 1.57 20.12 0.05
potato
Lunch Rice Rice 50g 178.17 3.97 39.12 0.26
(2PM)
Dal Palak 100g 24.37 2.14 2.05 0.64
Toor Dal 30g 98.7 6.5 13.95 1.59
Onion 30g 14.41 0.45 2.86 0.07
Tomato 20g 3.91 0.18 0.54 0.09
Egg Egg 50g 85 7 - 7
Cucumber 100g 45 2.0 11 -
Evening Salad Chickpea 50g 90 4.7 14.9 1.5
(5PM)
Dinner Chapati Wheat flour 60g 221.4 6.48 44.44 1.08
(8PM)
Curry Paneer 50g 148 9.15 1.2 9
Potato 50g 34.89 0.77 7.4 0.11
Onion 30g 14.41 0.45 2.86 0.07
Tomato 20g 3.91 0.18 0.54 0.09
Chilly 5g 2.1 0.13 0.31 0.35
Coriander 10g 3.1 0.35 0.19 0.07
Bedtime Milk Milk 100ml 72.89 3.26 4.94 4.48
(10PM)
Oil 10ml 90 - - 10
Sugar 10g 40 - 10 -
TOTAL 1700Kcal 75g 250g 54g

48
INTERPRETATION OF THE CASE:

A 58 years old female patient, moderately built and nourished, had complaints of pain
in the bilateral knee joint since2-3 months, pain got aggravated since 1 month and also
complaints of difficulty in walking. The patient got admitted to the ward with the above
mention complaints on 01/12/2024. Relevant investigations were done and the patient was
thoroughly evaluated. Right Total Knee Replacement was done on 01/12/2024. Patient
withstood the procedure well. During the course of stay in the hospital, patient was treated
with IV Fluids, PPI's, antibiotics, analgesics, antiemetic and other supportive measures.

During the stay in the hospital patient followed a regular Soft Low Salt Diet and her intake of
food was good, met almost her caloric and protein needs. Nutritional counselling was done to
the patient while discharge and was advised to take High Protein Diet for her post surgery
recovery.

49
 CASE STUDY-2

LEFT HIP HEMIARTHROPLASTY

A hemiarthroplasty is a surgical procedure that involves replacing half of the hip joint.
Hemi means “half” and arthroplasty refers to “joint replacement.” Replacing the entire hip
joint is called total hip replacement (THR).A hemiarthroplasty is generally used to treat a
fractured hip. It may also be used to treat a hip damaged by arthritis.

Replacing half of a hip joint is usually done after rare traumatic injury in which the
femoral head is fractured. This can be achieved in high impact falls where the hip has
become displaced and fractured. Hip fractures are usually outside of the socket in the joint
capsule, between the greater and lesser trochanter, or in the femur.During a hip
hemiarthroplasty, an incision is made over the outside of the hip.

The fractured ball (femoral head) is removed and replaced with an implant. In a
normal hip replacement surgery, the socket of the pelvis would also be replaced. This can be
done in patients with pre-existing arthritis of the hip, but in most cases of femoral neck
fractures the socket is left alone. The prosthetic stem can be cemented into the bone in
patients with thinner, more osteoporotic bone, or press-fit into patients with better bone
quality.

50
ANATOMY:

The hip joint is one of the true ball-and-socket joints of the body. The hip socket is
called the acetabulum and forms a deep cup that surrounds the ball of the upper thigh bone,
known as the femoral head. The thick muscles of the buttock at the back and the thick
muscles of the thigh in the front surround the hip.

The surface of the femoral head and the inside of the acetabulum are covered with
articular cartilage. This material is about one-quarter of an inch thick in most large joints.
articular cartilage is a tough, slick material that allows the surfaces to slide against one
another without damage.All of the blood supply to the femoral head (the ball portion of the
hip) comes through the neck of the femur (femoral neck), a thinner section of the thigh bone
that connects the ball to the main shaft of the bone.

One of the problems with hip fractures is that damage can occur to these blood
vessels when the hip breaks. This can lead to the bone of the femoral head actually dying.
Once this occurs, the bone is no longer able to maintain itself. This can lead to one of the
complications of a hip fracture called avascular necrosis (AVN). This condition occurs when
the blood supply to areas of the femoral head is damaged. The dead bone may eventually
collapse, causing pain in the hip.

51
SYMPTOMS:

• Inability to get up from a fall or to walk.

• Severe pain in the hip or groin.
• Inability to put weight on the leg on the side of the injured hip.
• Bruising and swelling in and around the hip area.
• Shorter leg on the side of the injured hip.
• Outward turning of the leg on the side of the injured hip.

RISK FACTORS:

Ø Blood clots: Clots can form in the leg veins after surgery. This can be dangerous
because a piece of a clot can break off and travel to the lung, heart or, rarely, the
brain. Blood-thinning medications can reduce this risk.
Ø Infection: Infections can occur at the site of the incision and in the deeper tissue near
the new hip. Most infections are treated with antibiotics, but a major infection near the
new hip might require surgery to remove and replace the artificial parts.
Ø Fracture: During surgery, healthy portions of the hip joint might fracture. Sometimes
the fractures are small enough to heal on their own, but larger fractures might need to
be stabilized with wires, screws, and possibly a metal plate or bone grafts.
Ø Dislocation: Certain positions can cause the ball of the new joint to come out of the
socket, particularly in the first few months after surgery. If the hip dislocates, a brace
can help keep the hip in the correct position. If the hip keeps dislocating, surgery may
be needed to stabilize it.
Ø Change in leg length: Surgeons take steps to avoid the problem, but occasionally a
new hip makes one leg longer or shorter than the other. Sometimes this is caused by a
contracture of muscles around the hip. In these cases, progressively strengthening and
stretching those muscles might help. Small differences in leg length usually aren't
noticeable after a few months.
Ø Loosening: Although this complication is rare with newer implants, the new joint
might not become solidly fixed to the bone or might loosen over time, causing pain in
the hip. Surgery might be needed to fix the problem.
Ø Nerve damage: Rarely, nerves in the area where the implant is placed can be injured.
Nerve damage can cause numbness, weakness and pain.

52
CAUSES:Conditions that can damage the hip joint, sometimes making hip replacement
surgery necessary, include:

a. Osteoarthritis. Commonly known as wear-and-tear arthritis, osteoarthritis damages

the slick cartilage that covers the ends of bones and helps joints move smoothly.
b. Rheumatoid arthritis. Caused by an overactive immune system, rheumatoid arthritis
produces a type of inflammation that can erode cartilage and occasionally underlying
bone, resulting in damaged and deformed joints.
c. Osteonecrosis. If there isn't enough blood supplied to the ball portion of the hip
joint, such as might result from a dislocation or fracture, the bone might collapse and
deform.

DIAGNOSIS:

A health care provider can often diagnose a hip fracture based on symptoms and the
abnormal position of the hip and leg. An X-ray usually will confirm the fracture and show
where the fracture is.

If X-ray doesn't show a fracture but still have hip pain, order an MRI or bone scan to look for
a hairline fracture.

Most hip fractures occur in one of two locations on the long bone that extends from the pelvis
to the knee (femur):

Ø The femoral neck. This area is situated in the upper portion of your femur, just below
the ball part (femoral head) of the ball-and-socket joint.
Ø The intertrochanteric region. This region is a little farther down from the hip joint,
in the portion of the upper femur that juts outward.

TREATMENT:

Treatment for hip fracture usually involves a combination of prompt surgical repair,
rehabilitation, and medication to manage pain and to prevent blood clots and infection.

Surgery:

The type of surgery generally depends on where and how severe the fracture is, whether the
broken bones aren't properly aligned (displaced), and your age and underlying health
conditions. Options include:

53
 a. Internal repair using screws: Metal screws are inserted into the bone to hold it
together while the fracture heals. Sometimes screws are attached to a metal plate that
runs down the thighbone (femur).
b. Total hip replacement: The upper femur and the socket in the pelvic bone are
replaced with artificial parts (prostheses). Increasingly, studies show total hip
replacement to be more cost-effective and associated with better long-term outcomes
in otherwise healthy adults who live independently.
c. Partial hip replacement: In some situations, the socket part of the hip doesn't need to
be replaced. Partial hip replacement might be recommended for adults who have other
health conditions or who no longer live independently.

Surgeons may recommend a full or partial hip replacement if the blood supply to the ball part
of the hip joint was damaged during the fracture. That type of injury, which occurs most often
in older people with femoral neck fractures, means the bone is less likely to heal properly.

LIFESTYLE MODIFICATIONS:

• Maintain a healthy weight: Obesity can put strain on the joints and create pain.
Getting rid of extra pounds eases this strain and lessens pain. Try to lose a few pounds
to relieve some of the strain on joints and prevent further deterioration.
• Healthy and proper diet:For a healthy life, one needs a balanced diet that includes
fruits, vegetables, grains, legumes, and dairy products. Bone health depends on
dietary elements like calcium, magnesium, and potassium as well as vitamins like
vitamin D.

54
NUTRITIONAL INTERVENTION:

It’s important to eat a balanced diet before and after joint replacement surgery. Good
nutrition helps to heal quickly, protect the joints and get strength back post-surgery.

"Prior to joint replacement surgery, patients should maintain a diet that includes: fruits,
vegetables, grains, lean meats, fish, poultry, low-fat dairy products, or other sources of
protein. Following joint replacement surgery, it’s imperative to continue eating a balanced
diet for long-term health and recovery,"

ü High-Quality Proteins: Eggs, poultry, fish, meat, and nuts are excellent sources of high-
quality proteins that provide the building blocks which help the body repair itself and
boost the body’s immunity.

ü Complex Carbohydrates: As a result of the surgery body metabolism will be elevated

which increases the body’s calorie requirements. But should make sure that calories are
obtained from complex carbohydrate such as whole grains, starchy vegetables, and
legumes. Avoid simple carbohydrates found in foods such as pastries, desserts, cookies,
candy, soda, and ice cream.

ü Anti-Inflammatory Fats: Salmon, mackerel, sardines, and anchovies are good examples
of fatty fish that contain high amounts of omega 3 fatty acids that have anti-inflammatory
properties which reduces the inflammation in the body caused by the surgery.

ü Calcium and Vitamin D: Calcium is key for maximizing bone and joint health especially
when undergoing joint replacement surgery. Good sources of calcium include spinach,
chia seeds, and kale as well as dairy products. Apart from eating calcium-rich foods, you
need to spend at least 15-20 a day outdoors in the daytime so your body can synthesize
vitamin D from sunlight which helps in the absorption of calcium from the food you eat.

55
ü Vitamin C: This vitamin is essential for the formation of collagen which is present in the
ligaments and tendons that connect the bones and muscles. Vitamin C rich foods include
citrus fruits such as oranges, lemon, kiwi, and grapefruit; and vegetables such as
cauliflower, capsicum, and Brussel sprouts.

NUTRITIONAL SCREENING:

Date of Assessment – 08/11/2024

PATIENT PROFILE:

PATIENT NAME: XYZ

AGE: 97 years

GENDER: Female

COMMUNITY: Hindu (Brahmins)

OCCUPATION: Home-maker

ECONOMIC STATUS: APL (Above poverty line)

NUMBER OF FAMILY MEMBERS: 5

FOOD ALLERGIES: Nothing significant

FOOD PREFERENCE: Vegetarian

PERSONAL HABIT: Nil

UHID: 12195123

DATE OF ADMISSION:08/11/2024

DATE OF DISCHARGE:11/11/2024

DIAGNOSIS: Left Hemi-Hip (Hemiarthroplasty) / Neck of Femur bone fracture

ANTHROPOMETRIC MEASUREMENTS:

HEIGHT: 150cm

WEIGHT:50kg

BMI:22.25

BMI CLASSIFICATION:Normal

IBW:50kg (height – 100)

56
WAIST CIRCUMFERENCE:UNS

HIP CIRCUMFERENCE: UNS

BMR: Using Thumb rule; Estimated calories = 1300Kcal and

Protein = 50-55g

PHYSICAL ACTIVITY: Sedentary

CLINICAL DATA:

PAST HISTORY: Hypertension (from 30years)

CHIEF COMPLAINTS: Pain in the left hip since2 days due to fall while walking at home,
unable to walk and had vertigo for the past 4 to 5 days.

CURRENT SYMPTOMS: Pain in the hip, nausea.

FAMILY HISTORY: Nil

PHYSICAL EXAMINATION:

a. Temperature: 98℉
b. Pulse rate: 110/ MIN
c. Blood Pressure: 110/60 mmHg
d. SpO2: 94%
e. GRBS: 139mg/dL

HAEMATOLOGY:BLOOD GROUP: A, Rh: Positive

BIOCHEMICAL PARAMETERS:

PARAMETERS UNIT 22/12/2022 NORMALVALUES

WBC Count thou/µL 11.50 4.0-10.0
RBC Count mil/µL 2.26 3.8-4.8
Hemoglobin (Hb) g/dL 7.3 12-15
Hematocrit (PCV) % 22.1 36-46
Red cell distribution % 14.9 11.6-14.0
width (RDW)
Neutrophils % 44 40-80
Lymphocytes % 47 20-40
Monocytes % 05 2.0-10.0
Eosinophils % 04 1-6
Basophils % 00 ≤1-2
Platelet Count thou/µL 136 150-410

57
 MEDICATIONS:

PARAMETERS UNIT 22/12/2022 23/12/2022 24/12/2022 NORMAL

VALUES
Blood urea Nitrogen mg/dL 58 60 61.9 6-20
Urea mg/dL 48 78 133 10-50
Creatinine mg/dL 1.30 1.40 1.80 0.50-0.90
Sodium, Serum mmol/L 128 139 131 137-145
Potassium, Serum mmol/L 5.0 5.49 5.3 3.6-5.0
Chloride, Serum mmol/L 98 105 104 98-107

MEDICATIONS DOSAGE MECHANISM OF ACTION

Anxit 0.25mg Tablet belongs to a class of medicines known

TAB. ANXIT 0.25 mg as benzodiazepines. It is used to treat anxiety. It alters brain
activity, calms it, and provides relief from panic attacks by
relaxing the nerves. It works by increasing the action of a
chemical messenger (GABA) which suppresses the abnormal
and excessive activity of the nerve cells in the brain.
It works by inhibiting the cell wall synthesis of bacteria,
INJ. SUPACEF 1.5mg which ultimately results in the death of bacteria. Supacef
1.5gm Powder for injection is used to treat various types of
bacterial infections such as infection of the respiratory tract,
soft tissue, urinary tract, ears, nose, and throat.
PCT Injection is a nootropic medicine. It works by increasing
INJ. PCT 1mg the activity of a chemical messenger (acetylcholine) which
improves communication between the nerve cells. It also
protects the brain and nervous system against shortness of
oxygen.
Rejunuron Injection 1ml contains Methylcobalamin, a form
INJ. 1 AMP of vitamin B12, which protects the nerves from damage and
REJINEURON promotes blood cell production. It regulates body functions,
such as cell multiplication, blood formation, and protein
synthesis.
PD Pan 40mg Injection is a proton pump inhibitor (PPI). It
INJ. PAN 40mg works by reducing the amount of acid in the stomach which
in turn relieves acid-related indigestion and heartburn.
Administration of 3% NaCl is primarily indicated to treat
3% SALINE 10ml/hour symptomatic hyponatremia.Hypertonic saline requires less
overall volume administered to achieve similar plasma
volumes as larger volumes of normal saline. Hypertonic
saline stimulates vasopressin release from the pituitary gland,
which decreases water loss through the kidneys.

58
 Emeset Injection is an antiemetic medication. It works by
INJ. EMESET 4mg blocking the action of a chemical messenger (serotonin) in
the brain that may cause nausea and vomiting during anti-
cancer treatment (chemotherapy) or after surgery.
(+)-Tramadol inhibits serotonin reuptake and (-)-tramadol
INJ. TRAMADOL 50mg inhibits norepinephrine reuptake, enhancing inhibitory
effects on pain transmission in the spinal cord. The
complementary and synergistic actions of the two
enantiomers improve the analgesic efficacy and tolerability
profile of the racemate.
Asthalin Respirator Solution is a bronchodilator. It works by
NEB. ASTHALIN - relaxing the muscles in the airways and widens airways. This
makes breathing easier.
K-Bind Powder is an ion exchange resin. It works by
K-BIND 15mg removing extra potassium from your body and brings its
POWDER levels back to normal. It is useful in patients who have
kidney diseases and those on dialysis.
Zocef 500 tablet works by stopping bacterial cell wall
TAB. ZOCEF 500mg synthesis; the absence of bacterial cell wall results in the
death of bacteria.
Lanol ER Tablet 10's works by inhibiting the production of
TAB. LANOL ER 650mg certain chemical messengers in the brain known as
prostaglandins. Thus, reduces pain. Also, Lanol ER Tablet
10's affects an area of the brain that regulates body
temperature known as the hypothalamic heat-regulating
centre. Thereby, it reduces fever.
Pantoprazole inhibits a pump called the proton pump in the
TAB. PAN D 40mg stomach wall, responsible for the secretion of stomach acids
for digestion and leads to reduced acid production.
Domperidone stops vomiting.

24HOUR DIETARY RECALL:

MENU:

Ø BREAKFAST: Upma
Ø LUNCH: Rice + Rasam + Curd
Ø EVENING: Coffee
Ø DINNER: Dosa + Milk (Horlicks)

59
 DETAILED MENU PLAN:

TIME MENU INGREDIENTS QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Breakfast Upma Semolina 30g 100 3.41 20.6 -
(9:30 am)
Carrot 20g 6.6 0.2 1.1 0.09
Beans 20g 6.2 0.4 1.4 0.04
Onion 10g 4.8 0.15 0.95 0.02
LUNCH Rice + Rice 40g 142.49 3.17 31.29 0.04
(1pm) Rasam
Curd Toor dal 30g 98.7 6.5 13.95 1.59
Tomato 20g 3.91 0.18 0.542 0.09
Coriander 10g 3.1 0.35 0.19 0.07
Chilly 5g 2.1 0.13 0.31 0.35

Curd 50ml 29 1.55 2.35 1.5

EVENING Coffee Milk 50ml 36.44 1.63 2.47 2.24
(5pm)
Coffee powder 1 teaspoon 12.05 0.61 2.05 0.025
DINNER Dosa + Dosa batter 50g 178 4.0 36 2.0
(9pm) Chutney
Milk Groundnut 20g 104 4.72 3.45 7.92
(Horlicks)
Chilly 5g 2.1 0.13 0.31 0.35
Milk 100ml 72.89 3.26 4.94 4.48
Horlicks powder 10g 36.2 0.91 7.73 0.23
TOTAL 838.58 31.3g 129.63g 21.03g
Kcal
NUTRITIONAL CALCULATION OF DIETARY RECALL:

ENERGY:838.58 Kcal

PROTEIN:31.3g

CARBOHYDRATE:129.63g

FATS:21.03g

60
FOOD FREQUENCY TABLE:

FOOD GROUPS NEVER DAILY WEEKLY MONTHLY YEARLY

CEREALS
●
PULSES ●
MILK ●
MILK ●
PRODUCTS
MEAT ●

OIL ●

VEGETABLES ●
FRUITS ●
SUGAR ●
NUTS ●
BEVERAGES ●
● = YES

HOSPITAL DIETARY RECALL:

DAY 1- 08/11/2024 - SOFT DIET (LOW SALT)

DAY 2-09/11/2024 - NPO (For Surgery)

DAY 3- 10/11/2024–LIQUID DIET 100ML@ 2ND HOURLY

DAY 4- 11/11/2024- SOFT DIET (LOW SALT)

DETAILED HOSPITAL DIETARY RECALL:

DAY 1–SOFT LOW SALT DIET

MENU:

BREAKFAST: Idli+ Chutney

LUNCH: Khichdi

DINNER: Pongal

61
 NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)

Breakfast Idli Rice 40g 142.49 3.17 31.29 0.04

(9AM)
Urad dal 20g 74.2 5.14 6.8 0.84
Chutney Ginger 10g 5.48 0.22 0.88 0.08
Coriander 10g 3.1 0.35 0.19 0.07
Chilly 5g 2.1 0.13 0.31 0.35
Lunch Khichdi Rice 30g 106.90 2.34 23.47 0.15
(2PM)
Toor dal 30g 98.7 6.5 13.95 1.59
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Onion 10g 4.8 0.15 0.95 0.024
Cumin seeds 5g 19 1.0 2.0 1.0
Dinner Pongal Moong dal 30g 104 7.16 18.79 0.34
(9PM)
Rice 30g 106.90 2.38 23.47 0.156
Chilly 5g 2.1 0.13 0.31 0.35
Pepper 5g 13 0.55 3.24 0.16
Cumin seeds 5g 19 1.0 2.0 1.0
Garlic 5g 6.91 0.34 6.46 0.008
Oil 10ml 90 - - 10
TOTAL 813.8Kcal 32.19g 137.5g 16.43g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 813.8Kcal

PROTEIN: 32.19g

CARBOHYDRATE: 137.5g

FAT: 16.43g

62
 DAY 2:NPO FOR SURGERY

DAY 3: LIQUID DIET @2ND HOURLY

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 150ml 77 5.09 7.29 3.09
(7AM)
Morning Ganji Rava 50g 180 6.3 36.42 0.52
(9AM)
Midmorning Soup Sweet Corn 40g 34.0 1.29 7.6 0.47
(11AM)
Ginger 5g 2.74 0.11 0.44 0.042

Afternoon Ganji Rava 50g 180 6.3 36.42 0.52

(1PM)
Afternoon Juice Watermelon 100g 30 0.61 7.5 0.15
(3PM)
Evening Milk Milk 150ml 77 5.09 7.29 3.09
(5PM)
Evening Juice Apple 100g 52 0.26 13.81 0.17
(7PM)
Bedtime Ganji Rava 50g 180 6.3 36.42 0.52
(9PM)
Sugar 10g 40 - 10 -
TOTAL 852.7Kcal 31.3g 163.1g 8.5g
TOTAL NUTRIENTS CONSUMED:

ENERGY: 852.7Kcal

PROTEIN: 31.3g

CARBOHYDRATE: 163.1g

FAT: 8.5g

DAY 4: SOFT LOW SALT DIET

EARLY MORNING: Milk

BREAKFAST: Upma

MIDMORNING: Fruits

LUNCH: Pongal + Curd

EVENING: Coffee

DINNER: Khichdi

63
 NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 100ml 72.89 3.26 4.94 4.48
(6AM)
Breakfast Upma Rava (Sooji) 70g 303.8 5.6 49.28 9.38
(9AM)
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Chilly 5g 2.1 0.13 0.31 0.35
Urad Dal 5g 18.55 1.28 1.7 0.21
Midmorning Fruits Watermelon 50g 15.0 0.3 3.78 0.08
(11AM)
Papaya 50g 129 2.02 32.48 0.46
Lunch Pongal Moong dal 30g 104 7.16 18.79 0.34
(2PM)
Rice 30g 106.90 2.38 23.47 0.156
Chilly 5g 2.1 0.13 0.31 0.35
Pepper 5g 13 0.55 3.24 0.16
Cumin seeds 5g 19 1.0 2.0 1.0
Garlic 5g 6.91 0.34 6.46 0.008
Curd Curd 50ml 29 1.55 2.35 1.5
Dinner Khichdi Rice 30g 106.90 2.34 23.47 0.15
(8PM)
Toor dal 30g 98.7 6.5 13.95 1.59
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Onion 10g 4.8 0.15 0.95 0.024
Cumin seeds 5g 19 1.0 2.0 1.0
Sugar 10g 40 - 10 -
Oil 10ml 90 - - 10
TOTAL 1199Kcal 38.4g 203g 31.6g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 1199Kcal

PROTEIN: 38.4g

CARBOHYDRATE: 203g

64
FAT: 31.6g

DISCHARGE DIET GIVEN AT THE HOSPITAL:

HIGH PROTEIN DIET

SAMPLE MENU:

According to Harris Benedict Equation:

BMR: 447.5 + (9.2*Weight) + (3.0*Height) – (4.3*Age)

=447.5+ (9.2*50) +(3.0*150) -(4.3*97)

=447.5+ 460 + 450- 417.1

BMR = 940Kcal

ENERGY: 940 * 1.2 =1128Kcal

PROTEIN: 1.2g/kg body weight = 60g

CHO: 1128/400* 60= 169g

FAT: 31g

EXCHANGE LIST:

FOOD GROUPS PORTION ENERGY PROTEIN CHO FAT

Kcal (g) (g) (g)
Cereals & millets 6 600 18 120 4.2
Pulses 2 200 12 30 1.4
Milk/Milkproducts 2 70 6 10 6
Root & Tubers 1 80 1.3 18 -
Green leafy 1 46 3.6 - 0.4
vegetables
Other Vegetables 2 56 3.4 - 0.4
Fruits 1 40 - 10 -
Sugar 1 20 - 5 -
Oil & Fats 1 45 - - 5
TOTAL 1150Kcal 41g 193g 18g

65
 MEAL DISTRIBUTION:
FOOD GROUPS PORTION EARLY BREAK- MID- LUNCH EVENING DINNER BEDTIME
MORNING FAST MORNING

Cereals & 6 2 2 2
millets
Pulses 2 1 1
Milk/Milk 2 1 0.5 0.5
products
Root & 1 1
Tubers
Green leafy 1 1
vegetables
Other 2 1 1
Vegetables
Fruits 1 0.5 0.5
Sugar 1 0.5 0.5
Oil & Fats 1 0.5 0.5
MENU:

EARLY MORNING: Milk+ Pentasure Protein powder

BREAKFAST: Oats porridge+ Apple

MIDMORNING: Mashed Channa Spinach Salad

LUNCH: Rice + Vegetable sambar

EVENING: Papaya

DINNER: Chapati + Potato peas mashed Curry

BEDTIME: Milk

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 100ml 72.89 3.26 4.94 4.48
(7AM)
Pentasure 2scoop 250 19 24 8
powder
Breakfast Porridge Oats 30g 117 5.0 19.8 2.07
(9AM)
Milk 50ml 31 1.6 2.3 1.68
Apple 50g 26 0.13 6.9 0.08

66
Midmorning Salad Palak 50g 12 1.43 1.82 0.2
(11AM)
Channa 30g 98 5.7 18.2 1.8
Lunch Rice Rice 40g 142.49 3.17 31.29 0.04
(2PM)
Sambar Toor Dal 30g 98.7 6.5 13.95 1.59
Onion 30g 14.41 0.45 2.86 0.07
Tomato 20g 3.91 0.18 0.54 0.09
Drumstick 100g 64 9.4 8.2 1.4

Evening Fruits Papaya 50g 20 0.3 4.9 0.07

(5PM)
Dinner Chapati Wheat flour 40g 136 5.4 29.0 0.75
(8PM)
Potato 50g 34.89 0.77 7.4 0.11
Peas 30g 24 1.63 4.34 0.12
Tomato 20g 3.91 0.18 0.54 0.09
Chilly 5g 2.1 0.13 0.31 0.35
Oil 10ml 90 - - 10
Sugar 10g 40 - 10 -
TOTAL 1251Kcal 64g 191g 32.9g

INTERPRETATION OF THE CASE:

A 97 years old female patient, moderately built and under-nourished, had history of
fall at residence while walking 2 days before admission. Patient also had complaints of
vertigo for past 4-5 days. The patient got admitted to the ward with the above mention
complaints on 08/11/2024. Relevant investigations were done and the patient was thoroughly
evaluated. Patient was posted for surgery on 09/11/20224. LEFT HEMIARTHOPLASTY
WITH MODULAR BIPOLAR PROSTHESIS was done. Patient withstood the procedure
well. During the course of stay in the hospital, patient was treated with IV Fluids, PPI's,
antibiotics, analgesics, antiemetic and other supportive measures.

During the stay in the hospital patient followed a regular Soft Low Salt Diet and her
intake of food was poor as she is aged, met almost her caloric and protein needs. Nutritional
counselling was done to the patient while discharge and was advised to take High Protein
Diet for her post surgery recovery.

67
 Patient got readmitted after 2 weeks again due to high potassium levels in the blood
and was diagnosed as HYPERKALEMIA. Patient attender provided a dietary history that,
patient took 2banana daily along with tender coconut water which increased her blood
potassium level.

68
 CASE STUDY-3

IC BLEED (INTRACEREBRAL HEMORRHAGE)

INTRODUCTION: An intracranial hematoma is a collection of blood within the skull.
It's usually caused by a blood vessel that bursts in the brain. It may also be caused by trauma
such as a car accident or fall. The blood may collect in the brain tissue or underneath the
skull, pressing on the brain. Itis the second most common cause of stroke (15-30% of strokes)
and mostdeadly.

Blood vessels carry blood to and from the brain. Arteries or veins can rupture, either
from abnormal pressure or abnormal development or trauma. The blood itself can damage the
brain tissue. Furthermore, the extra blood in the brain may increase the pressure within the
skull (intracranial pressure (ICP)) to a point that further damages the brain.

Ø Bleeding within the skull but outside of the brain tissue:

The brain has three membranes layers (called meninges) that lay between the bony skull
and the actual brain tissue. The purpose of the meninges is to cover and protect the brain.
Bleeding can occur anywhere between these three membranes. The three membranes are
called the dura mater, arachnoid, and pia mater.

a. Epidural bleed (hemorrhage): This bleed happens between the skull bone and the
outermost membrane layer, the dura mater.
b. Subdural bleed (hemorrhage): This bleed happens between the dura mater and the
arachnoid membrane.
c. Subarachnoid bleed (hemorrhage): This bleed happens between the arachnoid
membrane and the pia mater.

69
 Ø Bleeding inside the brain tissue:

Two types of brain bleeds can occur inside the brain tissue itself – intracerebral hemorrhage
(also called cerebral hemorrhage and hemorrhagic stroke) and intraventricular hemorrhage.

a. Intracerebral hemorrhage: This bleeding occurs in the lobes, pons and cerebellum
of the brain (bleeding anywhere within the brain tissue itself including the brainstem).
b. Intraventricular hemorrhage: This bleeding occurs in the brain’s ventricles, which
are specific areas of the brain (cavities) where cerebrospinal fluid is produced.

Since the brain cannot store oxygen, it relies upon a series of blood vessels to supply
oxygen and nutrients. When a brain hemorrhage occurs, oxygen may no longer be able to
reach the brain tissue supplied by these leaky or burst vessels. Pooling of blood from an
intracranial hemorrhage or cerebral hemorrhage also puts pressure on the brain and deprives
it of oxygen.

When a hemorrhage interrupts blood flow around or inside the brain, depriving it of
oxygen for more than three or four minutes, the brain cells die. The affected nerve cells and
the related functions they control are damaged as well.

ETIOLOGY:Intracerebral hemorrhage usually results from rupture of an arteriosclerotic

small artery that has been weakened, primarily by chronic arterial hypertension. Such
hemorrhages are usually large, single, and catastrophic. Other modifiable risk factors that
contribute to arteriosclerotic hypertensive intracerebral hemorrhages include cigarette
smoking, obesity, and a high-risk diet (eg, high in saturated fats, trans fats, and calories). Use
of cocaine or, occasionally, other sympathomimetic drugs can cause transient severe
hypertension leading to hemorrhage.
70
 Less often, intracerebral hemorrhage results from congenital aneurysm, arteriovenous
malformations, other vascular malformations, trauma, mycotic aneurysm, brain infarct
(hemorrhagic infarction), primary or metastatic brain tumor, excessive anticoagulation, blood
dyscrasia, intracranial arterial dissection, or a bleeding or vasculitic disorder.

Lobar intracerebral hemorrhages (hematomas in the cerebral lobes, outside the basal
ganglia) usually result from angiopathy due to amyloid deposition in cerebral arteries
(cerebral amyloid angiopathy), which affects primarily older people. Lobar hemorrhages may
be multiple and recurrent.

PATHOPHYSIOLOGY:

Intracerebral hemorrhage (ICH), a subtype of stroke, is a devastating condition

whereby a hematoma is formed within the brain parenchyma with or without blood extension
into the ventricles. Non-traumatic ICH comprises 10-15% of all strokes and is associated with
high morbidity and mortality.

Blood from an intracerebral hemorrhage accumulates as a mass that can dissect

through and compress adjacent brain tissues, causing neuronal dysfunction. Large hematomas
increase intracranial pressure. Pressure from supratentorial hematomas and the accompanying
edema may cause transtentorial brain herniation, compressing the brain stem and often
causing secondary hemorrhages in the midbrain and pons.

If the hemorrhage ruptures into the ventricular system (intraventricular hemorrhage),

blood may cause acute hydrocephalus. Cerebellar hematomas can expand to block the 4th
ventricle, also causing acute hydrocephalus, or they can dissect into the brain stem.
Cerebellar hematomas that are > 3 cm in diameter may cause midline shift or herniation.

Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage, acute

hydrocephalus, or dissection into the brain stem can impair consciousness and cause coma
and death.

71
SYMPTOMS:The symptoms of a brain hemorrhage can vary. They depend on the
location of the bleeding, the severity of the bleeding, and the amount of tissue affected.
Symptoms tend to develop suddenly. They may progressively worsen.The symptoms include:

• A sudden severe headache.

• Seizures with no previous history of seizures.
• Weakness in an arm or leg.
• Nausea or vomiting.
• Decreased alertness; lethargy.
• Changes in vision.
• Tingling or numbness.
• Difficulty speaking or understanding speech.
• Difficulty swallowing.
• Difficulty writing or reading.
• Loss of fine motor skills, such as hand tremors.
• Loss of coordination.
• Loss of balance.
• An abnormal sense of taste.
• Loss of consciousness.

72
CAUSES: Bleeding in the brain has a number of causes, including:

Ø Hypertension: chronic high blood pressure causes changes to the arteries of the brain
which can make them much more likely to rupture.
Ø Age: more common after age of 55, with buildup of protein in walls of arteries called
amyloid angiopathy.
Ø Gender: more common in men.
Ø Race: affects African Americans and Asians more than whites; likely related to higher
prevalence of Hypertension in those races.
Ø Previous history of stroke: increases risk 23 times.
Ø Alcohol use and street drugs: cocaine, amphetamines increase the risk.
Ø Liver disease: increases risk due to issues with blood clotting.
Ø Use of blood thinners.
Ø Primary brain causes: tumors, vascular anomalies, infection and venous sinus
thrombosis.

RISK FACTORS:

Ø Head trauma, caused by a fall, car accident, sports accident or other type of blow to
the head.
Ø High blood pressure (hypertension), which can damage the blood vessel walls and
cause the blood vessel to leak or burst.
Ø Buildup of fatty deposits in the arteries (atherosclerosis).
Ø Blood clot that formed in the brain or traveled to the brain from another part of the
body, which damaged the artery and caused it to leak.
Ø Ruptured cerebral aneurysm (a weak spot in a blood vessel wall that balloons out and
bursts).
Ø Buildup of amyloid protein within the artery walls of the brain (cerebral amyloid
angiopathy).
Ø A leak from abnormally formed connections between arteries and veins
(arteriovenous malformation).
Ø Bleeding disorders or treatment with anticoagulant therapy (blood thinners).
Ø Brain tumor that presses on brain tissue causing bleeding.
Ø Smoking, heavy alcohol use, or use of illegal drugs such as cocaine.

73
 Ø Conditions related to pregnancy or childbirth, including eclampsia, postpartum
vasculopathy, or neonatal intraventricular hemorrhage.
Ø Conditions related to abnormal collagen formation in the blood vessel walls that can
cause to walls to be weak, resulting in a rupture of the vessel wall.

DIAGNOSIS:

Diagnosis is usually made based on the results of:

• An evaluation of your physical symptoms.

• Computed tomography (CT) scan, magnetic resonance imaging (MRI) or magnetic
resonance angiogram (MRA) of your brain. These imaging tests determine the
location, extent and sometimes the cause of the bleed.
Other tests may include:
• Electroencephalogram, chest X-ray, and/or urinalysis.
• Complete vascular study, complete blood count (CBC), and/or blood studies.
• Spinal tap to examine the cerebrospinal fluid that surrounds the brain.
• In some cases, conventional angiography may be done to identify an aneurysm or
arteriovenous malformation.

TREATMENT:

Any type of bleeding inside the skull or brain is a medical emergency. It is important
to get to a hospital emergency room immediately to determine the cause of the bleeding and
to begin medical treatment.

74
 If a stroke has occurred, the cause (bleeding or blood clot) must be determined so that the
appropriate treatment can be started. Prompt medical treatment can help limit damage to the
brain, which will improve your chance of recovery.

• Surgery may be needed in the following situations:

• Bleeding (hemorrhage) may require immediate decompression of the brain to release
pooled blood and relieve pressure. Decompression may be done through a burr hole
procedure (drilling a hole in the skull to allow blood drainage), a craniectomy incision
(partial removal of the skull to allow the swelling brain to expand), or a craniotomy
(opening of the skull cavity).
• A cerebral aneurysm that has not ruptured may require clipping or filling (“sealing
off”) of the aneurysm through a craniotomy surgical procedure, or an angiography-
type procedure to prevent a future rupture.
• An arteriovenous malformation (AVM) that has not ruptured is treated by direct
removal of the AVM through surgery, use of computer-guided radiation to close off
the abnormal vessels or use of a special glue or other filler to block the blood flow
from smaller blood vessels into the AVM or the vessels that supply the AVM.

Some brain hemorrhages do not require surgery. The decision depends on the size, cause and
location of the bleed and other factors.

Ø Other treatments may include:

• Anti-anxiety drugs and/or medication to manage blood pressure.
• Anti-epileptic drugs for seizure management.
• Other medications needed to regulate other symptoms, such as painkillers for severe
headache and stool softeners to prevent constipation and straining during bowel
movements.
• Nutrients and fluids as needed. These may be given through a vein (intravenously), or
a feeding tube in the stomach (gastronomy tube), especially if the patient has
difficulty swallowing.

NUTRITIONAL INTERVENTION:

A healthy diet can reduce your risk for acquiring medical conditions such as
hypertension (high blood pressure), diabetes, high cholesterol (lipid) levels, coronary artery
disease and obesity. All of these conditions can increase your chance of having a stroke.If

75
calorie and nutritional needs cannot be met, the person may become malnourished, a
condition characterized by weight loss and a poor appetite.

Diet modifications need to be individualized according to the type and extent of these
impairments:

• Liquids of thicker consistency are easier to swallow.

• Drink eight cups of liquid each day to meet fluid needs.
• Very warm and well-chilled foods make swallowing easier.
• Eat small meals frequently throughout the day to meet nutrient needs.
• Eat moist foods, such as casseroles and foods with sauces.
• Eat a variety of foods.
• Maintain a healthy weight by balancing the calories eaten with physical activity.
• Choose more whole grains, vegetables and fruits.
• Choose foods low in saturated fat and cholesterol.
• Choose foods with moderate amounts of added sugar.
• Choose foods with moderate amounts of salt (sodium).

ü A healthy dietary pattern: Healthy dietary patterns are defined by the relative
absence of foods that are energy-dense, high in saturated fats (e.g., meat and full-fat
dairy products), fried, processed, or high in glycemic load. This should be
accompanied by the presence of higher amounts of fruits, vegetables, soy foods and
other legumes, nuts, unsaturated fats, and foods that are low in energy density and
high in fiber, among other characteristics.

76
ü Replacement of saturated fat and cholesterol with monounsaturated fat from
olive oil: Individuals with higher blood cholesterol concentrations (who consume
meat and other foods high in saturated fat and cholesterol) tend to have higher stroke
risk. Accordingly, consuming roughly 3.5 ounces per day of red meat is associated
with an 11% greater risk for stroke, while eating half that much unprocessed red meat
is associated with a 13% greater risk, compared with the lowest levels of intake.
ü Fish intake: Reviews have concluded that fish consumption and the intake of long-
chain omega-3 fatty acids is inversely associated with cerebrovascular disease risk,
and that higher compared with lower intakes significantly reduce the risk for ischemic
stroke in both men and women, and total stroke risk in women.
ü Diets rich in fruits, vegetables, and dietary fiber and low in refined
carbohydrates: Higher intakes of fruits and vegetables are inversely associated with
the risk for stroke. A dose-response relationship exists between these, so that for
every 200 g daily increment in fruit or vegetable consumption, the risk for stroke
decreases by 32% and 11%, respectively. Although this meta-analysis attributed a
great part of stroke protection to citrus fruits, apples/pears, and leafy vegetables,
another review found that higher compared with lower dietary intakes or blood levels
of lycopene (a carotenoid found almost exclusively in tomato products) were
associated with an almost 20% lower stroke risk. In addition to carotenoids such as
lycopene, these foods provide dietary fiber, vitamin C, vitamin E, folate, and
flavonoids, all of which have been associated with reduced stroke risk.
Dietary fiber intake is inversely associated with stroke risk, although this effect is not
attributable to the intake of whole grains.
ü Consuming less sodium and more potassium. Higher (compared with lower)
sodium intake is associated with an almost 25% greater risk for stroke.Conversely,
potassium intake is inversely associated with the risk for stroke.
ü Maintenance of healthy body weight: The risk for stroke increases with the degree
of overweight, and a meta-analysis of studies including over 2 million individuals
concluded that risk for stroke is 64% greater in obese individuals and 22% higher in
overweight persons, compared with those who are at normal weight.Evidence
supports the ability of losing excess weight to reduce future stroke risk.
ü Limiting alcohol consumption: Alcohol consumption may be more associated with
ischemic than hemorrhagic stroke. Compared with no alcohol consumption, having 1-
2 drinks per day was associated with a roughly 10% lower risk for ischemic stroke.

77
 Conversely, consumption of both 2-4 drinks per day and > 4 drinks per day was
associated with an 8% and 14% greater risk, respectively. Having > 4 drinks/day was
associated with a 67% and 82% greater risk for intracerebral hemorrhage and
subarachnoid hemorrhage.
ü Adequate vitamin D status: Compared with individuals with the highest blood level
of vitamin D, those with the lowest level have a 64% greater risk for stroke.

NUTRITIONAL SCREENING:

Date of Assessment – 19/12/2024

PATIENT PROFILE:

PATIENT NAME: XYZ

AGE:60years

GENDER:Male

COMMUNITY:Hindu

OCCUPATION:Engineer

ECONOMIC STATUS: Good

NUMBER OF FAMILY MEMBERS:4

FOOD ALLERGIES: Nothing significant

FOOD PREFERENCE:Non-Vegetarian

PERSONAL HABIT: Nil

UHID:12238287

DATE OF ADMISSION:11/12/2024

DATE OF DISCHARGE:19/12/2024

DIAGNOSIS:INTRACRANIAL BLEED (IC Bleed)

ANTHROPOMETRIC MEASUREMENTS:

HEIGHT:170cm

WEIGHT:85kg

BMI:29.41

78
BMI CLASSIFICATION:Overweight

IBW:70kg (height – 100)

WAIST CIRCUMFERENCE:42 inches

HIP CIRCUMFERENCE: 98cm

BMR: Using Thumb rule; Estimated calories = 1800Kcal and

Protein = 70g

PHYSICAL ACTIVITY: Sedentary

CLINICAL DATA:

PAST HISTORY: Nil

CHIEF COMPLAINTS: ℅ blurring vision since- one day, ℅ profuse sweating, patient
being unable to move his right sided limbs since 2days and breathlessness.

CURRENT SYMPTOMS: Blurred vision and increased sweating.

FAMILY HISTORY: Nil

PHYSICAL EXAMINATION:

a. Temperature: 99℉
b. Pulse rate:88/ MIN
c. Blood Pressure: 160/90 mmHg
d. SpO2: 98%
e. GRBS: 138mg/dL

HAEMATOLOGY: BLOOD GROUP: TYPE A

Rh: POSITIVE

PARAMETERS UNIT 15/01/23 17/01/23 19/01/23 NORMAL VALUES

WBC Count thou/µL 12.20 12.0 12.0 4.0-10.0
RBC Count mil/µL 4.96 4.9 5.0 4.5-5.5
Hemoglobin (Hb) g/dL 15.1 13.1 12.3 12-15

Hematocrit (PCV % 46.0 40.5 38.6 36-46

Neutrophils % 75 75 75 40-80

79
 Lymphocytes % 18 17 15 20-40
Monocytes % 05 04 04 2.0-10.0
Eosinophils % 02 04 06 1-6
Basophils % 00 00 00 ≤1-2
Platelet Count thou/µL 246 179 170 150-410

BIOCHEMICAL PARAMETERS:

PARAMETERS UNIT 15/01/23 16/01/23 17/01/23 18/01/23 19/01/23 NORMAL

VALUES
Blood urea mg/dL 21.0 21.4 21.0 21.0 20 6-20
Nitrogen
Urea mg/dL 29 46 45 46 46 10-50

Creatinine mg/dL 1.20 1.50 1.40 1.30 1.30 0.50-0.90

Sodium, Serum mmol/L 134 136 140 139 142 137-145

Potassium, Serum mmol/L 3.3 3.6 3.5 3.5 3.0 3.6-5.0
Chloride, Serum mmol/L 100 105 105 105 105 98-107

RADIOLOGY:

CT BRAIN (PLAIN):

FINDINGS:

Post evacuation of left intracerebral hemorrhage.

Post operative craniotomy changes in left front parietal and temporal bones.

Post operative changes seen in the left parietotemporal regions in the form of extra axial air
pockets and foci of hyper-density.

There is near complete evacuation / resolution of the hemorrhage which was seen in the left
parieto- temporal regions(now 15 x 14 mm).

Persistent Mass Effect over the left lateral ventricle and midline shift to right by 4 mm.

80
 Rest of the cerebral hemispheres, brainstem and cerebellum demonstrate normal
attenuation without focal abnormality. Rest of the basal ganglia, internal capsule, corpus
callosum and thalamus appear normal.

The cisternal spaces appear normal.

Sella and pituitary are normal. Parasellar structures are unremarkable.

There are no abnormalities in the cerebellopontine angle areas on both sides

IMPRESSION:

Post evacuation of left intracerebral hemorrhage.

Post operative craniotomy changes in left front parietal and temporal bones.

MEDICATIONS:

MEDICATIONS DOSAGE MECHANISM OF ACTION

INJ. KCL 60 MEQ IV Potassium chloride may decrease the excretion rate of Antithrombin
III human which could result in a higher serum level. Potassium
chloride may increase the hyperkalemic activities of Antrafenine.
Potassium chloride may decrease the excretion rate of Apalutamide
which could result in a higher serum level

INJ. LEVIPIL 500MG It functions by adhering to unique sites (SV2A) on nerve cell
surfaces. This prevents the spread of electrical signals that trigger
seizures by suppressing abnormal nerve cell activity in the brain
INJ. MANNITOL 100ML The mannitol causes the cells in the brain to dehydrate mildly. The
water inside the brain cells (intracellular water) leaves the cells and
enters the bloodstream as the mannitol draws it out of the cells and
into the bloodstream. Once in the bloodstream, the extra water is
whisked out of the skull.
INJ. STROCIT 500MG Strocit Injection is a nerve protecting medicine. It works on the brain
by nourishing the nerve cells, protects them from damage and
improves their survival.
INJ. COGNISTAR 60MG Cognistar 60 Injection contains Cerebroprotein Hydrolysate, which
belongs to a group of medicines called central nervous system
agents primarily, used to treat a head injury, stroke, and aprosexia in
dementia by protecting the nerves from damage and improving their
survival.
INJ. PARACIP 1GM Paracip Infusion is a common painkiller used to treat aches and
pains. It works by blocking chemical messengers in the brain. It is
effective in relieving pain caused by headache, migraine, nerve pain,
toothache, sore throat, period (menstrual) pains, arthritis, and muscle
aches.

81
INJ. PAN 40MG This drug acts to decrease gastric acid secretion, which reduces
stomach acidity.

INJ. LASIX 20MG It mainly works by inhibiting electrolyte reabsorption from the
kidneys and enhancing the excretion of water from the body.
Furosemide has a fast onset and short duration of action and has
been used safely and effectively in both pediatric and adult patients.
TAB. AMLONG 5MG Amlodipine is an angio-selective calcium channel blocker and
inhibits the movement of calcium ions into vascular smooth muscle
cells and cardiac muscle cells which inhibits the contraction of
cardiac muscle and vascular smooth muscle cells.
TAB. ATORVA 40MG It works by slowing the production of cholesterol in the body to
decrease the amount of cholesterol that may build up on the walls of
the arteries and block blood flow to the heart, brain, and other parts
of the body
TAB. MINIPRESS 5MG Prazosin is an alpha-blocker that causes a decrease in total
peripheral resistance and is used to treat hypertension.

INJ. METROGYL 500MG Metronidazole diffuses into the organism, inhibits protein synthesis
by interacting with DNA, and causes a loss of helical DNA structure
and strand breakage. Therefore, it causes cell death in susceptible
organisms.
TAB. LEVIPIL 500MG It functions by adhering to unique sites (SV2A) on nerve cell
surfaces. This prevents the spread of electrical signals that trigger
seizures by suppressing abnormal nerve cell activity in the brain.
TAB. PANTOCID 40MG This drug acts to decrease gastric acid secretion, which reduces
stomach acidity. Pantoprazole administration leads to long-lasting
inhibition of gastric acid secretion
TAB. CEREVATE 90MG Cerevate 90mg Tablet is a nerve repairing medicine. It works on the
brain by repairing the nerve cells and improves their survival.

24 HOUR DIETARY RECALL:

MENU:

Ø EARLY MORNING: COFFEE

Ø BREAKFAST: CHAPATI + BEETROOT PALYA
Ø LUNCH: RICE AND SAMBAR
Ø DINNER: CHAPATHI + CURD

82
 DETAILED MENU PLAN:

TIME MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Coffee Milk 50ml 36.44 1.63 2.47 2.24
Morning
(8AM) Coffee Powder 5g 12.05 0.61 2.05 0.025
Breakfast Chapati Wheat Flour 60g 220.2 6.5 46.2 1.02
(10AM)
Palya Beetroot 50g 22 0.8 4.78 0.08
Onion 30g 14.41 0.45 2.86 0.07
Chilly 5g 2.1 0.13 0.31 0.35
Lunch Rice Rice 40g 142.49 3.17 31.29 0.04
(2PM)
Sambar Palak 100g 24.37 2.14 2.05 0.64
Tomato 20g 3.91 0.18 0.54 0.09
Toor dal 30g 98.7 6.5 13.95 1.59
Chilly 5g 2.1 0.13 0.31 0.35
Dinner Chapati Wheat flour 60g 220.2 6.5 46.2 1.02
(7PM)
Curd 50ml 29 1.55 2.35 1.5
Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 937.97 30.29g 160.3g 19.01g
Kcal

NUTRITIONAL CALCULATION OF DIETARY RECALL:

ENERGY: 937.97Kcal

PROTEIN: 30.29g

CARBOHYDRATE: 160.3g

FAT: 19.01g

83
FOOD FREQUENCY TABLE:

FOOD GROUP NEVER DAILY WEEKLY MONTHLY YEARLY

CEREALS ●

PULSES ●

MILK ●

MILK ●
PRODUCTS
MEAT ●

VEGETABLES ●

FRUITS ●

SUGAR

NUTS ●

BEVERAGES ●

●= YES

HOSPITAL DIETARY RECALL:

DAY 1: NPO FOR SURGERY

DAY 2: RT FEEDS 100ML @2nd HOURLY (KABI PRO)- 13/12/2024

DAY 3: RT FEEDS -14/12/2024

DAY 4: RT FEEDS -15/12/2024

DAY 5: LIQUID DIET 150ML @2nd HOURLY -16/12/2024

DAY 6: SOFT DIABETIC DIET-17/12/2024

DAY 7: SOFT DIABETIC DIET -18/12/2024

DAY 8: SOFT DIABETIC DIET -19/12/2024

DETAILED HOSPITAL DIETARY RECALL:

DAY 1:NPO FOR SURGERY

DAY 2:RT FEEDS 100ML @2nd HOURLY- KABI PRO powder 2 scoops

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TIMINGS MENU QUANTITY ENERGY PROTEIN CHO FAT
(Kcal) (g) (g) (g)
Early Morning Feed 100ml 87.60 10.08 21.6 2.14
(7AM)
Morning Feed 100ml 87.60 10.08 21.6 2.14
(9AM)
Midmorning Feed 100ml 87.60 10.08 21.6 2.14
(11AM)
Afternoon Feed 100ml 87.60 10.08 21.6 2.14
(1PM)
Afternoon Feed 100ml 87.60 10.08 21.6 2.14
(3PM)
Evening Feed 100ml 87.60 10.08 21.6 2.14
(5PM)
Evening Feed 100ml 87.60 10.08 21.6 2.14
(7PM)
Bedtime Feed 100ml 87.60 10.08 21.6 2.14
(9PM)
TOTAL 700kcal 80.64g 172.8g 17.12g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 700Kcal

PROTEIN: 80.64g

CARBOHYDRATE: 172.8g

FAT: 17.12g

DAY 3: RT FEEDS 100ml @2ND HOURLY- KABI PRO powder 2 scoops

TIMINGS MENU QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk 100ml 72.89 3.26 4.9 4.4
(7AM)
Morning Ganji 100ml 180 6.3 36.42 0.52
(9AM)
Midmorning Feed 100ml 87.60 10.08 21.6 2.14
(11AM)
Afternoon Feed 100ml 87.60 10.08 21.6 2.14
(1PM)
Afternoon Feed 100ml 87.60 10.08 21.6 2.14
(3PM)
Evening Ganji 100ml 180 6.3 36.42 0.52
(5PM)
Evening Feed 100ml 87.60 10.08 21.6 2.14
(7PM)

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 Bedtime Feed 100ml 87.60 10.08 21.6 2.14
(9PM)
TOTAL 870.89Kcal 66.2g 185.7g 16.14g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 870.89Kcal

PROTEIN: 66.2g

CARBOHYDRATE: 185.7g

FAT: 16.14g

DAY 4: RT FEEDS 100ml @2ND HOURLY- KABI PRO powder 2 scoops

TIMINGS MENU QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk 100ml 72.89 3.26 4.9 4.4
(7AM)
Morning Ganji 100ml 180 6.3 36.42 0.52
(9AM)
Midmorning Feed 100ml 87.60 10.08 21.6 2.14
(11AM)
Afternoon Feed 100ml 87.60 10.08 21.6 2.14
(1PM)
Afternoon Feed 100ml 87.60 10.08 21.6 2.14
(3PM)
Evening Ganji 100ml 180 6.3 36.42 0.52
(5PM)
Evening Feed 100ml 87.60 10.08 21.6 2.14
(7PM)
Bedtime Feed 100ml 87.60 10.08 21.6 2.14
(9PM)
TOTAL 870.89Kcal 66.2g 185.7g 16.14g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 870.89Kcal

PROTEIN: 66.2g

CARBOHYDRATE: 185.7g

FAT: 16.14g

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 DAY 5: LIQUID DIET 150ML @2nd HOURLY

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 150ml 77 5.09 7.29 3.09
(7AM)
Kabi Pro 2 Scoop 87.60 10.08 21.6 2.14
Powder
Morning Juice Watermelon 100g 30 0.61 7.5 0.15
(9AM)
Midmorning Ganji Rava 50g 180 6.3 36.42 0.52
(11AM) (Semolina)
Afternoon Juice Pineapple 100g 48 0.54 12.63 0.12
(1PM)
Afternoon Soup Carrot 30g 9.9 0.2 1.6 0.14
(3PM)
Beans 30g 9.3 0.6 2.1 0.06
Sweet Corn 40g 34.0 1.29 7.6 0.47
Evening TCW Tender 150ml 58.5 1.03 13 0.28
(5PM) Coconut
Evening Ganji Rava 50g 180 6.3 36.42 0.52
(7PM) (Semolina)
Bedtime Milk Milk 150ml 77 5.09 7.29 3.09
(9PM)
Kabi Pro 2 Scoop 87.60 10.08 21.6 2.14
Powder
TOTAL 878.9Kcal 47.21g 175g 12.68g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 878.9Kcal

PROTEIN: 47.21g

CARBOHYDRATE: 175g

FAT: 12.68g

DAY 6:SOFT DIABETIC DIET

EARLY MORNING: Milk

BREAKFAST: Idli + Sambar

MIDMORNING: Mix Fruits

LUNCH: Khichdi

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 EVENING: Tea

DINNER: Pongal

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 100ml 72.89 3.26 4.94 4.48
(7AM)
Breakfast Idli Rice 40g 142.49 3.17 31.29 0.04
(9AM)
Urad dal 20g 74.2 5.14 6.8 0.84
Sambar Toor dal 30g 98.7 6.5 13.95 1.59
Onion 20g 9.6 0.30 1.9 0.04
Tomato 20g 3.91 0.18 0.54 0.09
Turmeric 1teaspoon 8.0 0.17 1.43 0.22
Midmorning Fruit Watermelon 50g 15.0 0.3 3.78 0.08
(11AM) Bowl
Papaya 50g 129 2.02 32.48 0.46
Lunch Khichdi Rice 30g 106.90 2.34 23.47 0.15
(2PM)
Toor dal 30g 98.7 6.5 13.95 1.59
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Onion 10g 4.8 0.15 0.95 0.024
Cumin seeds 5g 19 1.0 2.0 1.0
Evening Tea Milk 100ml 72.89 3.26 4.94 4.48
(5PM)
Dinner Pongal Moong dal 30g 104 7.16 18.79 0.34
(9PM)
Rice 30g 106.90 2.38 23.47 0.156
Chilly 5g 2.1 0.13 0.31 0.35
Pepper 5g 13 0.55 3.24 0.16
Cumin seeds 5g 19 1.0 2.0 1.0
Garlic 5g 6.91 0.34 6.46 0.008
Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 1233Kcal 47.48g 205g 27.37g

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 TOTAL NUTRIENTS CONSUMED:

ENERGY: 1233Kcal

PROTEIN: 47.48g

CARBOHYDRATE: 205g

FAT: 27.37g

DAY 7:SOFT DIABETIC DIET

EARLY MORNING: Milk

BREAKFAST: Upma

MIDMORNING: Sweet Corn Soup

LUNCH: Pongal + Curd

EVENING: Tea

DINNER: Khichdi + Curd

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Milk Milk 100ml 72.89 3.26 4.94 4.48
(7AM)
Breakfast Upma Rava (Sooji) 70g 303.8 5.6 49.28 9.38
(9AM)
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Chilly 5g 2.1 0.13 0.31 0.35
Urad Dal 5g 18.55 1.28 1.7 0.21
Midmorning Soup Sweet Corn 40g 34.0 1.29 7.6 0.47
(11AM)
Ginger 5g 2.74 0.11 0.44 0.042
Garlic 5g 6.19 0.345 6.46 0.008
Lunch Pongal Moong dal 30g 104 7.16 18.79 0.34
(2PM)
Rice 30g 106.90 2.38 23.47 0.156
Chilly 5g 2.1 0.13 0.31 0.35
Pepper 5g 13 0.55 3.24 0.16

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 Cumin seeds 5g 19 1.0 2.0 1.0
Garlic 5g 6.91 0.34 6.46 0.008
Curd Curd 50ml 29 1.55 2.35 1.5
Evening Tea Milk 100ml 72.89 3.26 4.94 4.48
(5PM)
Dinner Khichdi Rice 30g 106.90 2.34 23.47 0.15
(9PM)
Toor dal 30g 98.7 6.5 13.95 1.59
Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Onion 10g 4.8 0.15 0.95 0.024
Cumin seeds 5g 19 1.0 2.0 1.0
Curd Curd 50ml 29 1.55 2.35 1.5
Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 1192.85 43.18g 186.9g 37.75g
Kcal

TOTAL NUTRIENTS CONSUMED:

ENERGY: 1192.85Kcal

PROTEIN: 43.18g

CARBOHYDRATE: 186.9g

FAT: 37.75g

DAY 8:SOFT DIABETIC DIET

EARLY MORNING: Milk

BREAKFAST: Rava Idli + Chutney

MIDMORNING: Fruit Bowl

LUNCH: Mashed Rice + Drumstick Sambar + Cabbage palya + Curd

EVENING: Coffee

DINNER: Wheat Dosa + Ivy gourd palya+ Curd

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 NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Milk Milk 100ml 72.89 3.26 4.94 4.48
Morning
(7AM)
Breakfast Rava Rava 100g 360 12.68 72.83 1.05
(9AM) Idli (semolina)
Curd 100ml 58 3.1 4.7 3.0
Carrot 20g 6.64 0.19 1.1 0.09
Onion 10g 4.8 0.15 0.95 0.024
Chutney Groundnut 20g 113 5.16 3.23 9.85
Chilly 5g 2.1 0.13 0.31 0.35
Coriander 10g 3.1 0.35 0.19 0.07
Midmorning Fruit Apple 50g 26.0 0.13 6.9 0.08
(11AM) Bowl
Papaya 50g 129 2.02 32.48 0.46
Lunch Mashed Rice 50g 178.17 3.97 39.12 0.26
(2PM) Rice
Sambar Drumstick 100g 64 9.4 8.2 1.4
Potato 30g 23.1 0.6 5.52 0.03
Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Coriander 10g 3.1 0.35 0.19 0.07
Palya Cabbage 100g 24 1.4 5.8 0.12
Onion 20g 9.6 0.30 1.9 0.04
Chilly 5g 2.1 0.13 0.31 0.35
Curd Curd 50ml 29 1.55 2.35 1.5

Evening Coffee Milk 50ml 36.44 1.63 2.47 2.24

(5PM)
Coffee 5g 12.05 0.61 2.05 0.025
powder
Dinner Wheat Wheat Flour 50g 160 5.2 32 0.76
(9PM) Dosa
Palya Ivy gourd 100g 18 1.57 3.5 0.23

Onion 20g 9.6 0.30 1.9 0.04

Coriander 10g 3.1 0.35 0.19 0.07

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 Chilly 5g 2.1 0.13 0.31 0.35
Garlic 5g 6.19 0.345 6.46 0.008
Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 1479.5Kcal 55.48g 247.3g 37.30g

TOTAL NUTRIENTS CONSUMED:

ENERGY: 1479.5Kcal

PROTEIN: 55.48g

CARBOHYDRATE: 247.3g

FAT: 37.30g

DAY 9: DISCHARGE.

DISCHARGE DIET GIVEN AT THE HOSPITAL:

DIABETIC DIET WITH HIGH CALORIE

GUIDELINES:

• Eat regular meals throughout the day.

• Make vegetables the main part of the meal. Aim to fill at least half of the plate with
non-starchy vegetables or salad at both lunch and dinner time.
• One need to reduce the serving size of meals and snacks, as eating too much can lead
to weight gain and make diabetes harder to manage.
• Include a small serving of high-fiber carbohydrate at each meal. Examples of high-
fiber carbohydrate foods are wholegrain bread, cereals (such as oats, Vita Brits®, All-
Bran® and natural muesli), whole-meal pasta, brown rice, quinoa, fruit and starchy
vegetables (such as corn, sweet potato and potato).
• Choose reduced-fat or low-fat dairy products. Look for those with the least amount of
added sugar. Greek yoghurt with fresh fruit is a good choice.
• Choose lean meats and alternatives, such as skinless chicken and turkey, fish, eggs,
legumes (beans, lentils), tofu and nuts.

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• Limit the unhealthy (saturated) fats that are found in foods such as full-fat dairy
products, butter, cream, fatty and processed meats, fried foods, cakes, pastries, and
foods containing palm oil and coconut oil.
• Instead, replace saturated fats with healthy unsaturated fats like olive, canola or
sunflower oil, monounsaturated or polyunsaturated margarines, oily fish, avocado,
seeds and nuts.
• Oily fish is great for heart health. Aim to include oily fish such as salmon (tinned or
fresh), sardines, mackerel, herring or tuna at least 2 to 3 times per week.
• Save baked items like cakes and biscuits, slices and desserts for special occasions.
• Avoid sweet drinks (soft drink, cordial, sports drinks, flavored waters and energy
drinks).
• Don't add salt when you cook or at the table and reduce the use of high-salt foods.
• Use herbs and spices to add flavor to the food.
• Limit alcohol to 2 standard drinks per day, with some alcohol-free days each week.
• Patients who take insulin should not keep fast as it may result in hypoglycemia or low
blood sugars
• Do not skip your meal as it may result in low blood sugar
• Do not eat pastries, chocolates, bread, chips, etc. It can increase the blood sugar levels
• Do not eat fried and fatty food items
• Do not consume fatty dairy products.
• Avoid artificial sweeteners as much as possible.
• Try and drink coffee and tea without putting sugar in it
• Do not perform exercise on an empty or full stomach.
• Stop smoking.

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SAMPLE MENU:

According to Harris Benedict Equation:

BMR: 88.3 + (13.3*Weight) + (4.7*Height) – (5.67*Age)

=88.3+ (13.3*70) +(4.7*170) -(5.67*60)

=88.3+ 931+ 799 – 340.2

BMR = 1478Kcal

ENERGY: 1478* 1.2 =1779Kcal

PROTEIN: 1.1g/kg body weight =77g

CHO: 1770/400* 60= 265.5g

FAT: 47g

EXCHANGE LIST:

FOOD GROUPS PORTION ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Cereals & millets 8 800 24 160 5.6
Pulses 3 300 18 45 2.1
Milk/ Milk 2 140 6.0 10 6.0
products
Root & Tubers 2 160 2.6 36 -
Other Vegetables 2 56 3.4 - 0.4
Green leafy 1 46 3.6 - 0.4
vegetables
Fruits 1 40 - 10 -
Sugar 1 20 - 5 -
Oils & Fat 2 90 - - 10
Nuts 1 45 - - 5
Egg 1 85 7.0 - 7.0
TOTAL 1780Kcal 64.6g 266g 36.5g

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 MEAL DISTRIBUTION:
FOODGROUP PORTION EARLY BREAK- MID- LUNCH EVENING DINNER BEDTIME
MORNING FAST MORNING
Cereals & 8 3 2 3
millets
Pulses 3 1 1 1

Milk/ Milk 2 0.5 0.5 1

products
Root & 2 1 0.5 0.5
Tubers
Other 2 0.5 0.5 1
Vegetables
Green leafy 1 1
vegetables
Fruits 1 1

Sugar 1 1

Oils & Fat 2 0.5 1 0.5

Nuts 1 1

Egg 1 1

MENU:

EARLY MORNING: Fenugreek Seed Water + Almonds

BREAKFAST: Paneer Peas Pulao

MIDMORNING: Guava Juice

LUNCH: Brown Rice+ vegetable sambar+ Curd+ Methi palya

EVENING: Green gram Salad

DINNER: Wheat Chapati+ Lady’s finger curry

BEDTIME: Low Fat Milk

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 NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Morning Fenugreek Fenugreek 30g 97 4.9 17.5 1.9
(7AM) seeds
Nuts Almond 10g 60.92 1.84 0.304 4.84
Breakfast Pulao Rice 50g 178.17 3.97 39.12 0.26
(9AM)
Peas 50g 40 2.7 7.2 0.2
Paneer 50g 132.5 6.2 1.34 9
Onion 20g 9.6 0.3 1.9 0.08
Tomato 20g 3.91 0.18 0.54 0.09
Chilly 5g 2.1 0.13 0.31 0.35
Midmorning Juice Guava 100g 68 2.5 14.3 0.95
(11AM)
Lunch Rice Brown rice 50g 55 1.28 11.39 0.45
(2PM)
Palya Methi 100g 43 4.8 7.14 0.75
Onion 20g 9.6 0.3 1.9 0.08
Coriander 10g 3.1 0.35 0.19 0.07
Sambar Potato 50g 34.89 0.77 7.4 0.11
Egg plant 50g 12 0.5 2.85 0.1
Tomato 20g 3.91 0.18 0.54 0.09
Toor Dal 30g 37.5 6.3 6 0.3
Curd Curd 100ml 58 3.1 4.7 3.0
Egg Egg 50g 85 7 - 7
Evening Salad Green gram 70g 235 14.3 37.5 0.69
(5PM)
Onion 30g 14.41 0.45 2.86 0.07
Cucumber 30g 5.7 1.02 0.21 0.03
Dinner Chapati Wheat flour 60g 220.2 6.5 46.2 1.02
(8PM)
Palya Lady’s finger 100g 33 1.93 - 0.19
Onion 30g 14.41 0.45 2.86 0.07
Chilly 5g 2.1 0.13 0.31 0.35
Coriander 5g 1.55 0.17 0.09 0.035
Bedtime Milk Milk 100ml 72.89 3.26 4.9 4.4

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(10:30PM)
Sugar 5g 20 - 5 -
Oil 15ml 135 - - 15
TOTAL 1700Kcal 73g 230g 45g

INTERPRETATION OF THE CASE:

A 60 years old male patient, moderately built and nourished had complaints of
profuse sweating and blurring vision since2 days before admission. Patient was unable to
move his right sided limbs since2 days. Patient had history of diabetes from few years. The
patient got admitted to the ward with the above mention complaints on 11/12/20234. CT
Brain was done on 11/12/2024, report shows cerebral atrophic changes and patient was
posted for surgery. LEFT TEMPORO PARIETAL CRANIOTOMY AND EVACUATION
OF BLEED BONE was done on 11/12/2024. During the stay in the hospital, patient was
treated with IV fluids, PPI s, antibiotics, antiemetics, and other supportive measures.

Patient was under RT Feeds after surgery for 3days, later LIQUID Diet as his intake was low.
SOFT DIABETIC DIET was started on 16/12/2024 and his intake gradually increased.

Based on Harris Benedict’s equation, the BMR requirement for the patient is:

Energy: 1780Kcal, Protein: 77g, CHO: 265g, Fat: 47g

Therefore, Nutritional Counselling was done to the patient during discharge and Diabetic diet
with small frequent meals was prescribed.

8 days of Hospital recall was collected. During the hospital stay patient intake was good and
followed nutrition guidance.

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 CASE STUDY-4

UMBILICAL HERNIA
INTRODUCTION: An umbilical hernia is an outward bulge in the area around the belly
button. It occurs when internal organs or the abdominal lining bulges through the muscles
near the belly button.

An umbilical hernia occurs when part of the intestine bulges through the opening in
the abdominal muscles near the bellybutton (navel). Umbilical hernias are common and
typically harmless.

An umbilical hernia appears when fat, tissue or a loop of the bowel pushes through
the muscles around the navel. These muscles sometimes have a weakness at the navel,
allowing an umbilical hernia to push through.

An umbilical hernia can affect adults, children and babies. Umbilical hernias in adults
tend to be above or below the navel, these are sometimes called paraumbilical hernias.

Umbilical hernias are most common in infants, but they can affect adults as well. In
an infant, an umbilical hernia may be especially evident when the infant cries, causing the
bellybutton to protrude. This is a classic sign of an umbilical hernia.

PATHOPHYSIOLOGY:

An umbilical hernia is a ventral hernia located at or near the umbilicus. In general,

umbilical hernias tend to have a narrow neck, which increases the risk of strangulation and
incarceration. The majority of umbilical hernias in adults are acquired and may occur either
above or below the umbilicus.

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 An umbilical hernia forms when part of the intestine or fatty tissue protrudes through
an opening in the abdominal muscles near to the navel, causing the belly button to swell. This
type of hernia may develop in babies if the opening that the umbilical cord passes through
does not close properly after birth. This hernia can also affect adults, possibly due to repeated
abdominal strain.

Although a hernia can develop anywhere in the body, they usually occur somewhere
between the chest and hips, with abdominal hernia being the most common form. A weakness
in the abdominal wall leads to a hole forming and abdominal organs or adipose tissue then
push through the hole, creating a bulge. Hernias can also occur in other parts of the body such
as the spine when the intervertebral discs protrude outwards and press on nearby nerves.

Most hernias are reducible, which means the herniated contents can be manipulated
back into the abdominal cavity. Irreducible hernias, on the other hand, cannot be pushed back
to their original location. This can lead to strangulation, which refers to when pressure placed
on the hernial contents may compromise the blood supply to the tissue, leading to ischemia,
cell death and even gangrene. Obstruction may also occur if part of the gut herniates and the
bowel contents can no longer move through the herniated area. This can lead to cramps,
absence of defecation and vomiting.

SYMPTOMS:

A hernia in the abdomen or groin can produce a noticeable lump or bulge that can be
pushed back in, or that can disappear when lying down. Laughing, crying, coughing, straining
during a bowel movement, or physical activity may make the lump reappear after it has been
pushed in. More symptoms of a hernia include:

• Swelling or bulge in the groin or scrotum (the pouch that contains the testicles).
99
 • Increased pain at the site of the bulge.
• Pain while lifting.
• Increase in the bulge size over time.
• A dull aching sensation.
• A sense of feeling full or signs of bowel obstruction.

CAUSES:

The causes of an umbilical hernia are different in infants and adults. In adults, women
are more likely to get umbilical hernias than men — especially if they are pregnant or have
had multiple pregnancies. But men are more likely to have a strangulated umbilical hernia.

Most umbilical hernias occur in infants. This happens because the muscle around the
umbilical cord hasn’t completely closed yet. In babies, these hernias usually close up on their
own.Ninety percent of umbilical hernias in adults are acquired. Weakened abdominal
muscles and excessive abdominal pressure cause them.

Risk factors for adult umbilical hernias include:

• Being overweight or obese

• Having several pregnancies
• Buildup of fluid in the abdominal cavity (ascites)
• Previous surgery in the abdominal area
• Receiving long-term dialysis through the abdomen (peritoneal dialysis)

Adults may get an umbilical hernia by straining the abdominal area, being overweight,
having a long-lasting heavy cough or after giving birth.

100
TREATMENT:

Hernias usually do not get better on their own, and surgery may be the only way to
repair them.If an adult has an umbilical hernia, surgery is usually recommended because the
condition will not likely improve on its own and the risk of complications is higher.

One of three types of hernia surgery can be performed:

a. Open surgery: in which a cut is made into the body at the location of the hernia. The
protruding tissue is set back in place and the weakened muscle wall is stitched back
together. Sometimes a type of mesh is implanted in the area to provide extra support.
b. Laparoscopic surgery: involves the same type of repairs. However, instead of a cut
to the outside of the abdomen or groin, tiny incisions are made to allow for the
insertion of surgical tools to complete the procedure.
c. Robotic hernia repair: like laparoscopic surgery, uses a laparoscope, and is
performed with small incisions. With robotic surgery, the surgeon is seated at a
console in the operating room, and handles the surgical instruments from the console.
While robotic surgery can be used for some smaller hernias, or weak areas, it can now
also be used to reconstruct the abdominal wall.

PREVENTION:

• Maintain ideal body weight by eating a healthy diet and exercising.

• Eat enough fruits, vegetables and whole grains to avoid constipation.
• Use correct form when lifting weights or heavy objects. Avoid lifting anything that is
beyond your ability.
• Don’t smoke, as the habit can lead to coughing that triggers a hernia.

NUTRITIONAL INTERVENTION:

Once detected with a hernia, one would have to be very careful about the diet that he
or she is following in such a way that their abdomen or the groin area does not get affected.
Eating can make all the difference to the patient. Diet can play an important role in
controlling the major symptoms of hernia such as heartburn and acid digestion that are
commonly suffered by the patients.

It is important to maintain a good diet after surgery. A proper diet can help speed up the
process of healing after hernia treatment.

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• Protein Intake: protein intake should be high. Include eggs, soy, fish, cottage cheese,
nuts, dairy, and meat in diet.
• Vitamin C: Include vitamin C in diet for a speedy recovery. Include citrus fruits like
lemon and oranges, potatoes, tomatoes, spinach, and cauliflower.
• Vitamin D: Consume foods high in vitamin D. These include cereals, orange juice,
and almond milk
• Calcium intake: Calcium intake is important forbones and strength. Include dairies
like cheese, milk, and yogurt. Also add seeds like chia, sesame, and poppy seeds.
Almonds are also a good option.
• Fruit Items: Fruits fresh fruits that have high fiber content and are rich in antioxidants
should form a part of every meal. The high fiber content will ensure that one do not
get constipated and the antioxidants will help protect the body and boost the immune
system. Citrus fruits, berries, and apples are some examples of fruits with high fiber
and vitamin content.
• Vegetable Items: Vegetables these too have a high fiber content that will guard
against the dangers of constipation after umbilical hernia surgery. They also have high
levels of vitamins and minerals and should also be included with every meal.
• Meat Items: try to add lean meat, it is a source of protein, which is essential to the
repair of damaged tissue. Lean meat like poultry and fish is an excellent source of
low-fat protein. Have one good source of low-fat protein with every meal.
• Dairy Products: low-fat dairy products are a good source of protein and can be
alternated with lean meats to provide the body with sufficient protein.
• Fiber Food Items for Umbilical Hernia Patients: High fiber breakfast foods will aid
digestion and so, breakfast should consist of foods made from whole wheat flour,
wheat germ, oatmeal, or bran.

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NUTRITIONAL SCREENING:

Date of Assessment: 22/11/2024

PATIENT PROFILE:

PATIENT NAME: XYZ

AGE: 30Years

GENDER:Female

COMMUNITY: Hindu

OCCUPATION:Office employee

ECONOMIC STATUS: Good

NUMBER OF FAMILY MEMBERS:4

FOOD ALLERGIES: Nothing significant

FOOD PREFERENCE:Non-Vegetarian

PERSONAL HABIT:Nil

UHID:12238377

DATE OF ADMISSION:20/11/2024

DATE OF DISCHARGE:22/11/2024

DIAGNOSIS: Umbilical Hernia (Laproscopic Umbilical Herniaplasty)

ANTHROPOMETRIC MEASUREMENTS:

HEIGHT: 155cm

WEIGHT:61Kg

BMI:25.41

BMI CLASSIFICATION:Overweight

IBW: (Height – 100) = 155-100= 55Kg

WAIST CIRCUMFERENCE:79cm

HIP CIRCUMFERENCE:89cm

BMR: Using Thumb Rule; Estimated Calories= 1500Kcal and Protein= 55g

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PHYSICAL ACTIVITY: Moderate

CLINICAL DATA:

PAST HISTORY:Nil

CHIEF COMPLAINTS: ℅ Pain in the abdomen, ℅ swelling in the umbilical region since
3-4 months and Occasional pain. No history of fever and cough.

CURRENT SYMTOMS: Abdominal pain in the umbilical region since few days.

FAMILY HISTORY: Nil

PHYSICAL EXAMINATION:

a. Temperature: 98℉
b. Pulse rate: 104/Min
c. Blood Pressure: 130/80 mmHg
d. SpO2: 96% in RA
e. GRBS:86mg/dL

HAEMATOLOGY:Blood group: Oand Rh: POSITIVE

BIOCHEMICAL PARAMETERS:

PARAMETERS UNIT 15/01/2023 NORMAL VALUES

WBC Count thou/µL 13.60 4.0-10.0

RBC Count mil/µL 5.12 3.8-4.8
Hemoglobin (Hb) g/dL 9.7 12-15
Neutrophils % 59 40-80
Lymphocytes % 32 20-40
Monocytes % 05 2.0-10.0
Eosinophils % 04 1-6
Basophils % 00 ≤1-2
Platelet Count thou/µL 601 150-410
Creatinine mg/dL 0.80 0.50-0.90
Sodium, Serum mmol/L 138 137-145
Potassium, Serum mmol/L 4.0 3.6-5.0
Chloride, Serum mmol/L 105 98-107

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 MEDICATIONS:

MEDICATION DOSAGE MECHANISM OF ACTION

INJ. 1.2GM AUGMENTIN is an antibiotic used for the short-term treatment

AUGMENTIN of infections in different parts of the body caused by bacteria.
INJ. PAN 40MG This drug acts to decrease gastric acid secretion, which reduces
stomach acidity.
INJ. EMESET 4MG It works by blocking the action of a chemical messenger
(serotonin) in the brain that may cause nausea and vomiting
during anti-cancer treatment (chemotherapy) or after surgery.
INJ. DYNAPAR- 1AMP It is used for short-term relief of pain, inflammation, and
AQ swelling in conditions that affect joints and muscles. It works
by blocking chemical messengers in the brain that tell us we
have pain.
INJ. PCT 1GM It works by increasing the activity of a chemical messenger
(acetylcholine) which improves communication between the
nerve cells. It also protects the brain and nervous system
against shortness of oxygen.
INJ. TRAMADOL 100MG (+)-Tramadol inhibits serotonin reuptake and (-)-tramadol
inhibits norepinephrine reuptake, enhancing inhibitory effects
on pain transmission in the spinal cord. The complementary and
synergistic actions of the two enantiomers improve the
analgesic efficacy and tolerability profile of the racemate.
NEB. DUOLIN - They work by relaxing the muscles of these airways. This
makes it easier for air to get in and out. It will relieve symptoms
such as tightness in the chest, shortness of breath, wheezing and
coughing
NEB. BUDECORT - It works by preventing inflammation (swelling) in the lungs,
which makes the asthma attack less severe. Inhaled budesonide
may be used with other asthma medicines such as
bronchodilators, which are also used to open up narrowed
breathing passages in the lungs.

24 HOUR DIETARY RECALL:

MENU:

Ø EARLY MORNING: COFFEE

Ø BREAKFAST: IDLI
Ø LUNCH: CURD-RICE
Ø EVENING: FRUITS
Ø DINNER: MILK

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 DETAILED MENU PLAN:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Coffee Milk 50ml 36.44 1.63 2.47 2.24
Morning
(6AM) Coffeepowder 5g 12.05 0.61 2.05 0.025
Breakfast Bread Bread 50g 133 3.82 25.3 1.64
(9AM) omelet Onion 10g 4.8 0.15 0.956 0.024
Chilly 5g 2.1 0.13 0.31 0.35
Egg 100g 170 14 - 14
Lunch Curd- Rice 50g 178.1 3.9 39.12 0.26
(1:30PM) rice
Curd 100ml 58 3.1 4.7 3.0
Evening Fruits Apple 100g 62.38 0.29 13.9 0.64
(5PM) Banana 100g 110.65 1.25 24.95 0.32

Dinner Milk Milk 100ml 72.89 3.26 4.94 4.48

(8PM) Sugar 5g 20 - 5 -

TOTAL 860.4Kcal 32.14g 123.69g 26.9g

NUTRITIONAL CALCULATION OF DIETARY RECALL:

ENERGY: 860.4 Kcal

PROTEIN: 32.14g

CARBOHYDRATE: 123.69g

FAT: 26.9g

FOOD FREQUENCY TABLE:

FOOD GROUPS NEVER DAILY WEEKLY MONTHLY YEARLY

CEREALS ●
PULSES ●
MILK ●
MILK ●
PRODUCTS
MEAT ●
OIL ●
VEGETABLES ●
FRUITS ●

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 SUGAR ●
NUTS ●
BEVERAGES ●
●= YES

HOSPITAL DIETARY RECALL:

(20/11/24) – Admitted at Night

DAY 1:NPO (21/11/24) – FOR SURGERY

DAY 2:SOFT DIET (22/11/24)

MENU:

EARLY MORNING: Coffee

BREAKFAST: Rava Idli

MIDMORNING: Mix Fruits

LUNCH: Khichdi+ curd + Salad

DINNER: Wheat Dosa+ Lady’s finger Palya

NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENTS QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early Coffee Milk 50ml 36.44 1.63 2.47 2.24
Morning
(6:30AM) Coffee Powder 5g 12.05 0.61 2.05 0.025
Breakfast Rava Rava 100g 360 12.68 72.83 1.05
(9AM) Idli
Curd 100ml 58 3.1 4.7 3.0
Carrot 20g 6.64 0.19 1.1 0.09
Onion 10g 4.8 0.15 0.95 0.024
Chutney Red Chilly 5g 17 - 3.75 0.2
Groundnut 20g 113 5.16 3.23 9.85
Coriander 10g 3.1 0.35 0.19 0.07
Garlic 5g 6.19 0.345 6.46 0.008
Midmorning Mix Pineapple 50g 18.55 0.26 4.71 0.08
(11AM) Fruits
Watermelon 50g 15.0 0.3 3.78 0.08
Lunch Khichdi Rice 30g 106.90 2.34 23.47 0.15
(2PM)
Toor dal 30g 98.7 6.5 13.95 1.59

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 Carrot 20g 6.64 0.19 1.1 0.09
Beans 20g 8.55 1.44 2.37 0.19
Onion 10g 4.8 0.15 0.95 0.024
Curd Curd 50ml 29 1.55 2.35 1.5
Salad Onion 10g 4.8 0.15 0.956 0.024
Cucumber 10g 1.9 0.34 0.07 0.01
Tomato 10g 1.95 0.09 0.27 0.045
Dinner Wheat Wheat Flour 60g 221.4 6.48 44.44 1.08
(8PM) Dosa
Palya Lady’s Finger 100g 33 1.9 7.0 0.2
Onion 20g 9.6 0.3 1.9 0.08
Tomato 20g 3.91 0.18 0.54 0.09
Sugar 5g 20 - 5 -
Oil 10ml 90 - - 10
TOTAL 1291Kcal 46.3g 210.5g 31.79g

TOTAL NUTRIENTS:

ENERGY: 1291Kcal

PROTEIN: 46.3g

CARBOHYDATE: 210.5g

FAT: 31.79g

DISCHARGE DIET GIVEN AT THE HOSPITAL:

LOW FAT LOW CHOLESTEROL DIET

GUIDELINES:

TO EAT:The following foods are low in acid production and are less likely to worsen hernia
symptoms:

• Include HDL-rich foods like almonds, walnuts, oats, and flax seeds in diet.
• Tuna, sardine, salmon, and mackerel are examples of fatty fish.
• Consume egg whites and chicken skins.
• Whole grains, legumes, vegetables, and fruits are high in fiber and hence healthy
• Low-fat milk products should be included.
• Incorporate one cup of green tea
• Introduce some physical activity into your daily regimen.

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 • Include soluble fiber-rich foods including banana, oats, apple, guava, beans,
avocados, berries, barley, quinoa, flax and chia seeds, figs, coconut, and okra (lady’s
finger).
• Apples and bananas
• Broccoli, green beans, peas, carrots, and peas
• Cereals (bran and oatmeal), bread, rice, pasta, and crackers are examples of grains.
• Low-fat or skim milk, as well as low-fat yogurt
• Fat-free cheeses, cream cheese, and sour cream are all options.
• Fish, chicken, and lean meat
• Water
• Pretzels, graham crackers, rice cakes, and baked potato chips.
• Low-fat desserts (no chocolate or mint).

TO AVOID:

The meals listed below are either very acidic or may weaken the lower esophageal
sphincter, making it easier for stomach acids to back up into the esophagus. They have the
potential to induce heartburn problem:-

• Red meat, organ meats, and shellfish are high in cholesterol.

• Meals cooked with hot oil.
• Meals containing a lot of oil, as well as foods containing a lot of cream and cheese.
• Saturated fats such as palm oil, butter, margarine, and ghee should be avoided.
• Citrus fruits and juices such as oranges, grapefruits, cranberry juice, and lemonade, as
well as orange juice, grapefruit juice, cranberry juice, and lemonade
• Chocolate
• Onions with garlic
• Food that is hot and spicy
• Spearmint and peppermint
• Spaghetti sauce, pizza, chili, salsa, and tomato juice are all tomato-based meals.
• Coffee, tea (including decaffeinated varieties), and alcoholic beverages
• Beverages with carbonation

COOKING TIPS:These tips should be followed while preparing the meal:

• To sauté foods, use healthy oil such as olive oil, grapeseed oil, and avocado oil.

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 • Eat whole fibers whenever possible.
• Don’t deep fry foods.
• Restrict eating processed and packaged ingredients.
• Use healthy oils such as coconut oil, avocado oil that doesn’t break down in high heat
• During the preparation of foods such as pickles, yogurt make sure to incorporate
fermented foods.
• Eat small portion of meals frequently throughout the day.
• Drink lots of potable water. Aim for drinking almost eight glasses of water per day.
• Add probiotics in daily diet. Some examples are yogurt, kefir, kombucha, and pickles.

SAMPLE MENU:

According to Harris Benedict Equation:

BMR: 447.5 + (9.2*Weight) + (3.0*Height) – (4.3*Age)

=447.5+ (9.2*55) +(3.0*155) -(4.3*30)

=447.5+ 506 + 465- 129

BMR = 1289Kcal

ENERGY: 1289* 1.2 =1547Kcal

PROTEIN: 1.0g/kg body weight =55g

CHO: 1547/400* 65= 251.38g

FAT: 40g

EXCHANGE LIST:

FOOD GROUPS PORTION ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Cereals & millets 8 800 24 160 6.4
Pulses 2 200 12 30 1.4
Milk/ Milk 2 140 6.0 10 6.0
products
Root & Tubers 2 160 2.6 36 -
Green leafy 1 46 3.6 - 0.4
vegetables
Other Vegetables 2 56 3.4 - 0.4
Fruits 2 80 - 20 -

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 Sugar 1 20 - 5 -
Oil & Fats 1 45 - - 5
TOTAL 1547Kcal 51.6g 260g 21g

MEAL DISTRIBUTION:
FOOD PORTION EARLY BREAK- MID- LUNCH SNACKS DINNER BEDTIME
GROUPS MORNING FAST MORNING
Cereals & 8 3 2 3
millets
Pulses 2 1 1
Milk/ Milk 2 0.5 0.5 1
products
Root & 2 0.5 0.5 1
Tubers
Green leafy 1 1
vegetables
Other 2 0.5 0.5 1
Vegetables
Fruits 2 0.5 0.5 1
Sugar 1 0.5 0.5
Oils & Fats 2 1 1

MENU:

EARLY MORNING: Tender Coconut Water

BREAKFAST: Broken Wheat Porridge

MIDMORNING: Fruit Bowl

LUNCH: Rice + Palak fry + Vegetable sambar + Buttermilk

EVENING: Sprouted Green Gram Salad

DINNER: Chapati + Vegetable Kurma

BEDTIME: Milk

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 NUTRIENT CALCULATION:

TIMINGS MENU INGREDIENT QUANTITY ENERGY PROTEIN CHO FAT

(Kcal) (g) (g) (g)
Early TCW Tender 100ml 15.30 0.26 - 0.16
Morning coconut water
(6:30AM)
Breakfast Porridge Broken Wheat 100g 327 12.6 71.18 1.54
(9AM)
Milk 50ml 36.44 1.63 2.47 2.24
Apple 50g 26.0 0.13 6.9 0.08
Midmorning Fruit Papaya 100g 43 0.5 11 0.3
(11AM) Bowl
Watermelon 50g 15.0 0.3 3.78 0.08
Lunch Rice Rice 50g 178.17 3.97 39.12 0.26
(2PM)
Sambar Toor Dal 30g 98.7 6.5 13.95 1.59
Potato 50g 34.89 0.77 7.4 0.11
Brinjal 50g 12 0.5 2.85 0.1
Tomato 20g 3.91 0.18 0.54 0.09
Onion 20g 9.6 0.30 1.9 0.04
Palak fry Palak 100g 24.37 2.14 2.05 0.64
Buttermilk Curd 50g 29 1.55 2.35 1.5
Evening Salad Sprouted 100g 29 3.59 4.69 0.48
(5PM) Green gram
Onion 30g 14.41 0.45 2.86 0.07
Cucumber 30g 5.7 1.02 0.21 0.03
Dinner Chapati Wheat Flour 60g 221.4 6.48 44.44 1.08
(8PM)
Kurma Carrot 30g 9.9 0.2 1.6 0.14
Beans 30g 9.3 0.6 2.1 0.06
Peas 30g 24 1.63 4.34 0.12
Cauliflower 30g 8 0.59 1.59 0.03
Onion 20g 9.6 0.30 1.9 0.04
Tomato 20g 3.91 0.18 0.54 0.09
Chilly 5g 2.1 0.13 0.31 0.35
Coriander 10g 3.1 0.35 0.19 0.07
Bedtime Milk Milk 100ml 72.89 3.26 4.94 4.48
(10PM)

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 Oil 10ml 90 - - 10
Sugar 10g 40 - 10 -
TOTAL 1510Kcal 49.8g 232g 25g

INTERPRETATION OF THE CASE:

A 30 years old female patient, moderately built and nourished, had complaints of pain
in the abdomen, swelling in the umbilical region since3-4 months and occasional pain which
aggravated from few days. The patient got admitted to the ward with the above mention
complaints on 20/11/2024 .Relevant investigations were done and the patient was thoroughly
evaluated. USG abdomen and pelvis was done- report shows left kidney small in size.
Thickened endometrium, Reducible umbilical hernia. Patient was posted for surgery on
21/11/24. After preanesthetic evaluation and fitness, patient underwent LAPAROSCOPIC
MESH REPAIR + LAPAROSCOPIC ADHESIOLYSIS on 21/11/2024. Patient withstood the
procedure well. During the course of stay in the hospital, patient was treated with IV Fluids,
PPI's, antibiotics, analgesics, antiemetic and other supportive measures.

During the stay in the hospital patient followed a regular Soft Diet for her recovery and her
appetite was good, met almost her caloric and protein needs. Nutritional counselling was
done to the patient and advised about low fat and low cholesterol diet.

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