Question

NTR444/544: MNT-II

In-Class Case Study

Total: 8 points

Mr. Neely is a 58-year-old male diagnosed with stage IV squamous cell carcinoma of the right anterior tongue. The cancer has been found in the lymph but has not metastasized to other organs. The patient is s/p partial glossectomy with right neck dissection and PEG tube placement, currently post-op day 2. The dietitian has been consulted to manage enteral support.

The patient reports a 24-pound unintentional weight loss in the last 3 months. The patient reports decreased intake secondary to poor appetite, early satiety and oral pain when eating x 1 month prior to admit (PTA). He denies N/V, diarrhea and swallowing difficulties PTA. Mr. Neely reports working in construction for the last 20 years but he has been relatively sedentary in the last 2-3 months since his diagnosis. The plan is for Mr. Neely to maintain enteral nutrition support while undergoing radiation and adjuvant chemotherapy s/p discharge from the hospital.

Anthropometric data: Height 6’ 3”, Current Weight: 177 lbs

Laboratory Results

	Ref. Range	10/15 1523
Chemistry
Sodium (mEq/L)	136-145	136
Potassium (mEq/L)	3.5-5.5	3.6
Chloride (mEq/L)	95-105	98
Carbon dioxide (CO2, mEq/L)	23-30	26
BUN (mg/dL)	8-18	10
Creatinine, serum (mg/dL)	0.9-1.3	1.0
Glucose (mg/dL)	70-99	98
Phosphate, inorganic (mg/dL)	2.3-4.7	3.2
Calcium (mg/dL)	9-11	10.2
Protein, total (g/dL)	6-8	5.7 !
Albumin (g/dL)	3.5-5	3.0 !
Prealbumin (mg/dL)	18-35	12 !
Alkaline Phosphatase (U/L)	30-120	21
ALT (U/L)	4-36	99
AST (U/L)	0-35	33
Lactate Dehydrogenase (U/L)	208-378	290
CRP (U/L)	<1	141 !
Coagulation
PT (sec)	11-13	13
Hematology
WBC	3.9-10.7	6.9
RBC	4.5-6.2	4.3
Hemoglobin (Hgb, g/dL)	14-17 M	13.9 !
Hematocrit (Hct, %)	41-51 M	38 !

Questions

1. Would you consider Mr. Neely to be at nutritional risk? Why or why not?

Yes, due to his unintentional weigh loss of 24 lbs. in three months, reported poor intake of food due to various factors and lab results showing low total protein levels.

1. Does the patient meet the criteria for cancer cachexia? Why or why not?

   Yes, the unintentional weight loss, reduced intake and being sedentary for 2-3 months post diagnosis.

1. Estimated needs:
   1. What kcal/kg range would you recommend for Mr. Neely? Why?

80.45 kg * 30

1. In regards to protein, what g/kg body weight range would you recommend? Why?

1.3 g/kg

1. In regards to fluid, what are your recommendations?

1. Calculate Mr. Neely’s estimated energy, protein and fluid needs using the values from question 3 above.

1. The physician has ordered Jevity 1.2 at 60 ml/hr x 24 hour. Calculate total energy, protein and water provided at the current enteral goal rate. Will this goal rate meet Mr. Neely’s calculated energy and protein needs?

Calories (kcal/mL)

1.2

Protein (g/L)

55.5

Water (mL)

808

1. If Mr. Neely’s needs are not met:
   1. What goal rate would you suggest to better meets energy and protein needs?
   2. How much energy, protein and water is provided at the new goal rate?
   3. What are your water flush recommendations?

Answer 1

1. we can explain the terms energy and protein as the power that keeps us moving is energy and the substance that helps in growth is protein. The energy is provided by the carbohydrates, fats and protein. this energy is used for body functions and physical activities. The energy contribution from from the different substances is as follows: carbohydrates-55-75%, protein- 10-15%, and fat- 15-30%. the protein is used to repair all the body tissues. to increase the protein level in the body take food from animal sources because it is considered as complete protein. if Mr. Neely is a pure vegetarian he should take food from different plant sources because there is a missing amino acid in the each plant source for example grains are limited in lysine and legumes are limited in methionine. by taking all the foods the amino acid missed from one source will be substituted by other. Mr. Neely should take 65 gm to 75 gm of protein per day. meat, poultry, egg, fish and dry beans are good source of protein. try to implement them in your daily diet.

2. he should take 65 gm to 75 gm of protein per day, as our body contains 50-75% of water and it is essential for most of the body functions.he should take atleast 2 L of water per day. he should include food rich with water source. by taking the food rich with protein and fluids the body can build by energy.

3. our body has amazing complex system of detoxification which include skin, liver, kidneys, gastrointestinal system and lymphatic system. by drinking the minimum water through out the day our body can flush water simultaneously. if the patient is weak and can not move he can use urinary catheters for some days.