CASE STUDY ON-1

TKR
 TKR
TOTAL KNEE REPLACEMENT

Knee replacement, also called knee arthroplasty or total knee

replacement, is a surgical procedure to resurface a knee damaged by
arthritis. Metal and plastic parts are used to cap the ends of the bones
that form the knee joint, along with the kneecap. This surgery may be
considered for someone who has severe arthritis or a severe knee
injury.
 WHY ITS DONE

 The most cool on reason for knee replacement surgery is to relieve

severe pain caused by osteoarthritis. Osteoarthritis a degenerative
joint disease that effects mostly aged and older adults, may cause
the breakdown of joint cartilage and adjacent bone in the knees .
 Rheumatoid arthritis, while causes inflammation of the synovial
membrane and results in excessive synovial fluid, can lead to pain
and stiffness, arthritis due to injury, may cause damage to the
cartilage of the knee
 The goal of knee replacement surgery is to resurface the parts of the
knee joint that have been damaged and relieve knee pain that
cannot be controlled by other treatments.

OTHER REASONS FOR YOUR DOCTOR TO RECOMMEND A KNEE

REPLACEMENT SURGERY:
Anti-inflammatory medications
 Glucosamine and chondroitin sulphate
 Pain medications
 Limiting painful activities
 Assistive devices for walking (such as a cane)
 Physical therapy
OTHER REASONS FOR YOUR DOCTOR TO RECOMMEND A KNEE
REPLACEMENT SURGERY:
 Cortisone injections into the knee joint
 Cisco supplementation injections (to add lubrication into the joint
to make joint movement less painful)
 Weight loss (for obese patient )

Risks
 Risks of total knee replacement include blood clots in the legs
that can travel to the lungs .
Pulmonary embolism can cause
 Shortness of breath,
 Chest pain, and
 Even shock.
Other risks include
 Urinary tract infection,
 Nausea and vomiting (usually related to pain medication),
 Chronic knee pain and stiffness,
 Bleeding into the knee joint,
 Nerve damage,
 Blood vessel injury.
 SIGNS OF INFECTION

 Notify your doctor if you notice :

 Fever greater than 100 F (37.8 C)
 Shaking chills
 Drainage from the surgical site
 Increasing redness ,tenderness, swelling and pain in the knee
 An infected knee replacement usually require surgery to
remove the artificial parts and antibiotics to kill the bacteria
after the infection is cleared ,another surgery is performed to
install a new knee.

Before the procedure

Knee replacement surgery requires anaesthesia. Your input and
preference help the team decide whether to use general
anaesthesia, which makes you unconscious, or spinal anaesthesia,
which leaves you awake but unable to feel pain from your waist
down.
You’ll be given an intravenous antibiotic before, during and after
the procedure to help prevent post-surgical infection. You might
also be given a nerve block around your knee to numb it. The
numbness wears off gradually after the procedure.
During the procedure
Your knee will be in a bent position to expose all surfaces of the
joint. After making an incision about 6 to 10 inches (15 to 25
centimetres) long, your surgeon moves aside your kneecap and
cuts away the damaged joint surfaces.
After preparing the joint surfaces, the surgeon attaches the pieces
of the artificial joint. Before closing the incision, he or she bends
and rotates your knee, testing it to ensure proper function. The
surgery lasts about two hours.

After the procedure

You’ll be taken to a recovery room for one to two hours. You’ll
then be moved to your hospital room, where you’ll likely stay for
a couple of days. Medications prescribed by your doctor should
help control pain.
During the hospital stay, you’ll be encouraged to move your foot
and ankle, which increases blood flow to your leg muscles and
helps prevent swelling and blood clots. You’ll likely receive blood
thinners and wear support hose or compression boots to further
protect against swelling and clotting.
The day after surgery, a physical therapist will show you how to
exercise your new Knee. After you leave the hospital, you’ll
continue physical therapy at home or at a centre.
 Do your exercises regularly, as instruct? For the best recovery,
follow all of your care team’s instructions concerning wound care,
diet and exercise.
Results:
For most people, knee replacement provides pain relief, improved
mobility and a better quality of life. And most knee replacements can
be expected to last more than 15 years.

Three to six weeks after surgery, you generally can resume most daily
activities, such as shopping and light housekeeping. Driving is also
possible at rounds three weeks if you can bend your knee far enough to
sit in a car, if you have enough muscle control to operate the brakes
and accelerator, and if you’re not still taking narcotic pain medications.

After recovery, you can engage in various low- impact activities, such as
walking, swimming, golfing or biking. But you should avoid higher
impact activities — such as jogging, skiing, tennis and sports that
involve contact or jumping. Talk to your doctor about your limitations.
 CASE STUDY- 1

General information:
Name: XYZ
Age: 51 yrs
Sex: Female
Activity: Sedentary.
Medical history:
Family history: nil
Past medical history:HTN /CAD
Diagnosis: osteoarthritis of both knees.

Assessment of Nutritional status:

Food allergy None

Food preference Veg

GI Symptoms None

Functional No dysfunction
impairment

Adequacy of pre Greater than 75% in

admission intake take

Anthropometric measurements
Height 153cm
Weight 81kg
BMI 35
IBW/ABW 67ABW
Nutritional Severely
Assessment At Rating malnourished
Nutritionally At Risk Yes

Nutritional Requirement:
Recommended energy:
IBW /ABW x energy x stress factor
67 x 19 x 1.2 = 1500kcals
Recommended protein:
Protein factor x IBW/ ABW
67 x 1.2 = 95 gms

Biochemical Assessment
Parameters Day-1 Day-2
Sodium 135.5meq/l 135-150meq/l
Potassium 4.24meq/l 3.5-5-0meq/l
Chloride 96.6meq/l 94.0-110meq/l
Urea 55mg/dl 17.0-43.0mg/dl
Creatinine 1.1mg/dl 0.51-0.95mg/dl
Haemoglobin 11.3mg/dl 12.0-15.0mg/dl
Serum albumin 3.6mg/dl 3.5-5.2mg/dl

Clinical Assessment
Vitals Day-1 Day-2 Day-3
Temperature 98.5/F 98.5/F 97.1/F
Respiration 16mt 22mt 18mt
Pulse 100mt 100mt 67mt
Spo2 100% 97% 98%
Systolic BP 130 120 110
Diastolic Bp 90 80 80

Medical Treatments

Day-1 Day-2
Med-GLANPAN 40mg Med-GLANPAN 40MG
INJ
Med-MALIDENS IV Med-MALDIVES IV
100M 100M
ON DANSETRON 2ML Med-ON DANSETRON
2ML
TRD CONJECT 2ML Med-OPTIFAST
VANILLA
Med-TRD CONJECT
 2ML

24 HRS DIETARY RECALL

S.N Meal Item Quantity Energ Protei Fat Carb

O y n s
1 E.M Tea Milk (50ml) 50 3.68 0.58 5
Sugar (5g) 20 - - 5
2 B.F Idly Blackgram(20g 98 7 0.40 3.67
ms) +
Rice(40gm) 107.1 2.38 0.15 23.4
Cocon Coconut 106 1 5 5
ut chutney
chutne (30gms)
y oil (5ml) 45 - 5 -
3 Lunch Rice Raw milled 214.2 4.76 0.31 46.2
(60gm) 4
Paneer Paneer (50gm) 192.2 10.9 4.5 0.9
curry
onion (25gm) oil 14.22 0.45 0.04 2.89
Oil (5ml) 45 - - -
4 Evenin Tea Milk (50ml) 50 3.68 0.58 5
g Sugar (5gm) 20 - - 5
5 Dinner Phulka Wheat 200 4.2 0.6 30.8
s flour(60gm)
Tomat Redgram 99.6 6.51 0.46 17.2
o (30gm) 53.2 0.9 0.47 3.6
dal Tomato (50gm)

Total 1300 45 31 143

Diet during hospital stay
Day-1 patient is on NBM
Day-2 Started soft diet with HBV Protein
Day -3 Taking normal diet with HBV Protein 1300kcal 30gms Protein
Day -4 Taking normal diet with HBV Protein [Discharged after lunch]

Diet principles:
 High protein , High Fibre ,low fat , calcium rich diet.

Patient daily progress report:

Day 1: Vitals:Stable
Diagnosis:B/L TKR
Posted for surgery
Day 2: lab value with in normal limits
Treatment as advised in drug chat
Day 3: Vitals:stable
Systemic exam fidings- NAD,diag-pod ol TKR
Continue meditation as prescribed
Day 4: Vitals:stable
Physio to b continued
Countinue meditation as per prescribed
Plan for discharge

Discharge summary
Course in hospital : This patient presented with the above
mentioned complaint and was diagnosed as left TKR OA and admited
for surgery. After all relevant investigation and PAC, left total knee
replacement was done. Intra operative patient was uneventful. Post
operatively patient was stabilised in SICU. During the hospital stay
the patient was treated with IV fluids, IV antibiotics, analgesic, PPI’s
prophylaxis and supportive care. Patient recover well. Wound
dressing done wound healthy physiotherapy started. Patient is being
discharged in a stable condition with the following advise.

Discharge Medications
 Med-Thiosel tab aceclofenac +thiocolchicoside
 Med- Dolo 650mg tab paracetamol
  Med-pantovvay -ls cap -pantoprazo + levosulpiride
 Med-osteodon tab calcium citrate+ vitamin 03 zinc + magnesium
 Med- gabaprime -nt tab – gabapentin + nortryptyline
hydrochloride
 Med-limcee 500 mg chew tab vitamin

Dietary Recommendations:
Nutrititional advises:
Advised high protein,high fibre ,low fat , low salt ,calcium rich diet
1700kcal ,70gm protein
Early morning (6pm):
Supplement -high protein supplement 3scoops in 1 glass of plain glass
water
Breakfast (8pm):
Idly-2 with sambar-1 katori or tomato or ginger chutney-2 tlbs or dosa-
2 with sambar-1 katori or dhal or onion chutney-2 tlbs or vegetable
upma -1 katori or brown bread 2-3 slices with tomato/cucumber/onion
and mint chutney and egg white -2no
Mid-morning (11pm):
Fruit -orange -1 or sweet lime -1 or guava -1 or apple -1 or papaya
/pomegranate seeds -1 katori any seasonal fruit can be included
Lunch (1pm):
Green salad onion , carrot , cucumber,tomato-1 katori and rice 1-2 cups
and phulkas 2-3 no and dal -1 katori and vegetable curry -2 katoris (not
fried) and curd -1 katori and eggwhite -2no
Evening (4pm):
Supplement-high protein supplement 3 scoops in 1 glass of plain glass
water
Dinner (8pm):
Green salad onion ,carrot , cucumber,tomato-1 katori and phulkas 2-3
no or vegetable upma / rice 1-2 cups and
Green leafy vegetables dal -1 cup and vegetable curry-2 katori (not
fried( and curd -1 katori and egg white-2no
Bed time (10pm):
Fruit -ant one of the obove or buttermilk-1glass

Dietary Recommendations:
Eat a variety of foods in the desirable amount ( as mentioned )
Six small meals are better tolerated than three large meals
Maintain meal timings and avoid heavy meals.
Diet should be rich in fruits and vegetables, wholegrains , whole gram
pulses and sprouts to provide for vitamins, minerals , anti oxidants and
fibre.
Milk and milk products (curd , paneer ,) can be included in the diet
High protein foods like tofu , soy products can be consumed
alternatively to help in healthy eating
Limit your intake of transfat (hydrogenated fat) to less than 1% of
energy and this is in more quantities in snacks like bakery products.
Choose whole grains ,high fibre foods.
Minimize intake of beverage and foods with added sugars
Choose and prepare foods with little salt.
Use of oils should not exceed more than 3-4tsp per day , or
1/2liters/person/month
Regular physical activity at least for 4-5min after recovery.
Drink plenty of fluids to prevent dehydration

Note:
Skinless chicken/fish/low fat paneer/soya products can be included in
the diet twice or thrice in a week if preferable and prepared with less
oil and not fried.

Good food source of calcium:

Dairy: Daily products are rich in calcium in a form that is easily digested
and absorbed by the body , sources include milk, cheese, and yogurt
Vegetables and greens: Many vegetables specially green leafy
vegetables, are rich source of calcium try turnip greens, musturd greens
,brocolli , cabbage,greenpeans , asparagus
Beans:For another rich source of calcium ,try black beans ,kidney beans
white beans ,black eyed peas or baked beans
Herbs and spices: For a small but tasty calcium boost , flavour your
food with basil,thyme , cinnamon ,peppermint leaves ,garlic , oregano,
rosemary and parsley
 Others foods: other food source of calcium include salmon, tofu ,
oranges , almonds , Sesame seeds , and sea vegetables, and don’t
forget about calcium fortified such cereals and orange juice .

Fibre rich foods:

All leafy vegetables, carrot, beans , brown rice , brown bread ,peas
,brocolli , prunes ,pears ,nuts.

CASE STUDY ON- 2

CHOLECYSTECTOMY
 CHOLECYSTECTOMY

Introduction

WHAT ARE GALLSTONES?

Gallstones are deposits of digestive fluid that harden and form
stones in the gallbladder. They can be as small as a grain of sand
to as large as a golf ball. The gallbladder is a small, pear-shaped
organ on the right side of your abdomen, just beneath your liver.
The gallbladder holds a digestive fluid called bile that is released
into your small intestine.
WHAT CAUSES GALLSTONES?
The causes of gallstone development are not clear. But doctors
think gallstones may be a result of the following:

Bile with too much cholesterol : Bile contains enough chemicals

to dissolve the cholesterol excreted by your liver. But if the liver
excretes more cholesterol than your bile can dissolve, the excess
cholesterol may form into crystals and eventually form stones.

Bile with too much Bilirubin : Bilirubin is a chemical that’s

produced when your body breaks down red blood cells. Certain
conditions cause your liver to make too much bilirubin, including
liver cirrhosis, biliary tract infections and certain blood disorders.
The excess bilirubin contributes to gallstone formation.

Gallbladder not emptying correctly: If your gallbladder doesn’t

empty completely or often enough, bile may become very
concentrated, contributing to the formation of gallstones.
 WHAT ARE THE SYMPTOMS?
Gallstones may cause no signs or symptoms. If a gallstone lodges
in a duct and causes a blockage, the resulting signs and symptoms
may include:

 Sudden and strongly intensifying pain in the upper right

portion of your abdomen
 Back pain between your shoulder blades
 Pain in your right shoulder
 Nausea or vomiting
 Jaundice
 Pain may last several minutes to a few hours.

Risks
A cholecystectomy carries a small risk of complications
including:

 Bile leak
 Bleeding
 Infection
 Injury to nearby structures, such as the bile duct, liver and
small intestine
 Risks of general anesthesia, such as blood clots and
pneumonia.
.
 CASE STUDY-2

General information:
Name: XYZ
Age: 30yrs
Sex: Female
Activity: Sedentary
Medical History:
Family history: nil
Past medical history:Nil
Diagnosis: Gallstones Removal

Assessment of Nutritional information:

Food Allergy None

Food preferences Non veg

Gl symptoms None

Functional No dysfunction
impairment

Adequacy of pre Greater than 75%

admission intake intake
Anthropometric Measurements:
Height 162
Weight 92
BMI 35
IBW/ABW 77ABW
Nutrititional Severely
Assessment malnourished
Nutritionally at risk Yes

Nutrititional Requirements
Recommended Energy: ABW/IBW × Caloric factor × Stress factor
77×18×1.2=1700kcal
Recommended Protein:ABW/IBW×Protein factor
77×1.2= 90gms

Biochemical Assessment:
Parameters Day-1 Day-2
Sodium 138.2meq/l 135.5-150 meq/l
Potassium 3.52meq/l 3.5-5.0meq/l
Chloride 96.6meq/dl 94.0-110meq/l
Urea 30mg/dl 17.0-mg/dl
Haemoglobin 10.6mg/dl 12.0-15.0mg/dl
Wbc count 12,600 11,000-4,500
Clinical Assessment
Vitals Day-1 Day-2 Day-3
Temperature 98.2*F 98.2*F 98.2*F
Respiration 20mt 20mt 20mt
Pulse 99mt 99mt 99mt
Spo2 97% 95% 95%
Systolic bp 90mm 140mm 110mm
Diatolic bp 85mm 80mm 70mm

Medical treatment:
Med BUDECORT 1MG RE
Med DUOLIN RESPULSES
Med EMESET 4ML INJ
Med GLANPAN 40MG INJ
Med MONOCEF 1GM INJ
24 hour Dietary Recall

Meal Item Quantit Energy Protei Carbohydrat Fat

y n es
Breakfas Idli -3 60gm 99 2.4 20 -
t Idli Rava 30g 266 6 -
Bengal 15
gram 60g 45 12
Groundn 4 24
ut
chutney 5ml 45 -
Oil - 5

Mid Apple-1 100g 40 10 - -

morning
Lunch Rice 2cup 60g 200 6 40 -
Dal 30g 100 6 15 -
Curd-1 50g 40 3 3 -
Oil 5ml 45 - - 5
Evening Tea1 cup 50ml 33 3 5 -
Sugar 5gm 15 - - -
Dinner Chapathi- 60g 200 3 40 -
2
Rice-1cup 30g 100 3 10 -
Dal-1cup 30g 30 6 15 -
Broad 100g 100 3 -
beans -
curry
Oil 5ml 45 - - 5
Total 1300kcal 65g 167g 34
s g
Diet during hospital stay:
Day-1 patient is on NBM
Started liquid diet followed by soft diet
Day-2 Taking soft diet with 1300kcal 30gm protein
Day-3 Taking soft diet with 1300kcal 30gm protein

Diet principles:
High fibre , moderate protein ,low fat, calcium rich diet.

Patient daily progress report:

Patient shifted to OT
Patient is doing well
Patient feeling better ,no pain and comfortable
Patient can be discharged.

Discharge summary
Course in hospital:

The patient is admitted with complain of pain RUQ since 6

months. Necessary investigation were done. They showed altered
LFT. USG abdomen showed feathers of calculous chocystilis and
diluted CBD and mininal IHBRD patient and attendance explained
 about the nature of disease and line of management. Then
medical gastro option taken and ERCP+CBD clearance and
stenting done. Then she was taken up the surgery after PAC and
informed consent. Patient underwent laparoscopic
cholecystectomy the procedure was uneventful. Post operative
the patient was treated with antibiotics. PPL’s analgesic patient
improved well. She was allowed oral diet. Initially liquids followed
by soft diet. She tolerated diet well. Patient recovery was good
and hence being discharged with following meditation and advice.

Discharge Medications:
Med- Ceftum 500mgtab – cefuroxime
Med- Enzoflam tab -Serratio +diclofenac
Med- veloz 20mg tab -rabepra zolo
Med- sedogest 300mg tab-ursodeoxycholic acid

Dietary Recommendations
Nutrititional advises:
Advised high fibre , moderate protein,low fat ,iron rich, normal soft
diet 1600kcal and 80 gm protein High biological value protein
Early morning (6am):
1 glass milk or buttermilk/handfull of nuts
Breakfast (8am):
Idli 3-4 with sambar -1 katori or tomato or ginger chutney-2 tlbs OR
dosa 2-3 with sambar -1 katori or dhal or onion chutney-2 tlbs OR
vegetable upma 1-2 katori OR brown bread 3-4 slices with tomato /
cucumber/onion and mint chutney AND Eggwhite 2-no
Mid morning (11am):
Fruit -Orange-1 OR sweetlime -1 OR guava-1 OR apple -1 OR
papaya/pomegranate seeds -1 katori Any seasonal fruit can be included
Lunch (1pm):
Green salad onion,carrot , cucumber, tomato-1 katori AND phulkas 2-3
OR 1-2 cups AND dal 1-2 katori AND NON VEG CURRY /vegetable curry-
1 katori AND curd -1 katori AND egg white -2no
Evening (4pm):
Apple juice/poha/veg soup and any snack item [non fried items once in
a week]
Dinner (8pm):
Green salad onion, carrot, cucumber, tomato-1 katori AND phulkas 2-3
no OR vegetable upma 1-2 cups AND green leafy vegetable dal -1cup
AND vegetable curry-2 katori (not fried) AND curd -1 katori AND
Eggwhite-2no
Bedtime(10pm):
Fruit -Any one of the above OR buttermilk-1glass

Dietary Recommendations:
Eat a variety of foods in the desirable amount ( as mentioned )
Six small meals are better tolerated than three large meals
Maintain meal timings and avoid heavy meals.
Diet should be rich in fruits and vegetables, wholegrains , whole gram
pulses and sprouts to provide for vitamins, minerals , anti oxidants and
fibre.
Milk and milk products (curd , paneer ,) can be included in the diet
High protein foods like tofu , soy products can be consumed
alternatively to help in healthy eating
Limit your intake of transfat (hydrogenated fat) to less than 1% of
energy and this is in more quantities in snacks like bakery products.
Choose whole grains ,high fibre foods.
Minimize intake of beverage and foods with added sugars
Choose and prepare foods with little salt.
Use of oils should not exceed more than 3-4tsp per day , or
1/2liters/person/month
Regular physical activity at least for 4-5min after recovery.
Drink plenty of fluids to prevent dehydration
 Case study-03
CHRONIC LIVER DISEASE
 CHRONIC LIVER DISEASE
Introduction
What is cirrhosis?
Cirrhosis is when scar tissue replaces healthy liver tissue. This stops the
liver from working normally.
Cirrhosis is a long-term (chronic) liver disease. The damage to your liver
builds up over time.
The liver is your body’s largest internal organ. It lies up under your ribs
on the right side of your belly.
The liver does many important things including:
 Removes waste from the body, such as toxins and medicines
 Makes bile to help digest food
 Stores sugar that the body uses for energy
 Makes new proteins
When you have cirrhosis, scar tissue slows the flow of blood through
the liver. Over time, the liver can’t work the way it should.
In severe cases, the liver gets so badly damaged that it stops working.
This is called liver failure.

What causes cirrhosis?

The most common causes of cirrhosis are:
 Hepatitis and other viruses
 Alcohol abuse
 Nonalcoholic fatty liver disease (this happens from metabolic
syndrome and is caused by conditions such as obesity, high
cholesterol and triglycerides, and high blood pressure)
Other less common causes of cirrhosis may include:
 Autoimmune disorders, where the body’s infection-fighting
system (immune system) attacks healthy tissue
 Blocked or damaged tubes (bile ducts) that carry bile from the
liver to the intestine
 Use of certain medicines
 Exposure to certain toxic chemicals
 Repeated episodes of heart failure with blood buildup in the liver
Parasite infections
Some diseases passed from parent to child (inherited diseases) may
also cause cirrhosis. These may include:

 Alpha1-antitrypsin deficiency
 High blood galactose levels
 Glycogen storage diseases
 Cystic fibrosis
 Porphyria (a disorder in which certain chemicals build up in the
blood)
Hereditary buildup of too much copper (Wilson disease) or iron
(hemochromatosis) in the body

What are the symptoms of cirrhosis?

Your symptoms may vary, depending on how severe your cirrhosis is.
Mild cirrhosis may not cause any symptoms at all.
Symptoms may include:

 Fluid buildup in the belly (ascites)

 Vomiting blood, often from bleeding in the blood vessels in the
food pipe (esophagus)
 Gallstones
 Itching
 Yellowing of the skin and eyes (jaundice)
 Kidney failure
 Muscle loss
 Loss of appetite
How is cirrhosis diagnosed?
Your healthcare provider will look at your past health. He or she will
give you a physical exam.

You may also have tests including:

 Blood tests. These will include liver function tests to see if the
liver is working the way it should. You may also have tests to
see if your blood is able to clot.
 Liver biopsy. Small tissue samples are taken from the liver with
a needle or during surgery. The samples are checked under a
microscope to find out the type of liver disease
 Case study-3
General information:
Name: XYZ
Age: 62yrs
Sex: Male
Activity: Sedentary
Medical History:
Family history: Nil
Past medical history:CLD Anemia
Diagnosis: Cirrhosis of liver

Assessment of nutritional status:

Food Allergy No

Food preferences Veg

Gl symptoms None

Functional No dysfunction
impairment

Adequacy of pre Greater than 75%

admission intake intake
Anthropometric Measurements:
Height 175
Weight 80kg
BMI 26
ABW/IBW 75
Nutrititional Moderately
Assessment Rating malnourished
Nutritionally at risk Yes

Nutrititional Requirements:
Recommended Energy-ABW/IBW ×caloric factor ×Stress factor
75×22×1.2=1900kcal
Recommended Protein-IBW×protein factor
75×1.2=90gm

Biochemical parameters:
Hemoglobin 8.4mg/dl 12-15mg/dl
Potassium 4.83meq/l 3.5-5.1meq/l
Chloride 102meq/l 95-105meq/l
Sodium 140meq/l 136-146meq/l
Creatinine 1.2mg/dl 0.6-1.1mg/dl
Albumin 3.6mg/dl 3.5-5.0mg/dl
Bilirubin 0.4mg/dl 0.1-1.2mg/dl
Clinical Assessment:
Temperature 98*F 98*F

Pulse 82m 76m

Spo2 99 99
Systolic bp 130mmhg 110mmhg
Diatolic bp 80mmhg 80mmhg

Medical treatment:
Tab razo 20mg ,1tablet
Tab ciplar la,40mg
Syr sparacio 10ml
Tab lupiheme
Tab betadek
24hours Dietary Recall:

Meal Item Quantity Energy Protei CHO Fat

(K Cal) n
(g) (g)
(g)
Early Tea 50ml 35 1 2 2
morning (Without
sugar)
Breakfas Chapattis 2 in no. 167 5 34 1
t Tomato (50g)
curry 1cup (30g) 25 1 4 -
Oil (5ml) 45 0 0 5
Lunch Rice 2cups(60g) 200 6 40 2
 Bottlegourd 1cup(30g) 25 13 5 -
Curd
50ml 30 2 2 2
Oil (10ml) 90 0 0 10

Evening Tea 50ml 35 1 2 2

snacks (without
sugar)
Dinner Rice 2cups 200 6 40 5
(60g)
Bottlegourd 1cup(30g) 25 1 5 -
Curd 50ml 30 2 2 2
Oil (10ml) 90 0 0 10
Total 997 38 136 41
Diet during hospital stay:
Day-1Patient plan NBM for endoscopy
Day-2Started diabetic liquid diet followed by soft diet from dinner
Taking normal diet [Discharged after lunch]

Diet principle:
High fibre, high protein, low salt ,low fat, iron rich diet with plenty of
liquids

Patient daily progress report:

Day-1 pedal edema decreased now
No complaints, medications advised
Day-2 pt stable
Plan endoscopy tomorrow
PT is concious /coharent
Day-3 patient is on NBM for endoscopy
He is sleeping,sob,pedal edema is reducing

Discharge summary
Course in hospital:
Patient admitted with above complaints and necessary investigation are
done. His Hb was low 5.98 so 3 units of PRBS transfusion were done.
500mg IV iron given, He underwent UGIE on 6-12-2021 ,which
showed,antral ulcers, esophageal varicose post EVL .
His condition is improved during the course of his hospital stay. He is
being discharged in a homoeopathically stable condition.

Discharge Medications:
Tab razo 20mg ,1tablet ,twice a day ,before food for 2weeks
Tab ciplar la,40mg ,1tablet ,once a day to continue
Syr sparacio 10ml tid 2hours after food for 2weeks
Tab lupiheme once daily after food for 1month
Tab betadek once daily for 30days

Discharge diet chart:

Nutrititional advised:
Advised high fibre ,high protein, low salt ,low fat iron rich diet with
plenty of liquids 1700kcal ,80gms
Early morning(6am):
High protein supplement 3scoops in one glass of water
Breakfast(8am):
idly 2-3 with sambar -1katori or tomato or ginger chutney-2 tlbs OR
dosa -2 with sambar-1 katori or dhal or onion chutney-2 OR vegetable
upma-1-2katori OR oats porridge 1-2cups with fruit OR phulkas 2-3with
vegetable curry-1 katori AND Eggwhite-1no
Mid morning(11am):
Fruit-orange OR sweetlime-1 OR Guava -1 OR apple-1 OR
papaya/pomogranate seeds-1katori OR buttermilk-150ml OR soy milk
-150ml
Lunch(1pm):
Green salad onion,carrot , cucumber, tomato-1katori
Brown rice -1cup OR soft phulkas 2-3no AND dhal -1 katori AND
vegetable curry-2katori (not fried) AND low fat curd-1 katori

Evening(4am):
High protein supplement 3scoops in one glass of water
Dinner(8pm):
Green salad onion , carrot, cucumber,tomato -1katori
Soft phulkas 2-3no AND dhal -1katori AND vegetable curry-1katori (not
fried) AND low fat curd-1katori
Bed time(10am)
Low fat milk /buttermilk-1glass

Dietary Recommendations:
Carbohydrates:Diet should be high in complex carbohydrates (whole
cereals and grains )
Sources of complex carbohydrates: whole wheat,rice ,jowar, bajra ,corn
and their products.
Protein: protein should be adequate in the diet but not excessive in the
diet , cirrhotic patient tolerate protein from dairy and vegetarian
souces than from non vegetarian sources.
Fat: moderate dietary fat with more of MCT oil is sometimes necessary.
oil 10ml per day can be used for cooking.
Sodium: Diet need to be restricted in sodium .many processed foods
are also high in sodium .limit sodium to 1000-2000mg per day.

Sources of sodium:Table salt , sodium bicarbonate (baking soda) in

bakery foods , sodium alginate and monosodium glutamate in
processed and canned foods.
Potassium: potassium needs to be restricted OR increased based in the
serum potassium levels .hence monitoring serum electrolyte becomes
very essential in cirrhotic patients.
Goods sources of potassium: coconut water,fruit juices, cocoa ,
jaggery,instant coffee powder , cornflakes and processed foods .
Leaching of vegetables: cut and soak vegetables in warm water for
20mins ,drain the water ,then cook the vegetables
This will remove excess potassium.
Fluid: fluid is needed to be restricted when there is a fluid accumulation
in the body (ascitis and edema ).fluid allowance depends on
accumulation in the body and may vary between 500-1500ml per day .

CASE STUDY-04
CORONARY ARTERY DISEASE
 CORONARY ARTERY DISEASE

Introduction:
What is coronary artery disease?
Coronary artery disease is a narrowing or blockage of your coronary
arteries usually caused by the buildup of fatty material called plaque.
Coronary artery disease is also called coronary heart disease, ischemic
heart disease and heart disease.
What happens to the arteries in coronary artery disease?
Coronary artery disease is caused by atherosclerosis. Atherosclerosis is
the buildup of plaque inside your arteries. Plaque consists of
cholesterol, fatty substances, waste products, calcium and the clot-
making substance fibrin. As plaque continues to collect on your artery
walls, your arteries narrow and stiffen. .
How does plaque build-up in the arteries?
Coronary artery disease happens in everyone. The speed at which it
develops differs from person to person.
This thin cap over the plaque can break open (due to blood pressure or
other causes). Blood cell fragments called platelets stick to the site of
“the injury,” causing a clot to form. The clot further narrows arteries.
Sometimes a blood clot breaks apart on its own. Other times the clot
blocks blood flow through the artery, depriving the heart of oxygen and
causing a heart attack.

The process of how plaque builds up in your coronary arteries.

Who gets coronary artery disease?

SYMPTOMS AND CAUSES

Sometimes you won’t know you have coronary artery disease until you
have a heart attack. Symptoms of a heart attack include:

 Chest discomfort (angina) described as heaviness, tightness,

pressure, aching, burning, numbness, fullness, squeezing or
a dull ache. The discomfort can also spread to or only be felt
in your left shoulder, arms, neck, back or jaw.
 Feeling tired.
 Dizziness, lightheadedness.
 Nausea.
 Weakness.
Symptoms of a heart attack in women can be slightly different and
include:
 Discomfort or pain in the shoulders, neck, abdomen (belly) and/or
back.
 Feeling of indigestion or heartburn.
 Unexplained anxiety.
 Cold sweat.

MANAGEMENT AND TREATMENT

How is coronary artery disease treated?
Your healthcare provider will talk to you about the best treatment
plan for you. Follow your treatment plan to reduce your risk of
 problems that can result from coronary artery disease, like heart
attack and stroke.
Medications
Medication to lower your cholesterol levels, such as statins, bile acid
sequestrants, niacin and fibrates.
Medications to lower blood pressure, such as beta blockers, calcium
channel blockers, angiotensin-converting enzyme (ACE) inhibitors or
angiotensin II receptor blockers.
Medications to stop angina, such as nitrates/nitroglycerin or
ranolazine.
 CASE STUDY-4

General information:
Name:XYZ
Age: 57yrs
Sex: male
Activity: sedentary

Medical History:
Family history: nil
Past medical history:DM ,HTN
Diagnosis: CAD- unstable angina

Assessment of nutritional status:

Food Allergy No

Food preferences Non veg

GI symptoms None

Functional No dysfunction
impairment

Adequacy of pre Greater than 75%

admission intake
Anthropometric Measurements:
Height 170cm
Weight 83kg
BMI 28
IBW/ABW 73abw
Nutritional Moderately
assessment malnourished
Nutritionally at risk Yes

Nutritional Requirements:
Recommended Energy-ABW/IBW ×caloric factor ×stress factor
73×21×1.2=1900kcal
Recommended Protein-IBW×protein factor
73×1.2=87gm

Biochemical parameters:
Parameters Day-1 Normal range
Sodium 148 meq/I 135-150meq/I
Potassium 3.7 Meg/I 3.5-5Meq/I
Chloride 106.6 meq/I 95-110meq/I
Urea 26 mg/dl 26 mg/dI
Ammonia 40mg/dl 9-30 mg/dI
Protein 6.2 6.6-8.3
Creatinine 1.1 mg/dl 0.6-1.3 mg/dI
Clinical Assessment:
Temperature:98°F
Pulse: 92m
Systolic BP:120mmhg
Diastolic BP:70mmhg

Medical treatment:
INJ NITROCIN 25mg
INJ FENT 2ml
INJ ATROPINE 1ml
INJ AORENALIN
INJ NIKORAN 2mg

24hours dietary recall:

Meal Item Quality Energy Protein CHO(g) Fat(g)
(K. cal) (g)
EM Tea(without 50ml 50 1 2 2
sugar)
BF Chapattis 2in no. 167 5 34 1
Tomato
curry (50g)1cup 200 1 4 -

Oil(5ml) 45 0 0 5

Lunch Rice 2cups(60g 200 6 40 2

Bottlegourd ) 125 13 5 -
Curd 1cup(30g) 30 2 2 2
Oil 50ml 45 - - 5
 5ml
Evening Poha 30gm 100 1 2 2
snacks
Dinner Rice 2cups(60g 200 6 40 5
Bottlegourd ) 125 1 5 -
Curd 1cup(30g) 50 2 2 2
Oil 50ml 45 - - 5
(5ml)
Total 1300 38 136 41

Diet during hospital stay:

Day-1 patient was on NBM for surgery
Day-2 started liquid diet followed by diabetic soft diet
Day-3 patient taking diabetic normal diet with 1300kcal 35gms protein

Diet principles: Diabetic high fibre ,high protein low fat ,low salt diet

Patient daily progress report:

Day-1 patient is concious
Plan cag continue treatment as per chart
Day-2 patient is concious
GRBS -294mg/dl . patient is worried about his sugar levels
Day-3 plan CAG Patient was on NBM from 6am, shifted to post cath on
call. Posted from PTCA
No fresh complaint
Patient shifted to OT
Day-4 Post PTCA
No angina /sob
Afebrile
Plan discharge after rounds

Discharge summary
Course in hospital:
He was admitted with ACS unstable angina. Good LV function cardiac
makers troponin-1 was negative. He was managed with dual
antiplatelet,statins,LMWH,ARBS,antianginals V12 nitrates and
supportive adjunctive treatment after stabilization, he underwent CAG
which revealed single vessel disease, Distal LCX 80% Stenosis
subsequently PTCA+stend to distal LCX was done using a DES with good
results and established TIMI glow (detailed reports enclosed)
He is advised medical management for LAD and RCA disease. Procedure
and pay procedure hospital stay was uneventful. He is asymptomatic
and is being discharged in a stable hemodynamic condition.

Discharge Medications:
Tab- ecosprin 75mg once daily after lunch 2pm
Tab-brilinta 90mg twice daily 8am -8pm
Tab-storvas 80mg once daily after dinner 9pm
Tab-enitel 40mg once daily 8am
Tab-corbis 2.5mg once daily 8pm
Tab- pantocid 40mg once daily 7am
Tab-etizola 0.25mg once daily at bed time 9pm for 2weeks
Tab-Taxim o 200mg twice daily after food 9am-9pm for 3days
Tab- syp-looz 15ml at bed time /dos

Diabetic medication:
Inj human mixrard 30/70 s/c twice daily 15units before bf and dinner
Tab-glycomet 1000mg once daily after bf
TAB- ziten -m 20/500mg once daily after dinner

Discharge diet chart:

Nutritional advised:
Advised diabetic high protein,high fibre ,low fat , low salt diet 1600kcal ,
80gm protein
Early morning (7am):
Green tea/low fat milk-1cup (without sugar)
Breakfast (8-9am):
Phulkas-2 with vegetable curry -2cup OR jowar roti -2
Idly-2 with sambar -1 katori or tomato or ginger chutney-2tlbs OR
Dosa -2with sambar -1katori or dhal or onion chutney-2 tlbs OR
vegetable upma 1-2katori AND boiled eggwhite -1
Lunch(1pm):
Green salad onion, carrot, cucumber, tomato-1katori phulkas 2-3nos
AND brown rice -1cup
AND green leafy vegetables dhal-2 katori OR chicken curry AND
vegetable curry-1 katori (Not fried) AND low fat curd -1katori
Evening (4pm):
Ragi porridge/barley water -glass
Dinner (8pm):
Green salad onion , carrot, cucumber, tomato-1katori phulas2-3no OR
veg Dalia/oats upma1-2cups AND
Vegetable curry-1katori (Not fried ) AND green leafy vegetables dhal -1
katori AND low fat curd -1katori
Bedtime (10pm):
Low fat milk/ buttermilk-1glass
Alternate breakfast OR snacks items
Broken wheat porridge/oats porridge/fruit bowl other clear soups
Note:1half cup of rice is prepared from 45gms of raw rice and phulkas is
prepared from 45gms of whole wheat flour
Dietary Recommendations:
Eat a variety of foods in the desirable amount (as mentioned)
Balance food intake with physical activity . Regular exercise is required
to achieve and maintain the healthy body weight.
Six small meals are better tolerated than three large meals . maintain
meal timings and avoid heavy meals.
Diet should be rich in fruits , vegetable,whole grains,whole pulses and
sprouts to provide for vitamins, minerals ,anti oxidants and fibre.
Low fat milk and milk products can be included in the diet .
Regular physical activity at least for 45mins
Foods to be included:
Foods high in fibre like raw salads .
Permitted fruits like orange,papaya , guava , sweetlime,papaya OR
Apple
Sprouted legumes which are rich in fibre and B-complex vitamins
Foods to be used in moderation
Consumption of oil should not exceed more than 3-4tsp /day OR
1/2it /person /month
Toned milk 300ml/day , including curds and buttermilk.
Foods to be avoided:
Sugar ,jam ,jellies , ice cream,cakes ,soft drink and pastries
Foods high in salt pickles ,baked items
Fruits like mangoes ,grapes ,sapota , banana
Veg like potato ,sweet potato, beetroot,tapioco ,colacasia
Deep fried items
Beverage containing sugars are to be avoided
Note: Skinless chicken/fish /low-fat paneer can be included in the diet
twice in a week if preferable