Integrated Clinical Nutrition Studies Module

Malnutrition & Starvation (Case study)
• Melanie is a 48 year old woman who lives alone and has a part time job in a local bakery. She suffers from rheumatoid arthritis and has repeated mouth abscesses. She has just been admitted to the assessment unit at the local hospital, at the request of her rheumatologist.
• She is 1.79m tall and weighs 59kg. At her last rheumatology appointment (4 months ago) her weight was 65kg.
• She has recently (past 6 months) become depressed and her consultant has prescribed her Citalopram 20mg.
• She is currently taking amoxicillin for a mouth abscess (3 x 250mg daily, 5 day course).
• Due to her depression, sore mouth and ongoing nausea her nutritional intake has been fairly poor and she reports that food doesn’t taste the same as it used to:

A typical day’s intake for Melanie would be as follows:

o Breakfast: 1 mug peppermint tea. One slice thin white soft bread & marmalade when she can manage it.
o Lunch: 1 Boiled egg with 1 slice white bread & margarine, or spreading cheese. Low fat fruit yoghurt. 1 mug peppermint tea
o Dinner: Instant mashed potato & baked white fish or baked sausages (2) & baked beans. Maybe some tinned rice puIDing to follow, or instant packet custard. She doesn’t always finish this.
o Evening: One Digestive biscuit, with a glass of semi skimmed milk at 7pm and a mug of instant Horlicks drink at 11pm.
• Melanie was recently started on penicillamine for her rheumatoid arthritis and is being monitored by the rheumatology team who are concerned about her weight loss.
• She has been admitted for nutritional assessment and review of her current medication.
• An Occupational Therapy assessment has revealed limited food purchasing, preparation and cooking ability due to her arthritis.
• A physiotherapist has described her range of movement as very limited and is working with her to improve her mobility.

Current routine medication:
Citalopram (20mg/d), Penicillamine (250mg orally per day, usually taken mid-morning), Ibuprofen (1000mg per day)

Current biochemistry:
Haemoglobin (10.4 g/dl), Serum albumin (32 g/l), C-Reactive protein (26mg/l), urea 7.2mmol/l
Melanie is referred to the Nutrition & Dietetic department and is assigned to your care.

Give an overview of all the factors that you would consider in the nutritional assessment and treatment of this client. Consider this case under the following subtitles (not necessarily in this order):

• Dietary and nutritional assessment
• Clinical signs of malnutrition
• Interaction with other health professionals
• Medications & any drug-nutrient interactions / side effects
• Overall nutritional care aim
• Dietary targets for the short-term and long-term
• Your recommended improved dietary intake including calculations