Nutrition Case Report

Ms. S, a 30-year-old woman, was brought to the hospital due to her chief complaint of chronic fatigue, back pain and some skin rashes. She was diagnosed with systemic lupus erythematous (SLE). SLE is a chronic autoimmune disorder involving multiple systems. It is chronic in nature, characterized by fluctuating degrees of increased disease activity then followed by remission (Nettina, 2006). SLE has general manifestations that can be seen in Ms. S’s condition such as fatigue and joint complications (back and joint pain).

Patients with SLE experience weight changes, either weight loss attributed to decreased appetite, medications’ side effects, GI problems and fever or weight gain related to medications (corticosteroids) or retention of fluid (National Institute of Arthritis and Musculoskeletal and Skin Disease, 2006). With potential nutritional problems as such, Ms. S was referred to nutrition services to obtain appropriate nutritional regimen that is crucial in the overall treatment of the disease. Nutrition Assessment Upon the admission of Ms. S, a thorough nutritional assessment was done.

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The patient’s height (69 inches) and weight (123. 2 pounds) were taken as part of the anthropometric assessment. She has a body mass index of 18. 24. In the classification of overweight and obesity by BMI, the patient is underweight. Laboratory testing was done for the biochemical assessment of the patient’s nutritional status. Serum albumin and pre-albumin levels were taken. Ms. S has a serum albumin of 3. 3g/dl and pre-albumin of 14g/dl. Her urinalysis report consisted of trace albumin and 4-5/hpf RBC content (normal: <2/hpf) in the result.

The patient’s serum albumin and pre-albumin levels indicate that she has a compromised protein status. It is stated that factors that result in abnormally low levels of pre-albumin include stress and inflammation (Morgan & Weinsier, 1998). Lupus nephritis is a medical complication of SLE. About a third of patients with lupus develop it. If Ms. S has initial signs of this complication, medical evaluation and nutritional management are needed (Escott-Stump, 2008). Serum aspartate aminotransferase (AST) and alanine aminotranferase (ALT) are slightly elevated.

This is to be monitored since increase in these values indicates active SLE (Fauci et al. , 2008). The vital signs were as follows: BP – 120/62; PR – 75 bpm; RR – 16. After this, physical examination was done. Ms. S has a malar rash, a fixed erythema that maybe flat or raised on the face, ears, chin, V region of neck, upper back and extensor surfaces of the arms (Fauci et al. , 2008). Upon buccal inspection, mouth ulcers were present. The patient also expressed difficulty in swallowing. Mouth ulcers are a common feature of lupus.

This is usually present during flares accompanied by increased joint pains, rashes and hair loss (The Lupus Site, 2010). Pulmonary manifestation consists of increased interstitial markings. There are no significant cardiovascular and neurological manifestations of SLE. Ms. S complained of several instances of diarrhea after taking seafoods. The chief complaint of the patient is mild back pain and chronic fatigue. To assess the dietary intake of the patient, a 24-hour diet recall was used.

In this method, the patient was asked to report all foods and beverages consumed in the last 24 hours (Grodner, Long & De Young, 2004). However, this method was utilized because of its convenience to the patient; it is not representative of the patient’s actual diet. It was recognized that the client consumed foods that are saturated fats (processed meat and diary products). She was also careless in consuming food that she has allergy on (strawberry ice cream). Nutrition Diagnosis • Involuntary weight loss related to body adjustment to illness and new medications, or both as evidenced by low BMI of 18. 24


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