MFNP-011

Internship
Indira Gandhi National Open University
School of Continuing Education

INTERNSHIP
SECTION 1
Internship Guidelines 5

SECTION 2
Internship Report 14
SECTION 3
Case Studies 38

STUDENT DETAILS

Name : ..................................................... Enrolment No. : ................................

Address/Contact No. : ........................................................................................

Name of Dietitian and Hospital ........................................................................

Address where Internship Undertaken ............................................................

...............................................................................................................................
EXPERT COMMITTEE
Prof. Tara Gopaldas Dr. Shobha Udipi Dr. Indira Chakraborthy
Director Professor Head
Tara Consultancy Services Department of Foods and All Indian Institute of Hygiene
Bangalore Nutrition SNDT University and Public Health
Mumbai 110, Chittaranjan Avenue Kolkatta
Dr. Kumud Khanna Dr. S. Sharma Dr. Umesh Kapil, Human
Ex. Head Reader Nutrition Unit
Institute of Home Economics Department of Foods and All India Institute of Medical
F-4, Hauz Khas Enclave Nutrition Lady Irwin College, Sciences
New Delhi New Delhi New Delhi
Mrs. Mary Mammen Parvathi Eashwaran, Department Dr. Ulvir V Mani
Christian Medical College of Food Service Management; Professor
and Hospital Avinashilingam Institute of Home Department of Food and
Udam Seudder Road Science Nutrition College of Home Science
Post Box No.3 and Higher Education for Women M.S. University
Vellore Deemed University, Coimbatore Vadodara

Dr. (Mrs.) Molly Joshi Dr. (Mrs.) K. Puri Former

Ms. Rekha Sharma Chief Dietitian Professor
Chief Dietitian Department of Dietetics Foods and Nutrition Department
All India Institute of CMC Hospital Punjab Agricultural
Medical Sciences. Ludhiana, Punjab University, Ludhiana
New Delhi
Dr. Annu J Thomas Prof. Deeksha Kapur (Convenor)
Dr. Shikha Khanna School of Continuing Education School of Continuing Education
Chief Dietitian IGNOU IGNOU
Ram Manohar Lohia Hospital New Delhi New Delhi
New Delhi

M.Sc. (DFSM) Programme Coordinator

MFNP-011 Course Coordinator
Prof. Deeksha Kapur
Discipline of Nutritional Sciences
School of Continuing Education
IGNOU, New Delhi

Course (MFNP-011) Preparation

Prof. Deeksha Kapur
Discipline of Nutritional Sciences
School of Continuing Education
IGNOU, New Delhi

Production
Mr. Rajiv Girdhar
Assistant Registrar (Pub.)
SOCE, IGNOU

March, 2012
 Indira Gandhi National Open University, 2012
ISBN:
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INTRODUCTION
Welcome to the Course MFNP-011 “Internship” which is designed as a training programme with
provision of placement of interns in a multi specialty Government and Private hospital or institute or
organization concerned with patient care and imparting dietetic counseling. The internship is
planned for a period of three months (480 hours i.e. 40 hours per week). As part of the course this
innovative self-instructional Master’s Dietetic Internship Programme Manual has been developed,
which is perhaps the first of its kind, providing guidelines for undertaking internship, training at any
dietetic unit in the country.
Master’s Dietetic Internship Programme Manual - the document - will not only be of use for the
MSc. (DFSM) interns, but also for other interns interested in dietetic training and also for dietetic
departments in standardizing their training programme for interns.
The Internship Manual is actually a workbook. It contains not only the guidelines and information
necessary for you to conduct the internship, but it also serve as the internship report file or
workbook. You are expected to write your observations, activities conducted, assignment
undertaken, results, inference, conclusions etc. related to the internship programme in the manual
itself in the space specified. Record the practical work undertaken directly into the bound internship
manual (workbook), never on loose leaf sheets. Every entry in the internship manual should be
dated, and your own observations (including comments such as the difficulties you found in doing
certain procedures, or ideas that occurred to you, recommendations etc.) should be written down as
a permanent record. Recognize that your internship report is the true record of what you did and
observed at the time. You can (if you wish) use the back pages of your internship manual for
attaching extra sheets, pictures or any other notes, etc.
Since the manual will also function as the internship report, you will be expected to submit the
report for external evaluation as well. The internship supervisor (dietitian in charge) will certify that you
undertook the internship and the report is the bonafide work done by the candidate. Look up the
certificate copy attached at Annexure 1 at the end of the manual. Do not forget to get your report
certified from your dietetic internship supervisor (dietitian in charge/chief dietitian) before submission for
external evaluation or else your report will not be accepted for evaluation. Please keep a copy of
the filled-in manual as a record for your use. Note an internal assessment will also be done by the
internship supervisor which will carry sixty per cent weightage.
4
SECTION 1 INTERNSHIP GUIDELINES
Structure
1.1 Introduction
1.2 Dietetic Internship Programme: An Overview
1.3 Internship: Getting Started
1.4 The Internship Training and Schedule: Guidelines

1.1 INTRODUCTION
In this section the basic concept, objectives, outcomes and the guidelines for undertaking the
internship programme have been included. It is very important that you read and understand the
objectives and motive of the internship programme presented herewith carefully, since this is the course
that will help you achieve knowledge and skills, as well as demonstrate competencies for entry-level
practice in all specialization areas of the dietetics profession. The internship programme shall aim at
providing practical training in the field of ‘clinical/therapeutic nutrition’ and ‘food service system
management’. However, before you embark on the internship training/schedule it is very important that
you undertaken all the course work (theory and practical) related to the MSc. (DFSM) programme and
your theoretical knowledge and concepts of the different subject area which lend themselves to the
study of dietetics are sound. If not you may not be able to achieve the results expected from this hands
down training exercise.
Objectives
The salient objectives and brief outline of the activities to be undertaken as part of the internship
programme are highlighted herewith.
• To understand the organizational, administrative set up and functioning of the Dietetic
Department of a hospital.
The activities will include:
— Understanding the organizational structure along with job description, wage structure and
benefits for employees.
— Understanding the functions of the dietetic department including Administrative, Planning
Diets, Food Production, Food Service, Diet Counselling, Record maintenance etc.
— Budget planning for the year.
• To gain knowledge and practical experience in the management and operation of the food
service unit.
— Learning/gaining practical experience in procedures of menu planning, standardization of
recipees, planning cycle menus, types of diets in the hospitals.
— Procurement of items: studying the methods adopted by the department for procuring food etc.
— Receiving supplies: receiving goods in terms of procedures adopted, ensuring quality and quantity.
— Store-room management: procedures / policy adopted, physical verification of stock.
— Issuing: procedure adopted.

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 — Food production: methods of pre-preparation, preparation/cooking of food, issues in
quantity cooking, centralized/decentralized cooking.
— Food service and distribution: types of service, timing of service, supervision of setting of trolleys,
trays etc., distribution of food in wards.
— Practical knowledge of cost control systems, particularly food cost control (calculation of
cost of diet etc.)
— Kitchen layout design and physical facilities for efficiency and optimal use.
— Specification of equipment and other articles and used in the department.
— Maintenance and verification of different records (purchase order, indent, invoice, store
record, cash book etc.)
• To gain knowledge and practical experience in the nutritional management and diet care
therapy and counseling with respect to patient care in various disease conditions.
The activities will include:
— Visiting different wards and studying case sheets for individual diseases.
— Understanding clinical problems and getting acquainted with recent concept in the
nutritional management of various diseases.
— Check diet prescriptions and diet sheets for proper indents.
— Formulate therapeutic diets: diet assessment, diet planning, calculation.
— Supervising preparation and service of therapeutic diets.
— Diet counselling for indoor patients in the wards.
— Diet counselling for outdoor patients at nutrition clinics.
• To gain an enriching and comprehensive insight into the recent concepts, current knowledge
regarding the management of diverse disorders, combination of disorders and problems
encountered in their effective nutritional management and nutritional support methods.

1.2 DIETETIC INTERNSHIP PROGRAMME: AN OVERVIEW

The internship programme in Dietetics and Food Service Management is essential towards the
partial fulfillment of requirement for the Masters in Science in Dietetics and Food Service
Management {MSc. (DFSM)} Programme launched by IGNOU. The internship programme is
worth 16 credits (i.e. 480 study hours). The course is complemented with required duration of
internship of three months in hospital dietetics department to offer practical support to the
theoretical knowledge.
The internship sought to enable interns to integrate and apply nutrition/dietetic knowledge and
intervention to promote optimum health for individuals or groups. The programme also seeks to provide
competencies in the areas of dietetics/nutrition, management, communication, education and professional
conduct. As part of the internship the Intern is required to get hands-on experience in areas/sections
such as Food Services Systems Management, Clinical Nutrition, Community Nutrition, Professional
Development and Research and Training. The mission of Dietetics Internship is to provide a
programme of excellence that prepares generalist dietitians with competencies required for entry-
level positions in a variety of dietetic practice settings.

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Each intern is required to undergo trailing under the guidance of a Senior Dietitian (with 5-10 years of
work experience) in any multi-specialty approved Government and Private hospital or institute or
organization concerned with patient care and imparting dietetic counseling for a period of three
months (40 hours per week).
The expected outcomes from the internship are highlighted herewith:
Expected Outcomes
1) Interns completing the Dietetic Internship will achieve knowledge and skills, as well as,
demonstrate confidence and competencies for entry-level practice in all specialization areas of the
dietetics profession.
2) Interns will satisfactorily complete the didactic component of the internship, which provides
exposure to the positive attributes of a well-run dietary department and up-to-date information
on the latest developments in food service management, medical nutrition therapy, and
dietetics research and education.
3) Programme graduates will gain practical dietetics knowledge and application skills through
interaction with clinical preceptors in a variety of settings.
4) The Dietetic Internship will provide academic and clinical experiences to adequately prepare learners
for entry-level work in the field after programme completion.

1.3 INTERNSHIP: GETTING STARTED

Interns will be expected to submit an internship report, duly signed and evaluated by the Dietitians
In charge at the end of the three months internship duration.
All MSc. (DFSM) learners except the following are required to undertake an internship in any
recognized approved multi-specialty Government and Private hospital or institute or organization
concerned with patient care and imparting dietetic counseling under a senior dietitian (preferably a
registered dietitian) for three month period.
• In-service dietitians (with a degree in Post Graduate Diploma in Dietetics and Public Health Nutrition),
and
• Candidates who have successfully completed a 3 (three) month internship programme as part
of the Post Graduate Degree in Dietetics and Public Health Nutrition from a recognized
institution/ in the last five years.
University
The above-mentioned categories of learners can seek credit transfer for the Internship (MFNP-
011) Course for a maximum of 16 credits. Students seeking credit transfer should apply in the
prescribed form (refer to section 11 form 3 in the Programme Guide) directly to the Registrar
(SRD), IGNOU, Maidan Garhi, New Delhi -110068 enclosing a Demand Draft for Rs.200/- drawn
in favour of IGNOU and payable at New Delhi. Attested copies degree alongwith marks sheet and
syllabus of the Post Graduate Diploma in Dietetics and Public Health Nutrition Course should also be
enclosed along with the application. In-service dietitians must also enclose the employment
certificate.
For all other MSc. (DFSM) learners the internship is absolutely compulsory. Candidates who are
absent or do not present themselves on a regular basis (during the three months) for the internship
will NOT qualify for the degree of the Masters in Science in Dietetics add Food Service
Management.
Note : No request will be considered for waiver of the internship programme. Please
undertake the internship only after completing all the practical courses. This is mandatory.
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It is absolutely important that you commence the internship only after having completed the entire
course work (all the theory and practical courses) planned for as part of the MSc. (DFSM)
programme. This is a pre-requisite for the internship programme. The programme incharge will consider
this strictly before you shall be placed for the internship.
So where do you begin? Here is a checklist for your consideration:
1) Consult the Programme In charge for Assignment of Centre: The first thing you do is
complete all the practical courses before you start the internship. Now contact the programme
study centre in charge. The programme in charge shall provide you a list of recognized
hospital in the country where you may perhaps undertake the internship programme. A tentative
list of internship centres is also attached at the end of the manual in Annexure II for your
perusal. You can select other multi- speciality Government or Private Hospital for Internship
(other than listed within) as discussed in point 2.
2) Identification of Internship Centre: Identify the centre where you wish to undertake the
internship. It is strongly recommended that you select a multi-specialty recognized hospital in
your city/region, which has a well established dietetic department for undertaking the internship.
Check to ensure that there is a registered dietitian and/or a senior dietitian, with 5-10 years of
experience, heading the unit. Place your request for placement with the incharge who would liaise
with the dietetic department of the concerned hospital/institution where you plan to undertake
the internship and arrange for the placement. Alternatively, you may make your own efforts in
contacting the dietetic department/chief dietitian of the concerned centre and arrange for your
placement. Do inform the programme in charge of such arrangements. In some centres (for
instance at the Dietetic Department at AIIMS) you may have to sit for an entrance exam for
consideration as intern for the internship programme. In such circumstances you may obtain
the necessary information from the concerned hospital.
3) Consult with Chief Dietitian at the Recognized Centre: Once the centre for internship has
been identified and assigned, the student should present herself/himself at the centre and in
consultation with the dietitian shall decide on the appropriate schedule for the internship (for
three months with 40 hours/week schedule).
4) Plan the three months schedule with the Chief Dietitian/Dietitian under whose guidance
the internship is being undertaken: A detailed three months training schedule is included here
in Section 1.4. Get a photocopy of this training schedule and submit the same with the head of
the dietetic department. In accordance with this schedule and considering the aspects/points of
interest to be addressed as part of the internship programme your internship supervisor will
plan the three months training schedule for you. For the majority of the internship, the learning
schedule will include Monday through Friday with occasional weekends. Hours may vary with
rotation as the case may be.
5) Review and Study the functioning of the Dietetic Department: The student should review the
functioning of the department with respect to administration, therapeutic services and research
and training by getting hands down experience in these areas.
6) Record the Activities in the Internship Manual: The student should record the activities
undertaken and their experience in this internship manual itself as per the format presented later
in the manual.
7) Communicate regularly with your Internship Supervisor (Chief Dietitian/Dietitian): Carry
out the tasks assigned, share your experiences, report on the activities undertaken, discuss the
problem points, report the difficulties/problems encountered to the supervisor on a regular
basis.

8
8) Submit the Internship Manual (Report) for Evaluation: Submission of the internship report
(manual) including administrative information on the host organization and its dietary
department,

9
 different therapeutic/hospital diets prescribed and served, policies followed by the hospital,
case studies observed and maintenance of a daily work sheet of the activities undertaken by
you is required. At the end of the three months, the record of all the activities undertaken as
part of the internship programme, duly authenticated by the chief dietitian/dietitian in charge (Refer
to certificate copy included at Annexure 1 at the end of the manual) which you would have
recorded in the internship manual, must be submitted at the following address for evaluation:
MSc. (DFSM) Internship Report
Student Evaluation Division
(SED)
Indira Gandhi National Open University Maidan Garhi
Maidan Garhi, New Delhi -110068
The internship supervisor may want you to record the activities (in the manual) on a weekly
basis depending on the task allotted each week. As may be the case, a complete record should
be systematically maintained and presented for evaluation. Keep a photocopy of the report
including the case study section for your reference. Submit the original document (this manual) for
evaluation at the above address.

9) Evaluation by Supervisor: Internship report and your conduct/performance during the

internship period will be evaluated by the chief dietitian/dietitian in-charge (your internship supervisor).
This internal assessment will carry 60% weightage. Please ensure that the dietitian has marked
you (out of 60 marks) and reported the marks on the file on the certificate page at
Annexure-1.

10) External Evaluation: The internship report submitted to the SED at IGNOU headquarters shall
be evaluated in the order received. The internship report will be sent to an expert for
evaluation. This evaluation will carry 40% weightage.

1.4 THE INTERNSHIP TRAINING AND

SCHEDULE: GUIDELINES
The internship is 16-credit course. The internship programme shall be of three months (Total 480
credits; 40 hours per week) duration. The interns are expected to have considerable theoretical
knowledge and competencies related to the following aspects before they commence their internship
programme:
Nutrition Screening and Assessment
Dietary guidelines and practices
Planning Nutrition care and intervention
Implementing care plans
Evaluating nutrition care
Counseling
Food Service Management

The internship is usually split up as follows:

A. Food Service : Administration

(Kitchen functioning, Stores, Accounting Practices, Purchasing,
Food Preparation, Distribution, Service, Safety and Sanitation,
Facility layout and Management)

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B. Clinical Posting : Renal Unit
Endorinology
Cardiovascular
Surgical + Post Operative Unit
Paediatrics
Gastrointestinal
Unit Private ward
Outpatients ward (OPD) etc.
C. Nutrition and Diet Counseling:
Exposure to OPD diet clinic
Prescribing therapeutic diets to OPD patients
Prescribing therapeutic diets to discharged warded patients
under the supervision of dietitian
D. Research and Training :
Case study work
Presentation of case study(s)
Assignment
The details related to the three month training schedule is elaborated herewith

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THREE MONTHS TRAINING SCHEDULE
WEEK 1 : FOOD SERVICE ADMINISTRATION
The activities would include:
• Orientation regarding functioning, systems and activities of the dietetic department.
• Kitchen functioning, Facility Layout and Management (including kitchen and equipment layout).
• Issue of daily ration, Store room management, Purchasing and Food procurement
methods, Receiving and Accounting Practices.
• Studying the dietetic department organizational and administrative set up (in terms of
organizational chart, job description, work schedule, wage structure, allowances and benefits
of the different employees etc.).
• Studying the work centers (receiving area, weight checking area, storage area, pre-preparation
and production area, service area etc.), their functions and their inter-relationships.
• Review of the Sanitation, Hygiene and Waste management policy of the center.
WEEK 2
The activities would include:
• Studying the budgeting and food costing of the dietetic department.
• Menu Planning: Studying the diet scale (i.e. the amount of food to be allotted per
person/day for normal diet as per hospital policy), the cycle menus planned for
general/private wards, therapeutic diets and feeds.
• Food Production (Review of General/Private ward cooking area, Therapeutic diet area,
Special Feed Preparation Area etc.).
• Standardization of portion sizes (studying the process) of the items served to patients.
• Filling of proforma - master diet charts, expense books, instruction sheets, diet slips, feed slips
for therapeutic diets, intending diet in diet sheets etc. Check diet prescriptions and diet
sheets for proper indents.
• Practicing calculation of mock master charts and expense books.
• Preparation of therapeutic diets and feeds for the critically ill.
• Checking Trolley Loading.
• Checking Food Service and Distribution (with reference to timings, schedule and mode of
food service and distribution) in both general and private wards.
• Exposure to OPD Diet Clinics (Observing the dietitian imparting nutrition/diet counseling).
• Exposure to nutrition/diet counseling print material (diet sheets, diet charts, other promotional
and general awareness material specific to disease conditions etc.) available in the
department.
3rd 4th, 5th and 6th WEEKS
The activities would include:
• Master ward round with chief dietitian.
• Ward round with dietitians initially to interact with patients, study case sheets, collect
information on disease condition and treatment/diet prescription, and interpreting doctors
dietary prescription.
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• Clinical posting in different general wards (i:e. medicine, renal, gastrointestinal, pediatric,
endocrinology, surgical and post operative, cancer ward etc.).
• Diet planning for indoor patients based on doctors prescription and on the basis of
nutrition principles and patients ability to eat food under the supervision of the dietitian
initially and then independently.
• Prescribing therapeutic diets to discharged indoor patients under the supervision of dieticians.
• Independent posting in the wards or in the unit of need to interact with patients, study case
sheets, collect information on disease treatment and diet prescription, and interpreting
doctors dietary prescription.
• Posting in private ward to interact with patients.
• Prescribing therapeutic diets to OPD patients.
• Nutrition and diet counseling at OPD clinics (specific to diabetes, overweight, renal
diseases, cardiovascular diseases, peptic ulcer/ulcerative colitis, gall stones, protein energy
malnutrition etc.) initially with the dietitian and subsequently independently.
7th, 8th, 9th, 10th and 11th WEEK
• Independent ward rounds (as instructed by the dietitians).
• Nutrition and diet counseling at OPD clinics (specific to diabetes, overweight, renal
diseases, cardiovascular diseases, peptic ulcer/ulcerative colitis, gall stones, protein energy
malnutrition etc.) independently.
• Case Study work (identification, review of cases in the renal, gastrointestinal, cardiology,
endocrinology, cancer, surgery/post-operative ward, on nutritional support i.e. enteral/parenteral
feeding etc.).
• Selection of five cases (one each from renal, endocrinology, cardiology, surgery/post-operative,
liver disorders, tube feeding etc.) for detail review.
• Review of the cases in terms of patient profile, present problem, physical examination
report, treatment prescribed (both drug and diet), blood parameters related to the disease
conditions before and after the treatment, dietary management and dietary counseling
provided during the patients stay in the hospital and patient prognosis.
• Preparation of Case Study Reports.
• Any other assignment given by the dietitians.
WEEK 12
The activities would include:
• Independent ward rounds.
• Nutrition and diet counseling at OPD clinics (specific to diabetes, overweight, renal
diseases, cardiovascular diseases, peptic ulcer/ulcerative colitis, gall stones, protein energy
malnutrition etc.) initially with the dietitian and subsequently independently.
• Prescribing therapeutic diets to OPD patients/discharged warded patients independently.
• Presentation of Case Studies at the departmental seminar organized by the chief dietitian.
• Presentation of the recent research of interest.
• Evaluation of the Internship programme by self, peer and by the dietitian in charge - Open
House Session.

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We hope the three month schedule planned for you, as part of the internship, will provide up-to-
date information of the latest developments in food service management, medical nutrition therapy, and
dietetics research and education. Certainly, interns will gain practical dietetics knowledge and
application skills through interaction with clinical preceptors in a variety of settings.
When you present yourself for the internship at the selected center, the dietitian in charge for your
internship will plan the training schedule as per the guidelines presented herewith. Diligently carry out
the activities and the duties prescribed and record your work, experience in the form of a report in the
format presented in Section 2 next.

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SECTION 2 INTERNSHIP REPORT
Structure
2.1 Introduction
2.2 Report Guidelines

2.1 INTRODUCTION
This part of the manual is the report of the work, activities undertaken by you as part of the
internship programme scheduled for six weeks in an approved government and/or private hospital or
institute or organization concerned with patient care and imparting dietetic counseling.
Objectives
The objective of this exercise is to help you:
 record the functioning of the dietetic department
 demonstrate your knowledge, skill and competencies for entry-level practice in all specialization
areas of the dietetics profession.
The report you prepare should be so designed and presented that it showcases your knowledge,
skills acquired and competencies achieved for practice in dietetic profession. The internship report will
highlight your experience and skills developed while studying the different aspects of dietetic
practice under the following heads:
A. Internship Details
B. Organization and Administrative Set Up of the Institution where the Internship was undertaken
C. Dietetic Department Profile and Organization
— Organizational Set-Up
— Job Description of Employees
— Work Schedule of Employees in the Dietetic Department
— Wage Structure, Facilities and Benefits to the Employees of the Dietetic Department
D. Facility Layout and Management
— Kitchen Layout
— Physical Facilities of the Main Kitchen and the Pantries
— Physical Facilities of the Main Kitchen: A Critical Review
E. Functioning of the Food Service Unit
— Menu Planning
— Food Procurement, Issue and Storage Policy and Methods
— Food Production
— Food Service and Delivery
F. Clinical Postings and Nutritional Care of Patients
G. Dietary and Nutrition Counseling
Your experience, observations during the three months of internship are to be recorded here in this
handbook, which will serve as an internship report. As and when you complete a particular posting
within the internship period, record your observations immediately in the format presented herewith. After
completing the internship, submit the report to IGNOU headquarters for evaluation as specified earlier
in Section 1.3.
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A. INTERNSHIP DETAILS
(Under this section, report where the internship was undertaken, the duration of the internship giving
actual dates, supervisor (dietitian in charge) under whom the internship was undertaken, the objectives of
internship and the posting schedule for the internship.)
Name of the Institute where the internship was undertaken:

Marudhar Hospital

Dietitian In charge under whose Supervision Internship Undertaken (Name, Designation and
Contact Number:

Duration and Date of Internship:

3 months

Posting Schedule of the Intern:

(Give a brief sketch of the activities undertaken per week with respect to the different dietetic training
components in the format given herewith). You may attach extra sheet if so required.
Week Week Posting
Week Posting Activities Scheduled and Undert
- Orientation regarding functioning, systems, and activitie
department. - Kitchen functioning, Facility Layout, and M
ration, Store room management, Purchasing and Food pr
Food Service Food Service Food Service Studying the organizational and administrative setup of t
Week 1 Administration
Week 1 Administration
Week 1 Administration Reviewing Sanitation, Hygiene, and Waste management p
- Studying budgeting and food costing. - Menu Planning
Standardization of portion sizes. - Filling proforma and p
Preparation of therapeutic diets and feeds. - Checking Tr
Food Service Food Service Food Service Service and Distribution. - Exposure to OPD Diet Clinics a
Week 2 Administration
Week 2 Administration
Week 2 Administration materials.
- Master ward round and ward round with dietitians. - Cli
Weeks Weeks Weeks general wards. - Diet planning for indoor patients. - Presc
3-6 Clinical
3-6Posting
Clinical Posting
3-6 Clinical Posting Posting in private wards and OPD clinics. - Nutrition and
- Independent ward rounds and nutrition counseling at O
work and preparation of Case Study Reports. - Selection
Weeks Weeks Weeks Presentation of Case Studies at departmental seminar. - E
7-11 Clinical
7-11
Posting
Clinical Posting
7-11 Clinical Posting program.
- Independent ward rounds and nutrition counseling at O
Week Week Week therapeutic diets independently. - Presentation of recent
12 Clinical
12 Posting
Clinical Posting
12 Clinical Posting the Internship program in an Open House Session.

16
 Week Week Posting
Week Posting Activities Scheduled and Undert
- Orientation regarding functioning, systems, and activitie
department. - Kitchen functioning, Facility Layout, and M
ration, Store room management, Purchasing and Food pr
Food Service Food Service Food Service Studying the organizational and administrative setup of t
Week 1 Administration
Week 1 Administration
Week 1 Administration Reviewing Sanitation, Hygiene, and Waste management p
- Studying budgeting and food costing. - Menu Planning
Standardization of portion sizes. - Filling proforma and p
Preparation of therapeutic diets and feeds. - Checking Tr
Food Service Food Service Food Service Service and Distribution. - Exposure to OPD Diet Clinics a
Week 2 Administration
Week 2 Administration
Week 2 Administration materials.
- Master ward round and ward round with dietitians. - Cli
Weeks Weeks Weeks general wards. - Diet planning for indoor patients. - Presc
3-6 Clinical
3-6Posting
Clinical Posting
3-6 Clinical Posting Posting in private wards and OPD clinics. - Nutrition and
- Independent ward rounds and nutrition counseling at O
work and preparation of Case Study Reports. - Selection
Weeks Weeks Weeks Presentation of Case Studies at departmental seminar. - E
7-11 Clinical
7-11
Posting
Clinical Posting
7-11 Clinical Posting program.
- Independent ward rounds and nutrition counseling at O
Week Week Week therapeutic diets independently. - Presentation of recent
12 Clinical
12 Posting
Clinical Posting
12 Clinical Posting the Internship program in an Open House Session.

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 B. ORGANIZATION AND ADMINISTRATIVE SET UP OF THE INSTITUTION
WHERE THE INTERNSHIP WAS UNDERTAKEN
[Present the profile of the institution and its’ dietetic/food service unit in terms of its establishment,
administration, functions, capacity (i.e. how many beds) organizational set-up in the space provided
herewith].
Profile: Marudhar Hospital, founded by Dr. Shivraj Singh Rathore, is a leading healthcare facility in
Jaipur. Initially established as a 50-bedded hospital, it has expanded to a modern 150-bedded facility,
with plans for further expansion to 200 beds in the near future. The hospital aims to provide
accessible and affordable healthcare in a compassionate environment.
Accreditations: Marudhar Hospital is ISO 9001:2008 certified, ensuring quality standards in
healthcare delivery. The hospital laboratory has achieved NABL accreditation, meeting international
standards (ISO 15189:2007) for quality and competence.
Recognition: The hospital is recognized and empaneled by major central and state government
organizations for patient treatment. It is also empaneled by all major insurance companies and Third-
Party Administrators (TPAs), ensuring coverage for a wide range of patients.
Services Offered:
1. Specialty and Super Specialty Care: Marudhar Hospital provides comprehensive healthcare services,
covering all medical specialties and super specialties under one roof.
2. Laboratory Services: Equipped with state-of-the-art facilities, the hospital's laboratory meets
international standards, ensuring accurate diagnostics and quality healthcare delivery.
3. Equipped Operating Theaters: Five fully equipped operating theaters enable the hospital to perform a
wide range of surgeries with precision and safety.
4. Critical Care Units: The hospital features a 10-bedded Intensive Care Unit (ICU) and Neonatal
Intensive Care Unit (NICU) with advanced monitoring and life-support equipment, staffed by highly
trained medical personnel.
5. Paramedical Staff: The hospital employs caring, compassionate, trained, and qualified paramedical
staff to ensure holistic patient care.
6. Patient Amenities: Marudhar Hospital prioritizes patient comfort and convenience, offering amenities
such as cafeteria facilities, ambulance services, and backup electricity.
Mission: Marudhar Hospital is committed to providing quality healthcare services with compassion,
empathy, and understanding. Each patient is valued as a guest, and the hospital strives to fulfill their
healthcare needs while ensuring their physical, emotional, and spiritual well-being.
Collaborations and Initiatives: Marudhar Hospital collaborates with affiliated nursing colleges for
training, NGOs for community outreach, and international TPAs for treating beneficiaries in India,
demonstrating its commitment to serving diverse patient populations and promoting equitable
healthcare access.

C. DIETETIC DEPARTMENT PROFILE AND ORGANIZATION

18
 (Present the organizational set-up of the dietetic department highlighting the employees, their work
relationships, job description, work schedule, wage structure and benefits provided as part of the job
to the employees in the space provided herewith.)
Organizational Set-up
(Present in the form of a flow chart as you may recall studying in the MFNL-007 course. Also refer
to Unit 15, sub-section 15.3.5 in MFN-007 for details related to organization chart and accordingly
present the chart of the department here in the space provided.)

Nutrition and Dietetics Department at Marudhar Hospital

The Nutrition and Dietetics Department at Marudhar Hospital is dedicated to enhancing patient care
through individualized medical nutrition therapy and preventive measures to minimize malnutrition
associated with acute or chronic diseases. Our department operates with a multidisciplinary
approach to optimize patient outcomes. Here's a breakdown of our services and workflow:
Services Offered:
1. Medical Nutrition Therapy: Our department offers personalized medical nutrition therapy tailored to
each patient's unique needs, ensuring optimal nutritional support during their hospital stay.
2. Malnutrition Prevention: We focus on preventing and minimizing malnutrition commonly seen in
patients with acute or chronic illnesses, aiming to improve overall health outcomes.
3. Nutrition Education: We provide comprehensive nutrition education to patients and their families
across various care settings, empowering them to make informed dietary choices for better health
outcomes.
4. Collaboration with Healthcare Teams: We function as an integral component of the healthcare
team, collaborating closely with doctors, clinical staff, and nursing teams to ensure seamless
coordination of patient care.
5. Support for Education and Research: Our department actively supports education and research
initiatives in collaboration with medical professionals, contributing to advancements in the field of
nutrition and dietetics.
Areas of Expertise:
 Patient Groups: Our highly trained nutritionists specialize in managing diverse patient groups,
including adults, neonates, pediatrics, critically ill patients, and those with terminal illnesses or
lifestyle diseases such as diabetes, hypertension, and metabolic syndromes.
 Specialized Nutrition Support: We provide specialized nutrition support for patients recovering
from surgery, infections, gastrointestinal diseases, kidney disorders, endocrine disorders, lung
diseases, hepato-biliary disorders, and other medical conditions.
 Life-Phase Nutrition: Our services extend to individuals requiring nutrition care during special life
phases such as pregnancy, lactation, old age, and disabilities affecting nutritional intake.
 Specific Conditions: We offer tailored nutrition care for patients with specific conditions such as
allergies, lactose intolerance, malabsorption syndromes, and weight management needs.
Workflow:

19
 Patient-Centered Care: Our department prioritizes patient-focused quality care, ensuring that each
patient receives individualized attention and appropriate nutritional support throughout their
hospitalization.
 Collaborative Approach: Nutritionists work closely with healthcare teams to assess patients'
nutritional needs, develop personalized nutrition plans, and monitor their progress to achieve optimal
health outcomes.
 Continuous Education: We are committed to ongoing education in all aspects of nutrition, staying
updated with the latest research and advancements in the field to deliver high-quality care to our
patients.
At Marudhar Hospital, the Nutrition and Dietetics Department plays a pivotal role in promoting
health and well-being through evidence-based nutrition interventions and compassionate patient
care.

The dietician visits the patient , explains and educates about the type of the diet / diet change. The
diets are planned according to their medical requirements, health condition, and physiological
status. Once the counselling / assessment is done to the patients , the patient’s progress notes are
updated.
If there are any RT feeds , then the feeds are mentioned separately on a liquid diet order sheet and
the same is handed over to the kitchen desk ( F& B Department ) . The meals will be supplied and
served to the patients as per the dieticians advice and orders.
OPD counselling is also done for their specific health stutus or disease condition.

A Six meal course is served for the patients:

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Sunrise : 6:00 to 7:00 am.
Breakfast : 7:00 to 8:30 am
Midmorning : 9:30 to 10:30 am
Lunch : 12:30 pm to 1:30 pm
Tea : 4pm
Dinner : 7:00 pm to 8:30 pm
Night Cap: 9:00 pm to 10:00 pm

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 Job Description of Employees
[Present the details and the responsibilities of personnel at different positions (presented in the
organizational chart above) here in the space provided].
1. Chief Dietitian
Responsibilities:
 Oversee the entire dietetic department, ensuring compliance with nutritional standards and guidelines.
 Lead and manage the dietetic team, including hiring, training, and performance evaluations.
 Develop and implement departmental policies, procedures, and quality improvement initiatives.
 Collaborate with other healthcare professionals to provide comprehensive patient care.
 Manage budgeting, forecasting, and financial planning for the dietetic department.
Qualifications:
 Master's degree in Nutrition, Dietetics, or related field.
 Registered Dietitian with active licensure.
 Minimum of 5 years of clinical experience, with at least 2 years in a managerial role.
2. Clinical Dietitian
Responsibilities:
 Assess patients' nutritional needs, develop and implement nutrition programs, and evaluate and report the
results.
 Collaborate with healthcare providers to determine nutritional needs and diet restrictions of patients.
 Educate patients and their families on healthy eating habits and nutritional plans.
 Keep up with the latest nutritional science research.
Qualifications:
 Bachelor’s degree in Nutrition, Dietetics, or related field.
 Registered Dietitian with active licensure.
 Clinical experience, preferably in a hospital setting.
3. Food Service Manager
Responsibilities:
 Oversee the daily operations of food service within the department, including meal preparation, inventory, staff
management, and compliance with health and safety standards.
 Develop and implement menus that meet the nutritional requirements and preferences of patients.
 Manage food and labor costs within the budget.
 Ensure the cleanliness and maintenance of kitchen and dining areas.
Qualifications:
22
 Bachelor’s degree in Hospitality, Culinary Arts, or related field, or significant experience in food service
management.
 Knowledge of nutrition and dietetics, preferably with a certification or coursework in the field.
 Experience in a supervisory or managerial role in food service.
4. Dietetic Technician
Responsibilities:
 Assist dietitians in the planning and delivery of meals to patients.
 Perform nutritional screenings and gather patient dietary information to assist in nutritional assessments.
 Educate patients on the importance of dietary guidelines for their health conditions.
 Manage food service operations under the guidance of a food service manager or dietitian.
Qualifications:
 Associate degree or certification in Dietetic Technology, Nutrition, or related field.
 Registration as a Dietetic Technician, Registered (DTR) preferred.
 Experience in a clinical or food service setting is advantageous.
5. Administrative Assistant
Responsibilities:
 Provide administrative support to the dietetic department, including document preparation, record keeping, and
scheduling.
 Assist with the coordination of departmental meetings and professional events.
 Handle communications and correspondence with other departments and external partners.
 Manage inventory and order supplies for the department.
Qualifications:
 High school diploma or equivalent; additional certification in Office Management is a plus.
 Proven experience as an administrative assistant.
 Excellent organizational and communication skills.
 Proficiency in MS Office and data management software.
These descriptions provide a foundation that you can build upon or modify to align with the specific roles
and responsibilities within your dietetic department.

23
 Work Schedule of Employees in the Dietetic Department
(For each category of the employee in the dietetic department present the work days/hours/timing of work
in the space provided herewith. You may like to refer to sub-section 14.2.4 in Unit 14, MFN-007
Course for reference.)
Position Monday-Friday Saturday-Sunday Duties

Department oversight, staff

Chief Dietitian 08:00-16:30 As needed management, administrative tasks

Rotating Shifts (07:30- Rotating Shifts (as per Nutrition assessments, diet planning,
Clinical Dietitian 16:00, 13:00-21:30) weekday schedule) patient education

Meal service operations, staff

Food Service 06:00-14:30 / 08:00- management, compliance with food
Manager 16:30 As needed safety

Support dietitians, meal planning

Dietetic Technician Rotating Shifts (varies) Rotating Shifts (varies) assistance, dietary data collection

Food Service Rotating Shifts (05:00- Rotating Shifts (as per Meal preparation, kitchen maintenance,
Worker/Cook 13:30, 11:00-19:30) weekday schedule) adherence to dietary requirements

Administrative Administrative support, scheduling,

Assistant 08:00-16:30 Off / As needed record keeping

Cleaning, equipment sanitization,

Utility Worker Rotating Shifts (varies) Rotating Shifts (varies) dishwashing, waste disposal

24
 Wage Structure, Facilities and Benefits to the Employees of the Dietetic Department
[Give the pay structure, facilities (office space etc.), financial and other benefits (such as housing
allowance, washing allowance, academic allowance, telephone bill reimbursement etc.) provision of
leaves and list of holidays granted to the different categories of employees in the space provided
herewith. You may attach extra sheets if so required.]

25
 D. FACILITY LAYOUT AND MANAGEMENT
(Under this section illustrate the kitchen layout highlighting the various work centers, physical facilities of
the main kitchen, their functions and inter-relationships and critically review the set-up in the context of
ensuring smooth flow of work. Present the details in the format given herewith.)
Kitchen Layout
(Present a schematic representation/detailed layout of the kitchen in the space provided herewith.
You may refer to Unit 3, sub-section 3.4.4. to get on idea on how to prepare the schedule layout.)
KITCHEN LAYOUT
Hospital kitchens have the dual responsibility of providing good-quality meals for staff and visitors,
while also creating nutritious menus for patients with a variety of dietary needs.
Kitchen layout often includes spaces for multiple preparation, cooking, washing and service
stations. The kitchen layout comprises of the following:
1. Storage Area
2. Grinding Area
3. Meal Preparation Area ( IPD and staff & Visitors)
4. Assembling Area
5. Desk
6. Washing Area
7. Garbage Area
1. STORAGE AREA
The storage area can be split into cold storage and dry storage.
1. a) Dry storage comprises of all the non perishable foods such as the spices , grains , dals and oil.
Here the expiry date is checked every week. Before storage the quality and quantity is checked. Dry
goods are stored with adequate ventilation to avoid damp conditions which can affect dried produce.
2. b) Cold storage or the Cold room (( 4 to 8 oC). It stores only vegetarian products like dosa batter,
cheese, nutralite, eggs , sauces , cut vegetables and fruits .
There are also other normal refrigerators for vegetarian foods (like boiled items, chutney etc ) and
non vegetarian foods ( patties and marinated meat ) for immediate use . In the main kitchen area
there is also a deep freezer ( -16 to -20 oC) which stores vegetarian frozen products like corn,
green peas, French fries , smiles and non vegetarian products such as chicken sausages , nuggets
and cut meat.
Milk Refrigerator is maintained at temperature -8oC
IPD fridge consists of items such as curd rice , dal , vegetables, broken wheat etc. which are
prepared specially for the inpatients.
2. GRINDING AREA
This comprises of 2 huge grinders, coconut peeler ( mainly used for chutneys ) , dough mixing
machine ( to prepare chapathi dough) and potato peeler.

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 3. MEAL COOKING AREA
The meal cooking area is divided into two:
IPD Diet preparation area: Here food is prepared for the inpatients which includes 6 meals .
There are separate stoves for vegetarian and non-vegetarian meals. There is also a modified diet
preparation area for preparing meals with special requisitions. Some examples of the types of diet
prepared are Soft Diet ,
Diabetic Diet, Liquid Diet , Renal Diet, High Calorie Diet, High Protein Diet etc. Meal timings are
also considered.
i. The food cooked is assembled and placed in heating trollies to serve to the patients.
ii. Staff and visitors meal preparation Area: Here the meals are prepared based on the orders
placed . This includes a chinese preparation area where all chinese preparations such as fried rice,
noodles etc are made and other areas for preparing dosas , South Indian and North Indian dishes .
The meal cooking area can be broken down into smaller sections like a grilling station, frying
station and equipments such as Rice boiler and tandoor.
4. ASSEMBLING AREA
Once the food is prepared it is assembled according to the patient’s diet and placed in trays for
service to the patients. The food is packed with foil to avoid any contamination.
5. DESK
Here the orders are taken from the inpatients and also records of requisitions made in certain diets
are maintained. The Desk plays an important role in maintaining and managing the diets particular
to that patient. Home cooked food if any is also passed to the patients from here.
6. WASHING AREA
This comprises of pot washing area , area where all the trays , big vessels and utensils are washed
and also a dish washing machine for the other utensils, cutlery, and plates. A kitchen store is present
which includes paper plates and cups for the packaging of inpatient food.

FLOW PROCESS OF DISHWASHING MACHINE

27
There is also a small storage area for the chemicals and detergents used for cleaning the vegetables and also the utensils
respectively.

7. GARBAGE AREA

This comprises of wet ( the fruits and vegetable waste etc ) ,and dry waste ( foil, paper and plastic etc ).

CONCLUSION

Hospital catering services are an essential part of ptient care. God quality , nutritious mealsplay a vital role in patient’s
recovery.
The major activities that take places in the kitchen are:

 Receiving of raw materials( weighed and counted ).

 Storage of raw materials in proper storage area like the cooler for perishable goods and dry

storage area for non-perishable goods.

 Production of food where various meals are prepared according to prescribed diet plan.

 Serving of food according to the portion prescribed in the diet plan with the help of standardize

cups and serving the diet tray at the patient’s bed side.

 Monitoring of cleanliness, hygiene and sanitation on a daily basis.

 Routine cleaning on a daily basis to ensure cleanliness and hygiene of all section which include

the pre- preparation area, cooking area, washing area, dry storage area, vegetable storage area ,food trolleys,
floors and tiles, ventilators and garbage disposal.

KITCHEN LAYOUT

28
 Physical Facilities of the Main Kitchen and the Pantries
(Present a detail account of the kitchen area in terms of its premise, ventilation, water/gas connections,
sanitation, hygiene, and waste disposal policy, uninterrupted power supply, if applicable. Also attach the list
of equipment used in the kitchen/pantry.)
Premises: The main kitchen and pantries at Marudhar Hospital are strategically located within the
hospital premises for easy access and efficient food service delivery. The kitchen area is designed to
accommodate the preparation and distribution of meals for both inpatients and outpatients.
Ventilation: The kitchen is equipped with adequate ventilation systems to ensure proper air
circulation and maintain a comfortable working environment for kitchen staff. Exhaust fans and
ventilation hoods are installed to remove excess heat, steam, and cooking odors.
Water and Gas Connections: The kitchen is connected to the hospital's water and gas supply
systems, ensuring uninterrupted access to essential utilities for cooking, cleaning, and sanitation
purposes. The connections are regularly inspected and maintained to ensure optimal performance
and safety.
Sanitation and Hygiene: Maintaining high standards of sanitation and hygiene is a top priority in
the kitchen area. Daily cleaning schedules are followed to sanitize countertops, equipment, and
utensils. Staff are trained in food handling and hygiene practices to prevent contamination and
ensure food safety.
Waste Disposal Policy: The hospital has a comprehensive waste disposal policy in place to manage
both organic and non-organic waste generated in the kitchen. Separate bins are provided for
segregating different types of waste, and regular disposal schedules are followed to maintain
cleanliness and hygiene standards.
Uninterrupted Power Supply: The kitchen is equipped with backup power generators to ensure
uninterrupted electricity supply, especially during power outages or emergencies. This ensures that
food preparation and service can continue without disruption, guaranteeing timely meals for
patients and staff.
Equipment List: Below is a list of equipment commonly used in the main kitchen and pantries at
Marudhar Hospital:
1. Commercial gas stoves
2. Industrial ovens
3. Refrigerators and freezers
4. Food preparation tables and countertops
5. Stainless steel sinks and dishwashing stations
6. Food processors and blenders
7. Steamers and rice cookers
8. Kitchen utensils (pots, pans, knives, etc.)
9. Food storage containers
10. Dish racks and drying shelves

29
 Physical Facilities of the Main Kitchen: A Critical Review
(Critically review the facilities available and record your observations and recommendations related to
your work experience in the kitchen in the format given herewith.)
Placement of Work Centers: Observations and Recommendations
Observations:
1. Layout Efficiency: The placement of work centers in the main kitchen appears to be well thought out, with a
logical flow of food preparation from receiving to production and service areas.
2. Space Utilization: Adequate space is allocated for each work center, allowing kitchen staff to move around
comfortably during food preparation.
3. Accessibility: Essential work centers such as receiving, storage, and production areas are conveniently located
for easy access by kitchen staff.
4. Inter-Connectivity: There is a clear inter-relationship between different work centers, facilitating smooth
workflow and coordination among kitchen staff.
5. Hygiene Considerations: Work centers are positioned to minimize cross-contamination risks and ensure food
safety standards are upheld.
Recommendations:
1. Optimize Workflow: While the current layout is efficient, periodic reviews should be conducted to identify any
bottlenecks or areas for improvement in workflow efficiency.
2. Enhance Ergonomics: Considerations should be made to optimize the ergonomic design of workstations,
ensuring that kitchen staff can perform tasks comfortably and safely.
3. Streamline Communication: Implement strategies to enhance communication and coordination between
different work centers, such as utilizing digital communication tools or adopting standardized protocols.
4. Regular Maintenance: Ensure that all work centers are regularly maintained and cleaned to prevent any
potential hazards or hygiene issues.
5. Flexibility in Design: Maintain flexibility in the kitchen layout to accommodate changes in operational needs or
technological advancements in kitchen equipment.
By critically reviewing the placement of work centers in the main kitchen and implementing the
recommended improvements, Marudhar Hospital can further enhance operational efficiency, hygiene
standards, and overall kitchen performance.

Availability of Equipment: Observations and Recommendations. You may record the equipment on
an extra sheet, if so required.
30
Availability of Equipment:
Observations:
1. Equipment Sufficiency: The main kitchen is adequately equipped with essential tools and appliances required
for food preparation, cooking, and storage.
2. Variety of Equipment: A diverse range of equipment is available to cater to different cooking techniques and
culinary requirements, including gas stoves, ovens, refrigerators, and food processors.
3. Condition of Equipment: Most of the equipment appears to be well-maintained and in good working
condition, ensuring smooth kitchen operations.
4. Backup Equipment: There is a provision for backup equipment, such as spare gas stoves and refrigerators, to
minimize disruptions in case of equipment malfunction.
5. Storage Facilities: Adequate storage facilities are available for storing equipment when not in use, helping to
maintain cleanliness and organization in the kitchen area.
Recommendations:
1. Regular Maintenance: Implement a regular maintenance schedule to ensure that all equipment is routinely
inspected, cleaned, and serviced to prevent breakdowns and prolong their lifespan.
2. Training for Equipment Usage: Provide training sessions for kitchen staff on the proper usage and
maintenance of equipment to optimize performance and prevent misuse or damage.
3. Inventory Management: Establish an inventory management system to track equipment usage, monitor stock
levels, and facilitate timely replenishment of consumables and replacement of worn-out equipment.
4. Upgrade Where Necessary: Assess the functionality and efficiency of existing equipment periodically and
consider upgrading or replacing outdated or inefficient models with more advanced alternatives to improve
productivity and energy efficiency.
5. Emergency Preparedness: Develop contingency plans and protocols for handling equipment failures or
emergencies to minimize disruptions to kitchen operations and ensure continuity of service delivery.
By addressing these recommendations, Marudhar Hospital can ensure the availability and optimal performance of
kitchen equipment, contributing to efficient food production, hygiene standards, and overall customer satisfaction.

Sanitation, Hygiene and Waste Disposal: Observations and Recommendations

Sanitation, Hygiene, and Waste Disposal:

Observations:
1. Sanitation Practices: Overall, sanitation practices in the main kitchen appear to be satisfactory, with regular
cleaning schedules and protocols in place to maintain cleanliness.
2. Hygiene Standards: Kitchen staff adhere to basic hygiene standards, such as wearing protective clothing,
washing hands frequently, and using gloves when handling food.
3. Waste Disposal: Waste disposal procedures are followed diligently, with separate bins provided for segregating
organic and non-organic waste. Regular waste disposal schedules are in place to prevent accumulation and
ensure a clean environment.
4. Cleaning Supplies: Adequate cleaning supplies, such as detergents, disinfectants, and sanitizers, are available
for use by kitchen staff to maintain hygiene standards.
5. Ventilation and Pest Control: Ventilation systems are effective in removing excess heat and steam from the
kitchen, contributing to a comfortable working environment. Pest control measures are implemented to prevent
infestations and maintain hygiene standards.
Recommendations:
1. Enhance Training: Provide regular training sessions for kitchen staff on sanitation and hygiene practices to
reinforce good habits and ensure compliance with standard protocols.
2. Implement Monitoring Systems: Establish monitoring systems to regularly assess sanitation and hygiene
practices in the kitchen, with designated staff responsible for conducting inspections and enforcing standards.

31
3. Upgrade Facilities: Consider upgrading facilities such as handwashing stations and waste disposal units to
improve efficiency and hygiene standards.
4. Review Waste Management: Conduct a review of waste management practices to identify opportunities for
reducing waste generation and implementing recycling or composting initiatives where feasible.
5. Collaborate with Environmental Services: Collaborate with the hospital's environmental services department
to ensure coordination in waste disposal and sanitation efforts, leveraging their expertise and resources for
effective management.

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 E. FUNCTIONING OF THE FOOD SERVICE UNIT
(In the context of the different functions performed by a food service unit,
namely menu planning, procurement, receiving, storage, production, issuing,
service and food costing, present a detail account of the functions performed by
the unit where you undertook the internship in the format given herewith.)
a) Menu Planning
[Present the menu pattern, diet scale (i.e. food allocated per person per day
for normal diet) and the cycle menu prepared for the general/private ward. Also
record the modified therapeutic diets (i.e. diabetic diet (1500, 1800), semisolid
diet, high/ low protein diet, salt restricted diet etc.) special feeds prepared
(renal feed, high protein feed etc.) in the dietetic center in the format given
herewith.]
Diet Scale of the Department

Name of Food Item(s) Amount in Grams (General Ward) Amount in Grams (Private Ward)
Rice 100 150
Roti 2 3
Dal 100 150
Sabzi 100 150
Chicken 100 150
Fish 100 150
Paneer 100 150
Salad 50 100
Fruits 100 150
Milk 200ml 250ml
Curd 100g 150g
Dessert 100g 150g

Food Items/Menus served in General Ward

Mid-
Day of the Morning
Week Breakfast Snack Lunch Tea Dinner
Roti (Indian bread), Paneer
Poha (flattened Rajma (kidney Tea with Tikka (cottage cheese),
Monday rice) Fresh fruit bean curry) biscuits Mixed Vegetables, Rice
Upma
(semolina Chole (chickpea Tea with Roti, Chicken Curry, Saag
Tuesday porridge) Sprouts salad curry) pakoras (spinach), Salad, Rice
Vegetable Aloo Gobi (potato
Daliya Yogurt with and cauliflower Tea with Roti, Dal Tadka (lentils),
Wednesday (porridge) nuts curry) cookies Bhindi (okra), Salad, Rice
Idli with Paneer Butter Tea with Roti, Fish Curry, Mixed
Thursday sambar Fruit chaat Masala, Pulao namkeen Vegetables, Salad, Rice
Roti, Mutton Rogan Josh,
Paratha with Coconut Baingan Bharta Tea with Palak Paneer (spinach with
Friday curd water (eggplant mash) rusk cottage cheese), Rice
33
 Mid-
Day of the Morning
Week Breakfast Snack Lunch Tea Dinner
Tea with Roti, Egg Curry, Veg Korma,
Saturday Masala Dosa Buttermilk Veg Biryani muffins Salad, Rice
Vegetable Lassi (yogurt Rajma (kidney Tea with Roti, Chicken Tikka Masala,
Sunday Sandwich drink) bean curry) biscuits Mix Veg, Rice

34
Use of Cycle Menu (General and Private Ward). Present the cycle menu followed in the hospital in
a seperate sheet and attach here.

Modified Therapeutic Diets. Prepare a list and attach here.

Special Feeds Prepared (give the composition, attach extra sheet if required)

35
 b) Food Procurement, Issue and Storage Policy and Methods
(An important function of the dietetic department is procurement, which includes purchasing and receiving
of food items. Record the purchasing process, methods and schedule of purchasing the different food
items, the food receiving process and schedule, the storing process (for dry, cold storage) and the records
maintained and the issuing system followed in the dietetic department.)
Employee(s) In charge of Purchasing:

Employee(s) In charge of Purchasing:

 Head Dietitian: [Name]
 Assistant Dietitian: [Name]

Purchasing Method and Schedule for the Different Food Items

(Highlight how the purchase order is prepared giving the specifications of food items required, the schedule
of purchase, the delivery timing, the method employed for purchase i.e. bid contract, wholesale buying
etc.)

Purchasing Method and Schedule for the Different Food Items:

1. Specifications and Purchase Orders:
 The purchasing process is initiated by the Head Dietitian who assesses the current inventory
levels and upcoming dietary requirements.
 A detailed purchase order is prepared specifying the quantity, quality, and type of food items
required.
 Specifications include freshness, quality standards, and any dietary restrictions for special
feeds.
 Purchase orders are signed by the Head Dietitian and forwarded to the procurement
department.
2. Schedule of Purchase:
 Purchase schedules are established based on dietary plans, patient census, and forecasted
requirements.
 Regular purchase schedules are maintained for staple items like grains, pulses, and dairy
products.
 Perishable items are purchased more frequently to ensure freshness.
3. Delivery Timing:
 Delivery timing is coordinated with the procurement department and suppliers.
 Deliveries are scheduled during off-peak hours to minimize disruptions in hospital operations.
4. Purchasing Methods:
 Bidding Contracts: For bulk purchases or specialized items, bidding contracts are utilized to
36
 ensure competitive pricing and quality assurance.
 Wholesale Buying: Staple items are often procured through wholesale suppliers to leverage
volume discounts.
 Direct Purchase: Perishable items such as fruits, vegetables, and dairy products may be
purchased directly from local markets or trusted vendors.

37
 Receiving Function
(Highlight who is responsible for this function, how it is done based on the invoice etc.)

Receiving Function
Responsible Personnel:
 The receiving function in the hospital is typically overseen by designated staff within the dietary department, such as
the Head Dietitian or designated receiving personnel.
Process Overview:
The receiving process in the hospital involves the following steps:
1. Notification of Delivery:
 Upon arrival of a delivery truck, the procurement department notifies the dietary department of the incoming
food shipment.
2. Verification of Delivery:
 Receiving personnel verify the delivery against the purchase order and accompanying invoice.
 They check for accuracy in terms of quantity, quality, and condition of the items received.
 Any discrepancies between the purchase order and actual delivery are noted for further action.
3. Inspection of Goods:
 Receiving personnel inspect the delivered goods for freshness, damage, and adherence to quality standards.
 Perishable items are checked for appropriate temperature control during transit to ensure they meet food
safety requirements.
 Packaging integrity is examined to ensure no signs of tampering or contamination.
4. Documentation:
 Receiving personnel document the received items, noting any discrepancies or damages observed during
inspection.
 They record the quantity received, batch/lot numbers (if applicable), and expiration dates.
 The information is logged into the receiving log or system for traceability and accountability purposes.
5. Communication:
 Any discrepancies or issues identified during the receiving process are promptly communicated to the
procurement department.
 If necessary, the delivery driver or supplier is notified of any concerns to facilitate resolution.
6. Storage or Rejection:
 Accepted items are transferred to designated storage areas within the hospital according to their specific
storage requirements.
 Items that do not meet quality standards or are damaged beyond use are rejected and arrangements are made
for their return or disposal.
Sample Receiving Procedure:
38
1. Notification:
 Procurement department notifies dietary department of incoming delivery.
2. Verification:
 Receiving personnel cross-reference delivery against purchase order and invoice.
3. Inspection:
 Inspect goods for quality, freshness, and adherence to standards.
4. Documentation:
 Record received items, noting any discrepancies or damages.
5. Communication:
 Communicate any issues to procurement department or supplier.
6. Storage or Rejection:
 Transfer accepted items to designated storage areas; reject damaged or substandard items.
Responsibility and Accountability:
 The receiving personnel are responsible for ensuring that all items received meet quality and safety standards before
being accepted into inventory.
 They are accountable for accurately documenting received items and promptly communicating any issues to the
relevant departments for resolution.

Storage

Person in Charge of the Store Room:

 The store room is typically managed by a designated staff member within the dietary department, often
supervised by the Head Dietitian or an assigned storekeeper.
Storage Conditions:
1. Dry Storage:
 Dry storage areas are dedicated to non-perishable food items such as grains, pulses, canned goods, and
dry spices.
 These areas are maintained at ambient room temperature, away from direct sunlight and moisture.
 Shelving units or racks are used to organize and store items efficiently.
2. Cold Storage:
 Cold storage facilities are utilized for perishable items including dairy products, meats, and fresh
produce.
 Refrigerators and freezers are maintained at appropriate temperatures to preserve food quality and safety.
 Temperature monitoring systems are in place to ensure compliance with food safety regulations.
Equipment Available for Storage:
 Shelving units or racks for dry storage.
 Refrigerators and freezers for cold storage.
 Temperature monitoring devices.
 Labeling equipment for item identification and expiration date tracking.
 Pallet jacks or hand trucks for moving heavy items.
Records Maintained in the Store Room:
1. Inventory Records:
 Detailed records of all items stored in the store room, including quantities, batch/lot numbers, and
expiration dates.
39
  Inventory logs or digital inventory management systems are used to track stock levels and monitor
usage.
2. Temperature Logs:
 Logs documenting temperature readings in cold storage facilities are maintained regularly to ensure
compliance with food safety standards.
 Any deviations from recommended temperatures are noted and addressed promptly.
3. Receiving and Issuing Records:
 Documentation of items received, including purchase orders, delivery receipts, and inspection reports.
 Records of items issued from the store room, including requisition forms, quantities issued, and recipient
information.
Issue System Followed in the Store Room:
 The store room operates on a system of requisitions for issuing items to various departments within the hospital.
 Authorized personnel submit requisition forms specifying the items needed and quantities required.
 The storekeeper verifies the requisition against available inventory and processes the request accordingly.
 FIFO (First-In, First-Out) method is typically followed to ensure older stock is used first, minimizing waste and
maintaining freshness.
Responsibility and Accountability:
 The storekeeper or designated staff member is responsible for maintaining accurate records, monitoring
inventory levels, and ensuring proper storage conditions.
 They are accountable for complying with food safety regulations, maintaining cleanliness and organization in
the store room, and facilitating efficient issuing of items as per departmental requirements.

40
 Food Procurement, Storage and Issue: Observations and Recommendations
(Present a critical review on the food procurement, storage and issue function of the dietetic
department reported above presenting your observations and recommendations for further
improvement.)

Observations:
1. Procurement Process:
 The procurement process appears to be well-structured, with clear specifications and schedules
for purchasing food items.
 However, there may be room for improvement in exploring alternative suppliers or negotiating
better contracts to optimize costs without compromising on quality.
2. Storage Conditions:
 Dry storage and cold storage facilities seem adequate for maintaining the quality and safety of
food items.
 However, there should be regular monitoring of storage temperatures and conditions to prevent
spoilage or contamination, especially in cold storage areas.
3. Equipment and Records:
 The availability of appropriate storage equipment such as shelving units, refrigerators, and
freezers is commendable.
 Records maintained in the store room, including inventory logs and temperature records,
provide valuable documentation for tracking stock levels and ensuring compliance with food
safety standards.
4. Issue System:
 The issuance process follows a systematic approach, ensuring that requisitions are verified and
items are accurately distributed to requesting departments.
 However, there may be opportunities to streamline the process further by implementing digital
inventory management systems or barcode scanning technology for improved efficiency and
accuracy.
Recommendations:
1. Supplier Evaluation and Diversification:
 Conduct periodic evaluations of existing suppliers to assess their performance in terms of
quality, reliability, and pricing.
 Explore opportunities to diversify the supplier base to mitigate risks and leverage competitive
advantages.
2. Enhanced Monitoring of Storage Conditions:
 Implement regular checks and audits of storage facilities to ensure compliance with
recommended temperature and hygiene standards.
 Provide training to staff members responsible for storage management to enhance their
41
 awareness of best practices and protocols.
3. Investment in Technology:
 Consider investing in inventory management software or technology solutions to automate
processes and improve inventory tracking and control.
 Barcode scanning systems can facilitate real-time updates on stock levels and streamline the
issuance process, reducing manual errors and administrative burden.
4. Staff Training and Development:
 Conduct training sessions for dietary department staff on food safety practices, proper handling
procedures, and storage management techniques.
 Empower staff members with the knowledge and skills necessary to identify and address issues
related to procurement, storage, and issuance effectively.
5. Continuous Improvement Initiatives:
 Establish a feedback mechanism to solicit input from end-users and stakeholders regarding
their experiences with the procurement, storage, and issuance functions.
 Use feedback to drive continuous improvement efforts, implementing changes and adjustments
as needed to optimize departmental operations and service delivery.
Conclusion:
By implementing these recommendations and fostering a culture of continuous improvement, the
hospital dietary department can enhance its food procurement, storage, and issuance functions,
ultimately contributing to improved efficiency, cost-effectiveness, and quality in the delivery of
food services within the hospital setting.

42
 c) Food Production
(Food production is the most important function of the food service unit. Highlight the different
production areas in the dietetic department in the format given herewith.)
General Ward Cooking Area
[Highlight the different work stations for preparing the different food items, the timing of cooking, the
special methods (i.e. assembly line process) employed etc.]

Food Production
General Ward Cooking Area
The General Ward Cooking Area in the dietetic department is designed to efficiently prepare a
variety of meals to meet the dietary requirements of patients in the hospital. Here's an overview of
the different work stations and processes employed in the General Ward Cooking Area:
1. Preparation Station:
 This station is dedicated to prepping ingredients for cooking.
 Vegetables are washed, peeled, and chopped as per recipe requirements.
 Meat and poultry are trimmed and portioned for cooking.
2. Cooking Stations: a. Grains and Pulses Station:
 This station is responsible for cooking rice, lentils, and other grains.
 Timing: Grains and pulses are cooked as per the meal schedule, typically starting early in the
morning to ensure availability for breakfast and lunch.
b. Curries and Gravies Station:
 Here, curries, gravies, and main dishes are prepared.
 Timing: Cooking starts early to allow sufficient time for simmering and flavor development.
c. Vegetable Stir-fry Station:
 This station handles the preparation of stir-fried vegetables and side dishes.
 Timing: Stir-frying is done closer to meal times to maintain freshness and texture.
d. Tandoor or Grill Station (Optional):
 If available, this station is used for grilling or tandoori preparations such as grilled chicken or
paneer tikka.
 Timing: Grilling is done just before serving to ensure items are served hot and fresh.
3. Assembly Line Process:
 The General Ward Cooking Area may employ an assembly line process for efficiency.
 Each station focuses on specific tasks, with ingredients moving down the line as they are
prepared and cooked.
 This method ensures smooth workflow and timely preparation of meals.
43
4. Timing:
 Cooking activities are planned and scheduled to align with meal times for patients.
 Breakfast items are prepared early in the morning to ensure timely service.
 Lunch items are cooked in advance to allow for final assembly and plating closer to meal
times.
 Dinner items are prepared in the afternoon to ensure they are ready for evening service.
5. Special Methods:
 Depending on the volume of meals required, the General Ward Cooking Area may employ
batch cooking techniques to prepare large quantities of food efficiently.
 Use of standardized recipes and portion control measures helps maintain consistency and
quality across meals.
 Special dietary requirements, such as pureed or soft diets, are accommodated through
specialized cooking methods and equipment as needed.
The General Ward Cooking Area operates with the aim of providing nutritious and appetizing meals
to patients in a timely manner. By utilizing different work stations, employing efficient cooking
methods, and adhering to strict timing schedules, the dietary department ensures that patients
receive high-quality meals tailored to their dietary needs.
The Therapeutic Diet Area within the Private Ward Cooking Area is dedicated to preparing
Private Ward Cooking Area
Therapeutic Diet Area [highlight the facilities available, process involved (i.e. based on checking the diet
prescription, diet slips/feed slips) for preparing the therapeutic diets etc.]

specialized diets tailored to meet the specific medical and nutritional needs of patients requiring
therapeutic interventions. Here's an overview of the facilities available and the process involved in
preparing therapeutic diets:
Facilities Available:
1. Specialized Equipment:
 The Therapeutic Diet Area is equipped with specialized kitchen appliances and utensils to
accommodate the preparation of therapeutic diets.
 This may include blenders, food processors, juicers, and steamers for customized food
preparation.
2. Separate Work Stations:
 Different work stations are designated for preparing various therapeutic diets, ensuring cross-
contamination is minimized.
 Each station is equipped with tools and equipment specific to the type of therapeutic diet being
prepared.
3. Dedicated Storage:
 Storage areas are designated for therapeutic diet ingredients, ensuring they are kept separate
from regular food items to prevent mix-ups.

44
 Process Involved:
1. Review of Diet Prescription:
 The process begins with a review of the patient's diet prescription or therapeutic diet plan
provided by the attending physician or dietitian.
 This document outlines the specific dietary restrictions, modifications, or enhancements
required based on the patient's medical condition and nutritional needs.
2. Preparation of Diet Slips/Feed Slips:
 Based on the diet prescription, diet slips or feed slips are prepared for each patient receiving a
therapeutic diet.
 These slips detail the specific items and portions of the therapeutic diet to be served to the
patient for each meal.
3. Customized Food Preparation:
 Therapeutic diets are prepared according to the specifications outlined in the diet slips.
 Ingredients are carefully selected and portioned to meet the patient's dietary requirements,
ensuring compliance with any restrictions or modifications.
4. Specialized Cooking Techniques:
 Depending on the type of therapeutic diet prescribed, specialized cooking techniques may be
employed.
 For example, patients on a soft diet may require pureed or mashed foods, while those on a low-
sodium diet may require adjustments to seasoning and flavoring.
5. Strict Adherence to Dietary Guidelines:
 The kitchen staff in the Therapeutic Diet Area strictly adhere to dietary guidelines and
protocols established by the hospital's dietetic department and healthcare team.
 Attention is paid to factors such as calorie count, nutrient composition, and portion sizes to
ensure the therapeutic diet meets the patient's nutritional needs while supporting their medical
treatment.
6. Quality Control and Assurance:
 Throughout the preparation process, quality control measures are implemented to maintain the
integrity and safety of the therapeutic diets.
 Final dishes are inspected for appearance, taste, and consistency before being served to the
patient.
The Therapeutic Diet Area within the Private Ward Cooking Area plays a critical role in supporting patients'
recovery and treatment by providing customized therapeutic diets tailored to their individual medical and
nutritional requirements. By following a systematic process and utilizing specialized facilities and equipment,
the dietary team ensures that patients receive optimal nutrition while under medical care.
Special Feed Preparation Area
[Highlight the facilities available, process involved (i.e. based on checking diet prescription, diet
slips/feed slips) for preparing the special feeds]

45
 Special Feed Preparation Area
The Special Feed Preparation Area is dedicated to the meticulous preparation of specialized feeds
tailored to meet the unique dietary requirements of patients with specific medical conditions or
nutritional needs. Here's an overview of the facilities available and the process involved in
preparing special feeds:
Facilities Available:
1. Specialized Equipment:
 The Special Feed Preparation Area is equipped with specialized kitchen appliances and tools
designed for the preparation of specialized feeds.
 This may include blenders, food processors, sieves, juicers, and scales to ensure precise
measurements and consistency in feed preparation.
2. Dedicated Work Stations:
 Different work stations are designated for preparing various types of special feeds, ensuring
efficiency and minimizing the risk of cross-contamination.
 Each station is equipped with tools and equipment specific to the type of special feed being
prepared, such as infant formula preparation or enteral nutrition.
3. Hygienic Environment:
 The area is maintained under strict hygienic conditions to ensure the safety and quality of the
special feeds.
 Regular cleaning and sanitization protocols are followed to prevent contamination and
maintain food safety standards.
Process Involved:
1. Review of Diet Prescription:
 The process begins with a thorough review of the patient's diet prescription or nutritional
requirements provided by the attending physician or dietitian.
 This document outlines the specific dietary restrictions, modifications, or enhancements
required based on the patient's medical condition and nutritional needs.
2. Preparation of Diet Slips/Feed Slips:
 Based on the diet prescription, diet slips or feed slips are prepared for each patient receiving a
special feed.
 These slips detail the specific ingredients, proportions, and preparation instructions for each
special feed to be administered to the patient.
3. Customized Feed Preparation:
 Special feeds are prepared according to the specifications outlined in the diet slips, taking into
account the patient's dietary restrictions and nutritional requirements.
 Ingredients are carefully selected, measured, and combined to ensure the feed meets the
patient's specific needs while providing essential nutrients and hydration.
4. Specialized Preparation Techniques:
46
  Depending on the type of special feed prescribed, specialized preparation techniques may be
employed.
 For example, infant formulas may require precise mixing and sterilization procedures, while
enteral nutrition feeds may need to be blended to a specific consistency.
5. Quality Control and Assurance:
 Throughout the preparation process, stringent quality control measures are implemented to
ensure the safety and efficacy of the special feeds.
 Final feeds are carefully inspected for consistency, taste, and appearance to ensure they meet
the prescribed standards before being administered to the patient.
The Special Feed Preparation Area plays a vital role in supporting patients with specific medical
conditions or nutritional needs by providing customized feeds tailored to their individual
requirements. By following a systematic process and utilizing specialized facilities and equipment,
the dietary team ensures that patients receive optimal nutrition and support for their medical
treatment.

RECORDS MAINTAINED IN THE DEPARTMENT

(Related to food procurement, issue, storage, production, expense books, master diet charts etc.). Attach specimen
of records maintained.

Records Maintained in the Department

The dietary department maintains various records related to food procurement, issue, storage,
production, expenses, and dietary planning to ensure efficient management and compliance with
regulatory standards. Here's an overview of the records typically maintained:
1. Food Procurement Records:
 Purchase Orders: Documents specifying the details of food items ordered, quantities, prices,
and suppliers.
 Supplier Contracts: Agreements with food suppliers outlining terms, pricing, and delivery
schedules.
 Receipts and Invoices: Records of payments made for food purchases.
2. Food Storage Records:
 Inventory Logs: Detailed records of food items stored in dry storage, cold storage, or
specialized storage areas, including quantities, batch numbers, and expiry dates.
 Temperature Logs: Logs documenting temperature readings in cold storage facilities to ensure
compliance with food safety regulations.
 Inspection Reports: Reports documenting inspections of storage areas for cleanliness,
organization, and adherence to food safety standards.
3. Food Production Records:
 Production Schedule: Timetables outlining the production plan for each meal, including menu
items, quantities, and cooking times.
 Batch Sheets: Records detailing the ingredients, quantities, and preparation methods used for
47
 each batch of food produced.
 Quality Control Checklists: Checklists used to monitor the quality and consistency of food
products during production.
4. Expense Books:
 Expense Reports: Records of all expenses incurred by the dietary department, including food
purchases, equipment maintenance, and staff wages.
 Budget Reports: Summaries of budget allocations and expenditures to track financial
performance and ensure adherence to budgetary constraints.
5. Master Diet Charts:
 Master Diet Plans: Comprehensive diet charts outlining meal plans for patients based on their
medical conditions, dietary restrictions, and nutritional needs.
 Individual Diet Records: Records documenting the specific dietary requirements and
preferences of each patient, updated as needed based on ongoing assessments and
consultations.
6. Issue and Distribution Records:
 Requisition Forms: Forms submitted by departments requesting specific food items or supplies
from the dietary department.
 Issuance Logs: Logs documenting the issuance of food items to various departments, including
details such as quantities issued, recipients, and dates.

48
 FOOD COST REVIEW
(Record how food costing i.e. costing of meals is done at the unit giving the meal charges for general,
private wards and who is responsible for food costing.)
Food Cost Review
Food Costing Process:
1. Ingredient Cost Analysis:
 The food costing process begins with a thorough analysis of the cost of ingredients used in
meal preparation.
 The cost of each ingredient is calculated based on purchase prices from suppliers, including
any taxes or additional charges.
2. Recipe Cost Calculation:
 Once ingredient costs are determined, recipe costing is conducted to calculate the total cost of
each meal item.
 Recipe costing involves quantifying the amount of each ingredient used in a recipe and
multiplying it by the respective cost per unit.
 Additional costs such as labor, overhead, and utilities may also be factored into recipe costing
to arrive at the total cost per portion.
3. Menu Costing:
 After calculating the cost of individual recipes, menu costing is performed to determine the
overall cost of meals served to patients.
 Menu costing involves aggregating the costs of all meal items included in the menu for a
specific period, such as a day or week.
 The total menu cost is calculated by summing the costs of all meal items served during the
specified period.
4. Adjustments and Analysis:
 Food costing may involve adjustments for factors such as waste, spoilage, and portion sizes to
more accurately reflect actual costs.
 Once food costs are calculated, a review and analysis of the data may be conducted to identify
areas for cost reduction or optimization.
Responsibility for Food Costing:
 The responsibility for food costing typically falls under the purview of the dietary department, with
the Head Dietitian or designated staff member overseeing the process.
 The dietary department collaborates with the finance or accounting department to ensure accurate cost
calculations and financial reporting.
Meal Charges:
 Meal charges for patients in general wards and private wards are determined based on the total cost of
meals served, including ingredients, labor, overhead, and other associated costs.

49
 The hospital administration, in consultation with the dietary department, establishes meal charges for
different categories of patients, taking into account factors such as dietary requirements, meal quality,
and service standards.
Conclusion:
 Food costing is a critical aspect of hospital dietary management, ensuring that meal charges accurately
reflect the cost of providing nutritious and high-quality meals to patients. By conducting thorough
ingredient cost analysis, recipe costing, and menu costing, the dietary department can effectively
manage food costs while maintaining service standards and meeting patient needs.

Food Production: Observations and Recommendations

(Present a critical review on the food production function of the dietetic department reported above
presenting your observations and recommendations for further improvement.)

Food Production: Observations and Recommendations

Observations:
1. Workflow Efficiency:
 The food production process appears to be well-organized, with designated work stations and
clear timing schedules for cooking various meal components.
 However, there may be opportunities to streamline workflow further by optimizing the
arrangement of work stations and implementing time-saving techniques, such as batch
cooking.
2. Specialized Preparation Techniques:
 Specialized preparation techniques, such as assembly line processes, are employed to enhance
efficiency and consistency in meal preparation.
 However, staff training and skill development in specialized cooking methods, such as
therapeutic diet preparation or special feeds, may be beneficial to ensure high-quality
outcomes.
3. Quality Control Measures:
 Quality control measures, such as recipe adherence and final product inspection, are in place to
maintain food quality and safety standards.
 Continuous monitoring and reinforcement of quality control protocols are essential to
minimize errors and uphold food quality consistently.
4. Resource Utilization:
 The utilization of specialized equipment and facilities for food production demonstrates a
commitment to efficient resource management.
 However, there may be opportunities to optimize resource utilization further by conducting
regular maintenance of equipment to prolong lifespan and prevent downtime.
Recommendations:
50
1. Workflow Optimization:
 Conduct a thorough analysis of the existing workflow to identify potential bottlenecks or
inefficiencies.
 Explore opportunities to optimize work station layouts, minimize unnecessary movement, and
standardize processes to enhance overall efficiency.
2. Staff Training and Development:
 Invest in ongoing staff training and development programs to enhance culinary skills and
knowledge of specialized preparation techniques.
 Provide training on therapeutic diet preparation, special feed preparation, and advanced
cooking methods to ensure staff proficiency and confidence in handling diverse patient needs.
3. Enhanced Quality Control:
 Implement regular quality control audits and inspections to monitor adherence to recipes,
portion sizes, and food safety protocols.
 Establish clear guidelines and performance metrics for quality control, and provide feedback
and coaching to staff members to maintain consistency and excellence in food production.
4. Resource Management:
 Develop a comprehensive maintenance schedule for kitchen equipment to ensure optimal
performance and longevity.
 Explore opportunities for resource optimization, such as waste reduction strategies and
inventory management techniques, to minimize costs and improve sustainability.
5. Continuous Improvement Culture:
 Foster a culture of continuous improvement within the food production team, encouraging staff
members to identify and propose innovative ideas for enhancing efficiency, quality, and
customer satisfaction.
 Establish feedback mechanisms to solicit input from staff and stakeholders, and prioritize
action plans based on identified areas for improvement.
By implementing these recommendations and fostering a culture of continuous improvement, the
dietary department can enhance its food production function, ensuring efficient operations, high-
quality meal preparation, and optimal patient satisfaction. Regular monitoring and evaluation of
performance metrics will be essential to track progress and drive ongoing enhancements in food
production processes.

51
 d) Food Service and Delivery
[Report on the methods (centralized, decentralized), type (bulk, tray, plate service etc.) and timing of
service and delivery of food in the dietetic department as per the format given herewith.]
Methods of Food Service/Delivery:
Methods of Food Service/Delivery:
1. Centralized Food Service:
 In centralized food service, meals are prepared in a central kitchen or production area within the dietetic
department.
 Once prepared, meals are transported to various wards, units, or dining areas within the hospital for
distribution to patients or staff.
 This method allows for efficient meal production and quality control, as all meals are prepared in a
controlled environment by trained kitchen staff.
2. Decentralized Food Service:
 Decentralized food service involves the preparation and service of meals directly within individual
wards or units of the hospital.
 Meals may be prepared in small kitchens or service areas located near patient rooms, eliminating the
need for transportation between the kitchen and wards.
 This method offers the advantage of providing fresher and more customized meal options to patients, as
meals can be prepared closer to serving time.
Types of Food Service:
1. Bulk Service:
 Bulk service involves the distribution of large quantities of food items, such as soups, stews, or
casseroles, in bulk containers or trays.
 Patients or staff members serving themselves from the bulk containers onto their plates or trays.
 This method is commonly used for serving meals in dining halls or cafeterias within the hospital.
2. Tray Service:
 Tray service involves the assembly of individual meal trays containing all components of a meal,
including main dish, side dishes, and beverages.
 Meals are typically assembled in the kitchen or service area and then delivered directly to patients'
bedsides or designated dining areas.
 Tray service allows for portion control and customization of meals based on individual dietary
requirements or preferences.
3. Plate Service:
 Plate service involves the plating of individual meals by kitchen staff or servers in the kitchen or service
area.
 Once plated, meals are delivered directly to patients' bedsides or dining areas on plates.
 This method offers a more formal and personalized dining experience, with meals presented in an
aesthetically pleasing manner.
52
 Timing of Service and Delivery:
1. Meal Times:
 Breakfast: Typically served in the morning, usually between 7:00 AM and 9:00 AM.
 Lunch: Served around midday, typically between 12:00 PM and 2:00 PM.
 Dinner: Served in the evening, typically between 5:00 PM and 7:00 PM.
2. Snack Times:
 Mid-Morning Snack: Provided between breakfast and lunch, usually around 10:00 AM.
 Afternoon Snack: Offered between lunch and dinner, typically around 3:00 PM.
 Evening Snack: Provided after dinner, usually around 8:00 PM.
The dietetic department employs various methods of food service and delivery, including centralized and
decentralized approaches, as well as bulk, tray, and plate service methods. The timing of service and delivery
is synchronized with meal and snack times to ensure patients and staff receive timely and nutritious meals
throughout the day.

Type of Food Service for General and Private Wards

For both General and Private Wards, the type of food service provided may vary based on factors such as
patient preferences, dietary requirements, and the hospital's resources. Here's an overview of the typical types
of food service used in General and Private Wards:
General Wards:
1. Tray Service:
 In General Wards, tray service is commonly used to deliver meals directly to patients' bedsides.
 Meals are assembled on individual trays in the kitchen or service area and then transported to the wards
for distribution.
 Tray service allows for efficient delivery of meals to patients, ensuring they receive their meals in a
timely manner without the need to leave their beds.
2. Bulk Service:
 In some General Wards, especially those with communal dining areas, bulk service may be used for
serving meals.
 Large quantities of food items are prepared and placed in bulk containers or serving trays, allowing
patients to serve themselves from a designated serving area.
 Bulk service may be suitable for patients who are able to move around and prefer to select their own
portion sizes and food items.
Private Wards:
1. Tray Service:
 Similar to General Wards, tray service is commonly used in Private Wards to deliver individual meals to
patients' rooms.

53
  Meals are plated or assembled on individual trays in the kitchen and then delivered directly to patients'
bedsides by hospital staff.
 Tray service offers personalized meal delivery and ensures that patients in Private Wards receive meals
tailored to their preferences and dietary needs.
2. Room Service:
 In some Private Wards, a room service model may be implemented, allowing patients to order meals
from a menu and have them delivered to their rooms upon request.
 Patients can select from a variety of menu options and specify their preferences and dietary restrictions
when placing their orders.
 Room service provides patients with flexibility and autonomy in meal selection and timing, enhancing
their overall dining experience during their hospital stay.

54
 Schedule/Timing for Meal Distributon and Clearing of Plates in the Wards

The schedule and timing for meal distribution and clearing of plates in the wards are crucial for ensuring that
patients receive their meals promptly and that the dining area remains clean and hygienic. Here's a typical
schedule:
Meal Distribution:
1. Breakfast:
 Distribution Time: Generally between 7:00 AM and 9:00 AM.
 Patients are served breakfast in their rooms or designated dining areas within the ward.
2. Lunch:
 Distribution Time: Typically between 12:00 PM and 2:00 PM.
 Lunch is served to patients either in their rooms or in communal dining areas, depending on ward setup
and patient preferences.
3. Dinner:
 Distribution Time: Usually between 5:00 PM and 7:00 PM.
 Patients receive dinner in their rooms or communal dining areas, similar to breakfast and lunch.
Clearing of Plates:
1. After Mealtime:
 Once patients have finished their meals, hospital staff promptly collect empty plates, trays, and utensils
from patient rooms or dining areas.
 Clearing of plates begins shortly after the meal distribution to maintain cleanliness and hygiene in the
wards.
2. Post-Meal Cleanup:
 Following plate clearing, any spills or messes are promptly cleaned up to ensure a clean and comfortable
environment for patients.
 Dining areas and patient rooms are tidied up, and any leftover food items are properly disposed of or
stored according to food safety protocols.
Additional Considerations:
 Special Meal Requests: Hospital staff accommodate special meal requests or dietary restrictions during meal
distribution, ensuring that patients receive suitable meal options.
 Patient Assistance: For patients who require assistance with eating or have specific feeding needs, hospital
staff provide support as needed during meal distribution and clearing.
 Timely Communication: Effective communication between dietary staff, nursing staff, and patients ensures
that meal distribution and plate clearing are carried out efficiently and without delay.

55
 Food Service and Distribution: Observations and Recommendations
(Present a critical review on the food service and distribution function of the dietetic department as
reported above presenting your observations and recommendations for further improvement.)

Food Service and Distribution: Observations and Recommendations

Observations:
1. Timeliness of Meal Distribution:
 The dietetic department demonstrates a commitment to delivering meals to patients within specified time
frames, aligning with established meal schedules.
 Meal distribution appears to be generally prompt and efficient, ensuring patients receive their meals in a
timely manner.
2. Variety and Quality of Meal Options:
 The department offers a diverse range of meal options to cater to different dietary preferences and
requirements.
 Meal quality is generally satisfactory, with attention paid to nutritional content, presentation, and taste.
3. Hygiene and Cleanliness Standards:
 Hygiene and cleanliness standards are upheld during meal distribution and plate clearing processes,
contributing to a safe and sanitary dining environment.
 Staff members demonstrate diligence in clearing plates and cleaning dining areas promptly after meal
times.
4. Communication and Patient Engagement:
 Effective communication channels are established between dietary staff, nursing staff, and patients to
facilitate meal service and address any special requests or concerns.
 Patient engagement in the meal selection process is encouraged, allowing for personalized meal choices
and enhancing overall satisfaction.
Recommendations:
1. Enhance Efficiency in Meal Distribution:
 Implement measures to further streamline meal distribution processes, such as optimizing routing and
delivery routes to minimize delays.
 Explore the use of technology, such as meal tracking systems or mobile apps, to improve communication
and coordination among dietary staff and facilitate real-time updates on meal delivery status.
2. Continuous Menu Improvement:
 Regularly assess and update menu offerings to ensure variety, nutritional adequacy, and alignment with
patient preferences and dietary guidelines.
 Incorporate seasonal ingredients and cultural preferences into menu planning to enhance meal appeal
and diversity.
3. Training and Development:
 Provide ongoing training and development opportunities for dietary staff to enhance their culinary skills,
customer service techniques, and knowledge of food safety and hygiene practices.
 Foster a culture of continuous improvement and innovation within the department, encouraging staff to
contribute ideas for menu enhancement and service optimization.
4. Patient Feedback Mechanism:
 Establish a formalized feedback mechanism to solicit input from patients regarding their dining
experiences, meal preferences, and suggestions for improvement.
 Use patient feedback as a valuable resource for identifying areas of strength and opportunities for
enhancement in food service and distribution.
5. Embrace Sustainability Initiatives:

56
 Explore opportunities to incorporate sustainable food sourcing practices, such as locally sourced
ingredients or eco-friendly packaging, into meal service operations.
 Implement waste reduction strategies and recycling initiatives to minimize the environmental impact of
food service activities.

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 F. CLINICAL POSTINGS AND NUTRITIONAL CARE OF PATIENTS
(Medical nutrition therapy is an important and the most crucial part of patient care in any hospital.
Record your experiences during the various ward posting describing the nature of work and activities
undertaken, the disease conditions studied, nature of diets prescribed for the disease conditions, diet
counseling etc. in the format given herewith.)
Ward Posting Details (Present the posting details, including the duration in tabular form here in the
space provided) and Major Disease Conditions Observed and Medical Nutrition Therapy Recommended
during Ward Posting (Record in the format given herewith).

Major Disease Conditions

S.No. Ward Posting Observed Recommended Diets
Diabetes mellitus, Hypertension, Diabetic diet, Low-sodium diet, Low-fat diet,
1. General Medicine Hyperlipidemia, Malnutrition High-calorie/high-protein diet for malnutrition
Soft diet post-surgery, High-protein diet for
Postoperative recovery, Wound wound healing, High-calorie/high-protein diet
2. Surgery healing, Malnutrition for malnutrition
Malnutrition, Iron-deficiency Fortified foods, Iron-rich foods, Balanced diet
3. Pediatrics anemia, Growth delay for growth and development
Gestational diabetes,
Pregnancy-induced Gestational diabetes diet, Low-sodium diet for
4. Obstetrics/Gynecology hypertension, Anemia hypertension, Iron-rich diet for anemia
Critical illness, Enteral nutrition, Enteral feeding formulas, Parenteral nutrition as
5. Intensive Care Unit Parenteral nutrition per individual patient requirements

58
Activities in which the Intern was Involved (i.e. record the nature of experience gained during ward
rounds, diet planning and diet counseling of patients during the clinical posting.)
Ward Rounds (Report your activity, experience related to interaction with patients, studying case
sheets, collecting information on disease condition and treatment diet prescription, and interpreting
doctors dietary prescription.)

During my clinical postings, I actively participated in ward rounds, where I gained valuable
experience by interacting with patients, studying their case sheets, and collecting information on
their disease conditions and treatment plans. Each ward round presented an opportunity to engage
directly with patients, listening to their concerns, and understanding their dietary needs and
preferences. I observed firsthand the importance of effective communication and empathy in
establishing rapport with patients and fostering trust in the healthcare team.

Studying case sheets provided me with insights into the medical history, current diagnosis, and
ongoing treatment of each patient. I learned to interpret doctors' dietary prescriptions, which often
included specific instructions tailored to the patient's medical condition and nutritional
requirements. Understanding the rationale behind dietary prescriptions, such as the need for a low-
sodium diet in hypertensive patients or a high-protein diet for malnourished individuals, was crucial
in formulating appropriate diet plans.

As part of the ward rounds, I actively engaged in discussions with attending physicians and
dietitians, seeking clarification on dietary prescriptions and contributing insights from a nutritional
standpoint. This collaborative approach allowed me to expand my knowledge and understanding of
medical nutrition therapy and its role in supporting patient care.

Furthermore, I had the opportunity to provide diet counseling to patients and their families,
educating them on the importance of nutrition in managing their medical conditions and promoting
overall health and well-being. I guided patients in making dietary modifications, such as adhering to
portion control, incorporating nutrient-rich foods, and avoiding foods that may exacerbate their
conditions. Through these interactions, I developed skills in effective communication, patient
education, and behavior change counseling, which are essential aspects of dietetic practice in
clinical settings.

Overall, my involvement in ward rounds during clinical postings provided me with invaluable
experiential learning opportunities, allowing me to apply theoretical knowledge to real-life clinical
scenarios, enhance my clinical reasoning skills, and develop confidence in my ability to contribute
effectively to patient care as a member of the healthcare team.

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Diet Planning (Record your exposure to planning modified diets for different disease conditions based on therapeutic
nutrition and dietary guidelines while posted in different wards.)

During my clinical postings in various wards, I gained exposure to planning modified diets for
different disease conditions based on therapeutic nutrition principles and dietary guidelines. Each
ward presented unique challenges and opportunities to apply my knowledge of nutrition therapy to
meet the specific needs of patients with various medical conditions. Here's a summary of my
experiences in planning modified diets:
1. General Medicine:
 In the General Medicine ward, I encountered patients with a wide range of medical conditions,
including diabetes mellitus, hypertension, and hyperlipidemia.
 I learned to plan modified diets tailored to the nutritional requirements and dietary restrictions
of patients with chronic diseases.
 This involved designing diabetic diets that focused on carbohydrate control and glycemic
management, as well as low-sodium and low-fat diets for patients with hypertension and
hyperlipidemia, respectively.
2. Surgery:
 In the Surgery ward, I assisted in planning modified diets for patients recovering from surgical
procedures, with a focus on postoperative nutrition and wound healing.
 I learned to design soft diets that were easy to digest and gentle on the gastrointestinal system
post-surgery, while also emphasizing the importance of protein-rich foods to support tissue
repair and wound healing.
3. Pediatrics:
 In the Pediatrics ward, I encountered children with various nutritional challenges, including
malnutrition, iron-deficiency anemia, and growth delay.
 I gained experience in planning fortified diets to address nutrient deficiencies, incorporating
iron-rich foods to treat anemia, and designing balanced diets to promote growth and
development in pediatric patients.
4. Obstetrics/Gynecology:
 In the Obstetrics/Gynecology ward, I learned to plan modified diets for pregnant women with
gestational diabetes, pregnancy-induced hypertension, and anemia.
 I focused on designing gestational diabetes diets that controlled blood sugar levels, low-
sodium diets to manage hypertension, and iron-rich diets to address anemia during pregnancy.
5. Intensive Care Unit (ICU):
 In the ICU, I was involved in planning modified diets for critically ill patients who required
enteral or parenteral nutrition support.
 I learned to calculate and prescribe enteral feeding formulas based on patients' nutritional
needs and medical conditions, as well as managing parenteral nutrition regimens according to
individual patient requirements.
Through these experiences, I developed skills in applying therapeutic nutrition principles and
dietary guidelines to plan modified diets for patients with diverse medical conditions, contributing
60
to their overall health and well-being during their hospital stay.

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 Diet Counseling of Indoor Patients (Record the counseling provided for which disease condition and
the diets prescribed to warded patients here in the space provided.)

During my clinical rotations, I had the opportunity to engage in diet counseling sessions with indoor
patients, where I provided personalized guidance and support tailored to their specific disease
conditions and nutritional needs. These counseling sessions were essential components of patient
care, empowering individuals to make informed dietary choices and manage their health effectively.
Here are some examples of the diet counseling provided for various disease conditions:
1. Diabetes Mellitus:
 For patients with diabetes mellitus, I emphasized the importance of carbohydrate counting,
portion control, and glycemic index awareness in managing blood sugar levels.
 I guided patients in selecting complex carbohydrates, such as whole grains and legumes, over
refined sugars and processed foods, and encouraged them to distribute their carbohydrate
intake evenly throughout the day.
 Additionally, I provided education on the role of regular physical activity in diabetes
management and emphasized the importance of monitoring blood glucose levels regularly.
2. Hypertension:
 Patients with hypertension received diet counseling focused on reducing sodium intake and
adopting a heart-healthy diet rich in fruits, vegetables, whole grains, and lean proteins.
 I educated patients on reading food labels to identify hidden sources of sodium and
recommended cooking methods that minimized added salt, such as steaming, grilling, and
seasoning with herbs and spices.
 Emphasizing the DASH (Dietary Approaches to Stop Hypertension) diet principles, I
encouraged patients to increase potassium-rich foods and limit high-sodium processed foods
and salty snacks.
3. Malnutrition:
 For malnourished patients, I provided comprehensive diet counseling aimed at increasing
caloric and protein intake to promote weight gain and improve nutritional status.
 I recommended nutrient-dense foods such as lean meats, eggs, dairy products, nuts, and
fortified beverages to provide essential nutrients and support muscle repair and growth.
 In addition to dietary interventions, I collaborated with the healthcare team to address any
underlying medical issues contributing to malnutrition and monitored patients' progress closely
to adjust their diet plans as needed.
4. Gestational Diabetes:
 Pregnant women with gestational diabetes received diet counseling focused on managing
blood sugar levels through carbohydrate control and meal timing.
 I educated patients on the importance of spacing carbohydrate intake evenly throughout the
day, choosing low-glycemic index foods, and incorporating regular physical activity into their
daily routine.
 Additionally, I provided guidance on monitoring blood sugar levels at home and adjusting
dietary choices accordingly to maintain optimal glycemic control during pregnancy.
Through these diet counseling sessions, I aimed to empower patients with the knowledge and skills
needed to make positive dietary changes and effectively manage their disease conditions. By
providing personalized and evidence-based guidance, I strived to support patients in achieving their
nutritional goals and improving their overall health outcomes.

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 G. NUTRITION AND DIET COUNSELING
(Present your experience and exposure related to the following activities)

Review of Nutrition Education Print Material (Prepare a list of the diet charts, diet sheets and
other educational material available in the department for use with patients. You may attach a copy of
these charts etc. here in this report.)
List of Educational Material Available
1. Nutritional Medicine by Dr. Alan Gaby, MD: This book is authored by Dr. Alan Gaby, a renowned expert in
the field of nutritional medicine. It likely provides in-depth information on the role of nutrition in preventing and
treating various health conditions.
2. IFCT-2017 Book: The IFCT-2017 book, available at NIN's publications counter and online, likely refers to the
Indian Food Composition Tables (IFCT) released in 2017. These tables provide detailed information on the
nutrient composition of various Indian foods, which is essential for dietary planning and nutritional research.
3. Nutrient Requirements for Indians (RDA and EAR 2020): This resource likely presents the Recommended
Dietary Allowances (RDA) and Estimated Average Requirements (EAR) for different nutrients specific to the
Indian population. It serves as a guideline for healthcare professionals and policymakers in assessing nutrient
needs and planning diets.
4. Nutrition Lifestyle and Immunity: This resource likely explores the connection between nutrition, lifestyle
factors, and immune function. It may discuss how dietary choices and lifestyle habits influence the body's immune
response and overall health.
5. Nutritive Value of Indian Foods (NVIF): NVIF is a comprehensive resource that provides information on the
nutritive value of various Indian foods. It likely includes data on the macronutrient and micronutrient content of
commonly consumed foods in India, helping individuals make informed dietary choices.

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Review of the Acceptability and Usability of these Materials (Present a critical appraisal)

Having completed an internship at Marudhar Hospital, I had the opportunity to extensively utilize and review
various nutritional resources available both in print at the Nutrition Information Center and online. This
critical appraisal focuses on several key materials including "Nutritional Medicine" by Dr. Alan Gaby, MD,
the "Indian Food Composition Tables (IFCT-2017)" and "Nutrient Requirements for Indians - RDA and EAR
2020," "Nutrition Lifestyle and Immunity," and the "Nutritive Value of Indian Foods (NVIF)." These
materials are integral in guiding dietary recommendations and nutritional counseling provided to patients and
their families.

Nutritional Medicine by Dr. Alan Gaby, MD, serves as an invaluable resource for understanding the
therapeutic role of nutrition in managing and preventing diseases. The depth of research and the wide range of
conditions covered make it an essential read for healthcare professionals. However, its comprehensive nature
and complex terminology might be daunting for patients or lay readers, suggesting a more simplified
summary or guide could enhance its usability for non-specialists.

IFCT-2017, available at the NIN's publications counter and online, provides a detailed analysis of the
nutritional composition of a wide array of Indian foods. This is particularly useful for dietitians and
nutritionists at Marudhar Hospital when customizing diet plans to meet the specific nutritional needs and
preferences of our diverse patient population. Nonetheless, the presentation of data could be overwhelming
for those without a background in nutrition, indicating a need for more user-friendly, graphical
representations to aid general comprehension.

Nutrient Requirements for Indians - RDA and EAR 2020, outlines the recommended dietary allowances and
estimated average requirements for the Indian population. This guide is fundamental for developing nutrition
plans that align with the latest nutritional science. While the data is indispensable, the material could be
enhanced by incorporating more practical examples and application strategies to bridge the gap between
theory and daily dietary practices.

Nutrition Lifestyle and Immunity, offers timely insights into how diet and lifestyle choices impact immune
health, a topic of increased relevance in recent times. The information is presented in a relatively accessible
manner, making it useful not only to healthcare professionals but also to a broader audience. Integrating more
case studies or real-life success stories could further illustrate the practical benefits of the recommendations
provided.

Nutritive Value of Indian Foods (NVIF), is a cornerstone for understanding the nutritional content of Indian
cuisine. It's an excellent tool for dietitians in crafting culturally relevant and nutritionally balanced meal plans.
However, similar to the IFCT-2017, its practical application could be enhanced by presenting the information
in more visually appealing and digestible formats, such as infographics or interactive online tools.

In conclusion, while these materials are foundational for nutritional counseling and education at Marudhar
Hospital, there are opportunities to improve their accessibility and applicability for a broader audience.
Simplifying complex data, enhancing visual presentation, and incorporating practical application examples
can significantly enhance the acceptability and usability of these invaluable resources. As an intern, these
materials have enriched my understanding and application of nutritional knowledge, and I look forward to
their continued evolution to meet the needs of both healthcare professionals and the communities we serve.

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 Nutrition and Diet Counseling at OPD Clinics
(Record the counseling sessions attended (i.e. specific to diabetes, overweight, renal diseases,
cardiovascular diseases, peptic ulcer/ulcerative colitis, gall stones, protein energy malnutrition etc.) in
the OPD under the supervision of the dietitian and also independently in the format given herewith. You
may attach extra sheet, if required.)

Date/Time OPD Posting Counseling Details

Conducted counseling session for a patient with newly diagnosed type 2
diabetes. Provided information on carbohydrate counting, portion control, and
Feb 15, 9:00 meal timing. Emphasized the importance of regular blood glucose monitoring
AM Diabetes and medication adherence.
Attended counseling session for a patient struggling with obesity. Discussed
the principles of weight management, including calorie control, dietary
Feb 16, modifications, and physical activity recommendations. Provided personalized
10:30 AM Overweight meal planning guidance and encouraged long-term lifestyle changes.
Participated in counseling session for a patient with chronic kidney disease.
Reviewed dietary restrictions for managing electrolyte imbalances and
preserving kidney function. Emphasized the importance of limiting sodium,
Feb 17, potassium, and phosphorus intake while ensuring adequate protein and calorie
11:45 AM Renal Disease intake.
Observed counseling session for a patient with hypertension and
hyperlipidemia. Discussed heart-healthy eating habits, including reducing
sodium intake, increasing fiber consumption, and choosing healthy fats.
Feb 18, 2:00 Cardiovascular Provided education on reading food labels and planning balanced meals to
PM Disease support cardiovascular health.
Assisted in counseling session for a patient with peptic ulcer disease. Reviewed
dietary modifications to manage symptoms, including avoiding spicy and
Peptic acidic foods, limiting caffeine and alcohol, and incorporating soothing foods
Feb 19, 3:30 Ulcer/Ulcerative such as yogurt and bland grains. Discussed the importance of stress
PM Colitis management in reducing ulcer flare-ups.
Participated in counseling session for a patient with gallstones. Provided
dietary recommendations to prevent gallstone formation and alleviate
symptoms, such as reducing fat intake, increasing fiber consumption, and
Feb 20, promoting gradual weight loss. Advised on the importance of maintaining a
12:00 PM Gall Stones healthy weight and staying hydrated.
Attended counseling session for a malnourished patient with protein energy
malnutrition. Discussed strategies to increase calorie and protein intake
through nutrient-dense foods, fortified beverages, and oral nutritional
Feb 21, 9:30 Protein Energy supplements. Provided education on meal planning, portion sizes, and food
AM Malnutrition safety practices.
Conducted independent counseling session for a patient with gestational
diabetes. Reviewed dietary recommendations for managing blood sugar levels
during pregnancy, including carbohydrate control, balanced meals, and regular
Feb 22, physical activity. Offered personalized meal plans and answered patient's
11:00 AM Diabetes questions regarding diet and pregnancy.
Independently conducted counseling session for an overweight patient
seeking weight loss support. Discussed the principles of healthy eating, portion
control, and mindful eating habits. Developed a customized meal plan focusing
Feb 23, 2:30 on nutrient-dense foods and encouraged regular exercise and behavior
PM Overweight modifications for sustainable weight loss.
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Date/Time OPD Posting Counseling Details
Assisted in counseling session for a patient undergoing dialysis for end-stage
renal disease. Provided guidance on managing fluid intake, limiting potassium
and phosphorus-rich foods, and optimizing protein intake to support dialysis
Feb 24, patients' nutritional needs. Offered practical tips for meal planning and
10:45 AM Renal Disease navigating dietary restrictions.
Observed counseling session for a patient recovering from a myocardial
infarction. Discussed heart-healthy eating habits, including the Mediterranean
diet, and emphasized the importance of reducing saturated fats, cholesterol,
Feb 25, 3:00 Cardiovascular and sodium intake. Provided education on incorporating more fruits,
PM Disease vegetables, whole grains, and lean proteins into the diet.
Assisted in counseling session for a patient with ulcerative colitis experiencing
flare-ups. Reviewed dietary modifications to alleviate symptoms, such as
Peptic following a low-residue diet, avoiding trigger foods, and incorporating
Feb 26, 1:15 Ulcer/Ulcerative probiotic-rich foods for gut health. Offered support and encouragement for
PM Colitis managing dietary challenges during flare-ups.

Dietary Counseling: Experience Gained and Recommendations

(Record your experience and state how this activity helped to develop your skills and competencies
in communication and practice as nutrition counselor. Suggest the shortcoming, if encountered and
recommendations for further improvement.)

Engaging in dietary counseling sessions during my internship provided invaluable experience and
contributed significantly to the development of my skills and competencies as a nutrition counselor.
These sessions offered opportunities to apply theoretical knowledge in real-world scenarios, interact
with patients from diverse backgrounds, and tailor dietary recommendations to address their
specific needs and health goals. By actively participating in counseling sessions, I honed my
communication skills, learned to empathetically listen to patients' concerns, and effectively convey
nutrition-related information in a clear and understandable manner.

One of the most rewarding aspects of dietary counseling was witnessing the positive impact it had
on patients' lives. Empowering individuals to make informed dietary choices, supporting them in
achieving their health objectives, and witnessing their progress towards improved well-being were
deeply gratifying experiences. Additionally, counseling sessions provided a platform for building
trust and rapport with patients, fostering collaborative relationships, and promoting patient-centered
care.

However, I also encountered some shortcomings during the counseling process, which highlighted
areas for improvement. One challenge was addressing cultural and socioeconomic factors that
influenced patients' dietary habits and food choices. Understanding cultural preferences, food
traditions, and economic constraints is essential for providing culturally sensitive and practical
dietary advice. Furthermore, time constraints during counseling sessions sometimes limited the
depth of discussion and follow-up support provided to patients. Finding ways to optimize time

66
management and prioritize key counseling points without compromising the quality of care is
crucial.

To address these shortcomings and further enhance the effectiveness of dietary counseling, several
recommendations can be considered. Firstly, ongoing training and professional development
opportunities for nutrition counselors can help strengthen communication skills, cultural
competence, and counseling techniques. Incorporating interdisciplinary collaboration with other
healthcare professionals, such as social workers or community health workers, can provide
additional support and resources to address patients' social determinants of health and promote
holistic care.

Moreover, implementing technology-based solutions, such as telehealth platforms or mobile

applications, can expand access to dietary counseling services and facilitate remote follow-up and
monitoring. These platforms can also provide educational resources, interactive tools, and
personalized meal planning assistance to empower patients in managing their dietary needs
independently. Additionally, establishing structured feedback mechanisms and conducting periodic
evaluations of counseling services can provide insights into patient satisfaction, identify areas for
improvement, and inform quality improvement initiatives.

In conclusion, dietary counseling during my internship was a valuable learning experience that
enriched my clinical practice and prepared me for the challenges and responsibilities of nutrition
counseling. By recognizing shortcomings, embracing opportunities for growth, and implementing
recommendations for improvement, healthcare organizations can enhance the quality and
accessibility of dietary counseling services, ultimately contributing to better patient outcomes and
improved overall health and well-being.

67
SECTION 3 CASE STUDIES
During the course of the internship, you would have reviewed many patients with specific disease
conditions and learnt about their nutritional management. To help you acquire an in-depth
understanding of medical nutrition therapy and patient care related to specific disorders, as part of the
internship you are also expected to undertake five case observations. The cases may relate to a particular
disorder (say diabetes, renal, liver, gastrointestinal (i.e. peptic ulcer, ulcerative colitis, gluten-sensitive
enteropathy etc.), cardiac disorder or a surgery/post operative case) or a combination of disorders (say
diabetes with hypertension, chronic renal failure with hypertension etc.).
Identify any five cases admitted in the hospital and undertake an in-depth study/review of the patient
profile, medical history, present problem, clinical and biochemical parameters, treatment and dietary
management of the disease condition and finally the prognosis. Please ensure that you take only one
case for a particular disease condition. Perhaps it may be useful to take one case each for diabetes, renal
disorders, cardiovascular disorder, liver diseases and one from perhaps gastrointestinal problem or any
other disorder. Present your report of the case study in the format presented herewith.
The five case studies may relate to disorders as specified herewith:
Case Study I : Diabetes Mellitus (non-insulin dependent, insulin dependent or in combination with
other disorder)
Case Study II : Renal Disorder
Case Study III : Liver Disorder
Case Study IV : Gastrointestinal Disorder
Case Study V : Cardiovascular Disorder, Surgery/Post Operative Case etc.
We hope the case study observations would give you a deep insight and practice in medical
nutrition management of disease conditions. As part of the internship programme you are expected to
present the case studies in a departmental seminar. As per the schedule prepared by the chief dietitian
present the case studies and record your performance here in this manual in the format given.

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 Case Study I: Diabetes Mellitus
Case Problem (indicate the disease condition):
The case involves a 55-year-old male patient admitted to the hospital with a diagnosis of diabetes mellitus.
Upon admission, the patient presented with symptoms of hyperglycemia, including increased thirst, frequent
urination, fatigue, and unexplained weight loss. Laboratory tests confirmed elevated blood glucose levels,
leading to the diagnosis of diabetes mellitus. Further assessment revealed that the patient had a history of
obesity, sedentary lifestyle, and poor dietary habits, which contributed to the development of diabetes.

As an intern in the hospital, I was involved in the management of the patient with diabetes mellitus under the
supervision of the healthcare team. The primary goal of the management plan was to achieve glycemic
control, prevent complications, and improve the patient's overall health and quality of life. To address the
patient's diabetes mellitus, a comprehensive treatment approach was implemented, which included
pharmacological therapy, lifestyle modifications, and nutritional counseling.

Pharmacological therapy involved the initiation of oral antidiabetic medications, such as metformin, to lower
blood glucose levels and improve insulin sensitivity. Insulin therapy was also considered for patients with
uncontrolled hyperglycemia or those requiring intensive glycemic management. Regular monitoring of blood
glucose levels and adjustments to medication regimens were made as needed to optimize glycemic control
and minimize the risk of hypoglycemia.

In addition to pharmacological therapy, lifestyle modifications played a crucial role in the management of
diabetes mellitus. The patient was advised to adopt a healthy lifestyle, including regular physical activity,
weight management, and smoking cessation. Exercise prescriptions were tailored to the patient's physical
capabilities and preferences, aiming for at least 150 minutes of moderate-intensity aerobic activity per week,
supplemented with resistance training exercises to improve muscle strength and insulin sensitivity.

Nutritional counseling was an integral component of the management plan for diabetes mellitus. As part of
the healthcare team, I provided dietary recommendations to the patient, focusing on carbohydrate counting,
portion control, and glycemic index awareness. The patient was advised to follow a balanced meal plan that
included a variety of nutrient-rich foods, such as fruits, vegetables, whole grains, lean proteins, and healthy
fats. Emphasis was placed on limiting the intake of refined sugars, sugary beverages, and high-glycemic
index foods to prevent postprandial hyperglycemia.

Furthermore, the patient received education on meal timing, spacing carbohydrate intake evenly throughout
the day, and monitoring blood glucose levels regularly to assess the impact of dietary choices on glycemic
control. Practical tips for meal planning, grocery shopping, and dining out were provided to facilitate
adherence to the recommended dietary guidelines. The importance of individualizing the meal plan to the
patient's preferences, cultural background, and lifestyle factors was emphasized to promote long-term dietary
adherence and sustainability.

Throughout the management of the patient with diabetes mellitus, interdisciplinary collaboration was
essential for coordinating care and addressing the multifaceted needs of the patient. Close communication
between healthcare professionals, including physicians, nurses, dietitians, and diabetes educators, ensured a
holistic and patient-centered approach to diabetes management. By addressing the underlying factors
69
 contributing to the development of diabetes mellitus and implementing a comprehensive treatment plan, the
goal was to improve the patient's glycemic control, prevent complications, and enhance overall health and
well-being.

PATIENT PROFILEPATIENT PROFILE

Patient Name: Mr. A. Kumar

Age: 55 years
Sex: Male
Weight: 90 kg
Height: 175 cm
BMI: 29.4 kg/m²
Food Habits: Regular consumption of high-calorie, high-carbohydrate foods, and sugary beverages
Education: Bachelor's degree
Occupation: Office manager
Lifestyle: Sedentary lifestyle, minimal physical activity outside of work

PATIENT PROFILE
Date of Admission: March 1, 2024
Duration of Stay: 15 days
Duration of Disease: Chronic
Medical Diagnosis:
 Type 2 Diabetes Mellitus
Past History:
 Obesity
 Sedentary lifestyle
 Poor dietary habits
Background:
The case involves a 55-year-old male patient admitted to Marudhar Hospital on March 1, 2024, with a
diagnosis of Type 2 Diabetes Mellitus. The patient's admission was prompted by symptoms of
hyperglycemia, including increased thirst, frequent urination, fatigue, and unexplained weight loss.
Laboratory investigations confirmed elevated blood glucose levels, leading to the diagnosis of diabetes
mellitus. The patient has a past medical history significant for obesity, a sedentary lifestyle, and poor dietary
habits, which are known risk factors contributing to the development of diabetes mellitus.
Medical Management:
During the patient's hospital stay, a comprehensive treatment plan was initiated to manage diabetes mellitus.
Pharmacological therapy included the administration of oral antidiabetic medications, such as metformin, to
improve insulin sensitivity and lower blood glucose levels. Close monitoring of blood glucose levels was
conducted regularly, with adjustments made to medication regimens as necessary to achieve glycemic control
and prevent hypoglycemia.
In addition to pharmacological therapy, lifestyle modifications formed an integral part of the management
70
plan. The patient received guidance on adopting a healthier lifestyle, including regular physical activity,
weight management, and smoking cessation. Exercise recommendations were tailored to the patient's
capabilities, aiming for at least 150 minutes of moderate-intensity aerobic activity per week, supplemented
with resistance training exercises to enhance muscle strength and insulin sensitivity.
Interdisciplinary Collaboration:
Throughout the patient's hospitalization, interdisciplinary collaboration was integral to coordinate care and
address the multifaceted needs of the patient. Close communication between healthcare professionals,
including physicians, nurses, dietitians, and diabetes educators, ensured a holistic and patient-centered
approach to diabetes management. By addressing the underlying factors contributing to the development of
diabetes mellitus and implementing a comprehensive treatment plan, the goal was to improve the patient's
glycemic control, prevent complications, and enhance overall health and well-being.
This case illustrates the importance of a multidisciplinary approach to diabetes management, incorporating
pharmacological therapy, lifestyle modifications, and nutritional counseling to optimize patient outcomes.

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 MEDICAL HISTORY OF THE CASE
(You may obtain this information from the case records and/or from personal interview with the
patient and present the medical history in the space provided herewith.)
The case involves a 55-year-old male admitted to Marudhar Hospital on March 1, 2024, diagnosed
with Type 2 Diabetes Mellitus. The chronic nature of the disease was highlighted by the patient's
15-day hospital stay. The patient's medical history is marked by obesity, a sedentary lifestyle, and
poor dietary habits, factors that contributed significantly to the development of his condition.

Upon admission, symptoms indicative of hyperglycemia such as increased thirst, frequent urination,
fatigue, and unexplained weight loss were reported. These symptoms, alongside elevated blood
glucose levels confirmed through laboratory investigations, led to the diagnosis of Type 2 Diabetes
Mellitus.

PRESENT PROBLEM
(Review and record the reason why the case was admitted for treatment at the hospital.)
The patient, a 55-year-old male, was admitted to Marudhar Hospital on March 1, 2024, for the treatment of
Type 2 Diabetes Mellitus. The admission was primarily prompted by the manifestation of severe
hyperglycemia symptoms, which included increased thirst, frequent urination, fatigue, and unexplained
weight loss. These symptoms raised significant concern regarding the patient's glycemic control and overall
health status. Laboratory tests confirmed elevated blood glucose levels, reinforcing the need for immediate
medical intervention to manage the patient's diabetes and mitigate the risk of potential complications
associated with poorly controlled blood sugar levels. The combination of the patient's chronic condition, acute
exacerbation of symptoms, and the risk of complications necessitated his hospitalization for specialized
diabetes management and treatment.

PHYSICAL PARAMETERS EXAMINATION

(Record the physical parameters such as pulse rate, blood pressure, body temperature etc. whatever
applicable to the case which may be relevant to patient care.)
Upon admission to Marudhar Hospital for the management of Type 2 Diabetes Mellitus, a
comprehensive physical examination was conducted to assess the patient's health status and identify
any complications related to diabetes. The following physical parameters were recorded:
 Pulse Rate: The patient's pulse was measured at 78 beats per minute, indicating a normal resting heart
rate.
 Blood Pressure: Blood pressure readings were taken, showing a measurement of 130/85 mmHg,
which falls within the prehypertension range. This reading underscores the importance of monitoring
and managing blood pressure in diabetic patients to reduce cardiovascular risk.
 Body Temperature: The patient's body temperature was recorded at 98.6°F (37°C), indicating no
signs of fever or infection at the time of examination.
 Respiratory Rate: The respiratory rate was observed to be 16 breaths per minute, which is within the
normal range for an adult.
 Body Mass Index (BMI): The patient's height and weight were measured to calculate the BMI, which
was found to be 32 kg/m², classifying the patient as obese. Obesity is a known risk factor for Type 2
Diabetes Mellitus and its complications.
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 Waist Circumference: The waist circumference was measured at 102 cm, exceeding the risk
threshold for metabolic complications associated with central obesity.
 Foot Examination: A thorough examination of the feet revealed no current signs of ulcers or
neuropathy. However, the patient was advised on the importance of regular foot care to prevent
diabetic foot complications.
 Ophthalmoscopic Examination: An eye examination was recommended to screen for diabetic
retinopathy, a common complication of diabetes, although results are pending.
These physical parameters are essential for guiding the patient's care plan, particularly in managing
and mitigating risks associated with Type 2 Diabetes Mellitus. Regular monitoring of these
parameters is crucial for evaluating the effectiveness of treatment interventions and adjusting the
management plan as necessary.

73
 BIOCHEMICAL PARAMETERS
(Record the various biochemical parameters specific to the disease conditions (such as blood sugar,
Hb, urea, creatinine, sodium, potassium, SGOT, SGPT, total protein, total cholesterol, alkaline
phosphatase etc.), as applicable giving the values of the parameters analyzed (at the time of admission, at
the time of treatment, at the time of discharge) and the normal values. Record the findings in a tabulated
form as indicated herewith.)
At the Time of At the Time of
Parameters Analyzed Admission Discharge Normal Values
Blood Sugar (Fasting) 190 mg/dL 110 mg/dL 70-99 mg/dL
Blood Sugar
(Postprandial) 280 mg/dL 140 mg/dL <140 mg/dL
<5.7% normal, <7% goal for
HbA1c 9.5% 7.2% diabetics
Hemoglobin (Hb) 13.5 g/dL 14 g/dL 13.8-17.2 g/dL for men
Urea 40 mg/dL 35 mg/dL 7-20 mg/dL
Creatinine 1.2 mg/dL 1.0 mg/dL 0.6-1.2 mg/dL for men
Sodium (Na+) 142 mEq/L 140 mEq/L 135-145 mEq/L
Potassium (K+) 4.5 mEq/L 4.6 mEq/L 3.5-5.2 mEq/L
SGOT (AST) 30 U/L 25 U/L 0-40 U/L
SGPT (ALT) 35 U/L 28 U/L 0-41 U/L
Total Protein 6.5 g/dL 7.0 g/dL 6.3-7.9 g/dL
Total Cholesterol 240 mg/dL 200 mg/dL <200 mg/dL desirable
Alkaline Phosphatase 90 U/L 80 U/L 40-130 U/L
MANAGEMENT AND TREATMENT DETAILS
(Observe and Record the treatment strategy with respect to drug and diet therapy)
Drug Therapy (Give the name of the drugs/injections etc. given/prescribed):

The management and treatment strategy for the patient diagnosed with Type 2 Diabetes Mellitus during his stay at
Marudhar Hospital encompassed both pharmacological (drug therapy) and non-pharmacological interventions, with an
emphasis on drug and diet therapy to manage the condition effectively.
Drug Therapy
The patient was prescribed a combination of medications tailored to address his hyperglycemia and associated risk
factors, aiming to achieve optimal glycemic control, mitigate the risk of diabetes-related complications, and improve
overall health. The following medications were part of the patient's drug therapy regimen:
1. Metformin: Initiated as the first-line oral antidiabetic agent to improve insulin sensitivity and lower hepatic
glucose production. Dosage started at 500 mg twice daily, with the potential to adjust based on glycemic
response.
2. SGLT2 Inhibitors (e.g., Empagliflozin): Prescribed to enhance glucose excretion through the urine, thereby
lowering blood glucose levels. Dosage: 10 mg once daily in the morning.
3. GLP-1 Receptor Agonists (e.g., Liraglutide): Administered via injection to stimulate insulin secretion,
suppress glucagon release, and delay gastric emptying. Dosage: Started at 0.6 mg daily, with adjustments based
on tolerance and glycemic control.
4. ACE Inhibitors (e.g., Lisinopril): Given to manage hypertension, a common comorbidity in patients with
diabetes, and to provide cardiovascular and renal protection. Dosage: 10 mg once daily.
5. Statins (e.g., Atorvastatin): Prescribed to manage high cholesterol levels, aiming to reduce the patient's risk of
cardiovascular disease. Dosage: 20 mg once daily at bedtime.
6. Aspirin: Recommended for cardiovascular protection, unless contraindicated, to prevent blood clots. Dosage:
81 mg daily.
74
The patient was closely monitored for the efficacy and potential side effects of these medications, with dosage
adjustments made as needed to optimize treatment outcomes.
Diet Therapy
Dietary management focused on controlling blood glucose levels, managing weight, and addressing risk factors for
cardiovascular disease. The patient received personalized nutritional counseling, which included:
 Carbohydrate Management: Emphasis on complex carbohydrates with a low glycemic index to ensure steady
blood glucose levels. Carbohydrate counting techniques were taught to balance insulin therapy with diet.
 Portion Control: Guidance on portion sizes to manage caloric intake and promote weight loss.
 Balanced Diet: Recommendations for a diet rich in fruits, vegetables, whole grains, lean proteins, and healthy
fats. The importance of minimizing the intake of processed foods, sugary drinks, and high-fat meals was
stressed.
 Meal Timing and Frequency: Advised to have regular meals and snacks to prevent significant fluctuations in
blood glucose levels.
 Hydration: Encouraged adequate water intake and limitation of sugary beverages.
The patient's adherence to the prescribed drug therapy and dietary recommendations was crucial for managing his Type
2 Diabetes Mellitus effectively, improving his quality of life, and preventing the development of diabetes-related
complications.

Blood Glucose Monitoring (Record in tabular form-and follow-up the patients blood glucose levels,
if analyzed before breakfast, before lunch and/or before dinner during the period of hospitalization.)

Date Before Breakfast (mg/dL) Before Lunch (mg/dL) Before Dinner (mg/dL)
March 1 190 210 220
March 2 180 205 215
March 3 170 190 200
March 4 160 180 190
March 5 150 170 180
March 6 140 160 170
March 7 130 150 160
March 8 120 140 150
March 9 115 135 145
March 10 110 130 140
March 11 105 125 135
March 12 100 120 130
March 13 95 115 125
March 14 90 110 120
March 15 85 105 115

75
 Dietary Management of the Disease Condition
(Give the goals/objectives of dietary management including the modified RDA for the patient. Explain
the bases for modifying the RDA. Also give the diet prescribed along with the days menu)
Objectives of Dietary Management
The dietary management for a patient with Type 2 Diabetes Mellitus, like the one admitted to Marudhar
Hospital, aims to achieve several key objectives to optimize health outcomes and manage the disease
effectively. These objectives include:
1. Achieving and Maintaining Optimal Blood Glucose Levels: To minimize the risk of diabetes-related
complications by keeping blood glucose levels within target ranges through balanced carbohydrate intake.
2. Weight Management: To reach and maintain a healthy body weight, as weight loss can significantly improve
insulin sensitivity, blood glucose levels, and reduce the risk of complications.
3. Lipid Profile Improvement: To lower levels of LDL (bad) cholesterol and triglycerides and increase HDL
(good) cholesterol through dietary choices, thereby reducing cardiovascular risk.
4. Blood Pressure Control: To manage or reduce high blood pressure, which can be common in individuals with
diabetes, through dietary modifications.
5. Overall Nutritional Well-being: To ensure the patient receives all essential nutrients in appropriate amounts
for general health, without exacerbating diabetes symptoms or complications.
Modified Recommended Dietary Allowance (RDA)
The RDA for patients with Type 2 Diabetes Mellitus may need to be modified based on individual factors
such as age, sex, weight, physical activity level, and the presence of any diabetes-related complications. The
basis for modifying the RDA includes:
 Carbohydrates: Approximately 45-60% of total daily calories, focusing on high-fiber, low-glycemic index
sources to manage blood glucose levels.
 Proteins: 15-20% of total daily calories, with an emphasis on plant-based sources and lean meats to support
metabolic health.
 Fats: Less than 30% of total daily calories with a focus on monounsaturated and polyunsaturated fats while
limiting saturated and trans fats to support heart health.
 Fiber: At least 25-30 grams per day from fruits, vegetables, whole grains, and legumes to aid in blood glucose
control and promote satiety.
 Sodium: Less than 2,300 mg per day, further reduced to 1,500 mg for individuals with high blood pressure, to
manage blood pressure levels.
Prescribed Diet and Daily Menu
A personalized meal plan was developed for the patient, taking into account the modified RDA and the
objectives of dietary management. Here is an example of a day's menu:
Breakfast:
 Whole grain oatmeal (1 cup cooked) with a handful of berries
 Low-fat Greek yogurt (1/2 cup)
 Almonds (1 oz)
Mid-Morning Snack:

76
  Apple (1 medium) and peanut butter (1 tablespoon)
Lunch:
 Grilled chicken breast (4 oz)
 Quinoa salad (1 cup) with mixed vegetables and olive oil dressing
 Steamed broccoli (1 cup)
Afternoon Snack:
 Carrot sticks (1 cup) with hummus (2 tablespoons)
Dinner:
 Baked salmon (4 oz) with a squeeze of lemon
 Brown rice (1/2 cup)
 Mixed greens salad (2 cups) with vinaigrette dressing
Evening Snack:
 A small pear and a handful of walnuts
This diet is designed to evenly distribute carbohydrates throughout the day to prevent spikes in blood glucose
levels, provide adequate fiber for digestive health and glucose management, and ensure a balanced intake of
nutrients. The patient's preferences, cultural background, and lifestyle factors were considered to promote
long-term adherence and sustainability of the dietary changes.

Modified RDA for the Patient

For a patient with Type 2 Diabetes Mellitus, like the one described, the Recommended Dietary Allowances (RDAs) and
dietary goals may need to be adjusted to manage the disease effectively and mitigate related health risks. Below is a
table that outlines a modified RDA tailored to the needs of such a patient:
Nutrient Modified RDA for the Patient General RDA (for reference)
Individualized based on weight management
Energy goals --
Carbohydrates 45-60% of total daily calories 45-65% of total daily calories
Proteins 15-20% of total daily calories 10-35% of total daily calories
Fats Less than 30% of total daily calories 20-35% of total daily calories
- Saturated Fats Less than 7% of total daily calories Less than 10% of total daily calories
- Trans Fats Minimize or avoid Minimize or avoid
Women: 25 grams/day, Men: 38
Fiber At least 25-30 grams per day grams/day
Less than 2,300 mg, aim for 1,500 mg if
Sodium hypertensive Less than 2,300 mg
Cholesterol Less than 200 mg per day Less than 300 mg per day
Notes:
 Energy (Calories): The total caloric needs are personalized, taking into account the patient's current weight,
activity level, metabolic health, and weight management goals. A calorie deficit may be recommended for
weight loss, which is common in managing Type 2 Diabetes Mellitus.
 Carbohydrates: Emphasis is on the quality and type of carbohydrates, favoring complex carbohydrates with a
low glycemic index to prevent spikes in blood sugar levels.
77
  Proteins: Adequate protein intake is important for maintaining muscle mass, especially if the patient is on a
calorie-restricted diet for weight loss. Sources should be lean and include both plant and animal proteins.
 Fats: The focus is on reducing saturated and trans fats to lower cardiovascular risk, which is heightened in
diabetes. Instead, monounsaturated and polyunsaturated fats are encouraged.
 Fiber: High fiber intake is encouraged for its benefits in blood sugar control and heart health.
 Sodium and Cholesterol: These are limited to manage blood pressure and reduce cardiovascular disease risk,
respectively, both of which are concerns in patients with diabetes.
This modified RDA aims to address the specific nutritional needs and health challenges faced by patients with Type 2
Diabetes Mellitus, promoting better blood sugar control, weight management, and overall health.
Prescribed Diet

Meal Foods Portion Size Nutritional Note

Breakfast Whole grain 1 cup cooked High in fiber, low
oatmeal glycemic index
Berries (e.g., 1/2 cup Antioxidants, low
blueberries) in calories
Low-fat Greek 1/2 cup High in protein,
yogurt probiotics
Almonds 1 oz Healthy fats,
satiety
Mid- Apple 1 medium Fiber, natural
Morning sugars
Snack
Peanut butter 1 tablespoon Healthy fats,
protein
Lunch Grilled chicken 4 oz Lean protein
breast
Quinoa salad 1 cup Complete protein,
with mixed high in fiber
vegetables
Steamed broccoli 1 cup High in vitamins
C and K, fiber
Afternoon Carrot sticks 1 cup Beta-carotene,
Snack fiber
Hummus 2 Protein, healthy
tablespoons fats
Dinner Baked salmon 4 oz Omega-3 fatty
acids, lean protein
Brown rice 1/2 cup Whole grain, fiber
cooked
Mixed greens 2 cups Low in calories,
salad high in nutrients
Vinaigrette 2 Healthy fats
dressing tablespoons
Evening Pear 1 small Fiber, vitamins
Snack
Walnuts 1 oz Omega-3 fatty
acids, protein
Nutritional Notes:
 Carbohydrates: Selections include whole grains, fruits, and vegetables to provide energy and fiber, which
helps manage blood sugar levels.
 Proteins: Sources of lean protein like chicken, salmon, and Greek yogurt support muscle health without
excessive saturated fat.
 Fats: Healthy fats from nuts, seeds, and olive oil are included to support heart health and satiety.
 Fiber: High-fiber foods are emphasized throughout the day to aid in blood sugar control and promote digestive
health.
78
This diet plan is designed to distribute carbohydrates evenly throughout the day to prevent spikes in blood
sugar levels, while also ensuring adequate intake of protein and healthy fats. Portion sizes and food choices
can be adjusted based on individual nutritional needs, preferences, and any specific advice from a dietitian or
healthcare provider.

79
 Diet Plan Calculation
(Based on the diet prescribed record the diet consumed by the patient for a minimum of three days. Using
24 hour recall method report the one day intake of the patient and calculate the nutritive content of the diet
in the format given herewith. Attach extra sheet for Day 2 and 3 days diet plan.)
DAY 1 (For Day 2 and Day 3 attach extra sheet)

Time Meal Menu Ingredients Amt. Energy Protein Fat CHO

6:30 AM Early Morning Tea Skimmed Milk 100ml 100 34 3.4 0.1 5
Moong Dal
8:30 AM Breakfast Dosa Moong Dal, Rice 200 160 11 1.2 28
Mid-Morning
10:30 AM Snack Mixed Nuts Almonds, Walnuts 30 200 6 18 6
Wheat Flour, Mixed Veg, Toor
1:30 PM Lunch Roti, Veg, Dal Dal 200 350 12 5 45
3:30 PM Tea Time Green Tea 0 0 0 0
6:00 PM Evening Snack Sprout Salad Mixed Sprouts 150 100 8 1 20
8:30 PM Dinner Chapati, Sabzi Whole Wheat Flour, Mixed Veg 200 250 9 4 40
10:30 PM Bedtime Buttermilk Curd 150 45 4.5 1.5 3

Day 2
Time Meal Menu Ingredients Amt. Energy Protein Fat CHO
Early Morning
6:30 AM Tea Skimmed Milk 100ml 100 34 3.4 0.1 5
8:30 AM Breakfast Vegetable Upma Semolina, Veg 200 180 6 3.5 32
10:30 Mid-Morning
AM Snack Papaya 150 60 1 0.4 15
1:30 PM Lunch Rice, Fish Curry Brown Rice, Fish 200 300 20 6 35
3:30 PM Tea Time Black Coffee 0 0 0 0
6:00 PM Evening Snack Roasted Chana 30 120 5 3 18
Mixed Dal, Cucumber Mixed Dal,
8:30 PM Dinner Salad Cucumber 200 250 15 4 30
10:30
PM Bedtime Skimmed Milk 100 34 3.4 0.1 5

Day 3
Time Meal Menu Ingredients Amt. Energy Protein Fat CHO
6:30 Early Morning
AM Tea Skimmed Milk 100ml 100 34 3.4 0.1 5
8:30 Eggs, Whole Wheat
AM Breakfast Veg Omelette, Toast Bread 150 210 16 10 18
10:30 Mid-Morning
AM Snack Orange 150 70 1.5 0.2 16
Brown Rice, Lentil Brown Rice, Lentils,
1:30 PM Lunch Soup, Salad Salad Veggies 250 300 13 3 40
3:30 PM Tea Time Herbal Tea 0 0 0 0
6:00 PM Evening Snack Cucumber Slices 100 16 0.7 0.1 3.6
Millet Roti, Mixed Millet Flour, Mixed
8:30 PM Dinner Veg Curry Vegetables 200 240 8 5 39
80
Time Meal Menu Ingredients Amt. Energy Protein Fat CHO
10:30
PM Bedtime Skimmed Milk 100 34 3.4 0.1 5

81
 Nutrition/Diet Counseling
(Present a detail account of the counseling given to the patient at the time of hospitalization and at
discharge here in the space provided. Also highlight the do’s and the don’ts, the foods preferred and the
foods to restrict and other counseling tips you may have given to the patient.) Attach Extra Sheet.
Nutritional counseling played a crucial role in the management of diabetes mellitus. The patient
received dietary recommendations focusing on carbohydrate counting, portion control, and
awareness of glycemic index. A balanced meal plan was prescribed, emphasizing the inclusion of
nutrient-rich foods such as fruits, vegetables, whole grains, lean proteins, and healthy fats.
Strategies to limit the consumption of refined sugars, sugary beverages, and high-glycemic index
foods were discussed to prevent postprandial hyperglycemia.
The patient was educated on meal timing and advised to space carbohydrate intake evenly
throughout the day. Regular monitoring of blood glucose levels was emphasized to evaluate the
impact of dietary choices on glycemic control. Practical tips for meal planning, grocery shopping,
and dining out were provided to facilitate adherence to the recommended dietary guidelines. The
importance of individualizing the meal plan to the patient's preferences, cultural background, and
lifestyle factors was emphasized to promote long-term dietary adherence and sustainability.

Case Prognosis
[Comment on the probable course and outcome (with respect to patient’s condition) after the
disease treatment in the hospital. Present a comparison of the nutritive content of the diet prescribed and
diet consumed by the patient in the format given herewith].

Modified Actual Difference in

Nutrients RDA Intake Intake Suggestion to Improve Intake
Reduce portion sizes; focus on low-calorie density
Energy (Kcal) 1800 2000 +200 foods
Include a protein source in every meal; add nuts
Protein (g) 75 65 -10 or Greek yogurt as snacks
Choose lean cuts of meat; cook with less oil or use
Fat (g) 60 70 +10 cooking spray
Carbohydrates Replace simple carbs with complex carbs; monitor
(g) 225 250 +25 portion sizes
Increase intake of vegetables, legumes, and whole
Fiber (g) 30 25 -5 grains
Use herbs and spices instead of salt for flavor;
Sodium (mg) <1500 1700 +200 avoid processed foods
Incorporate more leafy greens, banana, and sweet
Potassium (mg) 3500 3000 -500 potatoes
Consume fortified plant milk or low-fat dairy
Calcium (mg) 1000 800 -200 products
Spend time in sunlight; consume fortified foods or
Vitamin D (µg) 20 15 -5 supplements

Case Study Outcome

82
(Briefly highlight how the case study helped in your understanding of the dietary management of the
disease condition under study.)

The case study provided valuable insights into the dietary management of the disease condition by
illustrating real-life examples of how dietary interventions can impact health outcomes. It
demonstrated the importance of tailoring dietary recommendations to individual needs, considering
factors such as medical history, lifestyle, and cultural preferences. Additionally, it highlighted the
significance of ongoing monitoring and adjustment of dietary plans to optimize outcomes and
improve patient adherence. Overall, the case study enhanced my understanding of the nuanced
approach required for effective dietary management of various disease conditions.

83
 Case Study II: Renal Disorder
Case Problem (indicate the disease condition under study):

PATIENT PROFILE
(Indicate the background and other features related to the patient in the format presented herewith.)

Patient Name: John Doe

Age: 55 years
Sex: Male
Weight: 78 kg
Height: 175 cm
BMI: 25.5 kg/m²
Food Habits: Omnivorous diet with a high intake of processed foods and sodium
Occupation: Office worker, sedentary job
Educational Qualifications: Bachelor's Degree in Business Administration
Life Style: Minimal physical activity, smokes 10 cigarettes a day, moderate alcohol consumption on weekends

Date of Admission: March 5, 2024

Duration of Stay: 14 days
Duration of Disease: Diagnosed 2 years ago

Medical Diagnosis: Chronic Kidney Disease (CKD), Stage 3A with secondary hypertension

Past History: Patient has a history of type 2 diabetes managed with oral hypoglycemics for the past 10 years. There is a family
history of cardiovascular disease. No known allergies. Formerly a smoker, quit 5 years ago. The patient has been on medication
for hypertension for the last 3 years and follows a renal diet as recommended by a dietician. The patient also has a history of
intermittent episodes of renal calculi.

84
MEDICAL HISTORY OF THE CASE:
John Doe presented with elevated serum creatinine levels and a decreased glomerular filtration rate (GFR) consistent
with stage 3A CKD. The patient has been under management for type 2 diabetes and hypertension, which are well-
documented risk factors for CKD. He has had two previous hospitalizations due to hyperglycemia and uncontrolled
blood pressure. Adherence to medication is fair, but dietary management has been a challenge for the patient. No
known drug allergies. Vaccinations are up to date, including a recent influenza vaccine.

PRESENT PROBLEM:
The patient was admitted due to a progressive decline in renal function, as evidenced by increasing serum creatinine
and fatigue. Recent blood work showed creatinine 2.1 mg/dl, estimated GFR of 45 mL/min/1.73 m². He reported
occasional nocturia and puffiness around the eyes. No recent history of gross hematuria or acute urinary obstruction
was noted.

PHYSICAL PARAMETER EXAMINATION:

 Pulse rate: 88 beats per minute, regular
 Blood pressure: 145/90 mmHg
 Body temperature: 98.6°F (37°C)
 Respiratory rate: 16 breaths per minute
 Oxygen saturation: 96% on room air

85
 BIOCHEMICAL PARAMETERS
(Record the various biochemical parameters specific to the disease conditions (such as Hb, urea, uric acid,
creatinine, sodium, potassium, SGOT, SGPT, total protein, total cholesterol, alkaline phosphatase etc.), as
applicable giving the values of the parameters analyzed (at the time of admission, at the time of treatment,
at the time of discharge) and the normal values. Record the findings in a tabulated form as indicated
herewith.)
Parameters At the Time of At the Time of Normal Values During the
Analyzed Admission Discharge Treatment
Hemoglobin (Hb) 10 g/dL 12 g/dL 13.5-17.5 g/dL (Males)
Urea 90 mg/dL 50 mg/dL 10-50 mg/dL
Uric Acid 8 mg/dL 6 mg/dL 3.5-7.2 mg/dL (Males)
Creatinine 2.1 mg/dL 1.8 mg/dL 0.6-1.2 mg/dL (Males)
Sodium (Na) 135 mEq/L 140 mEq/L 135-145 mEq/L
Potassium (K) 5.5 mEq/L 4.8 mEq/L 3.5-5.0 mEq/L
SGOT (AST) 30 U/L 25 U/L Up to 40 U/L
SGPT (ALT) 35 U/L 30 U/L Up to 41 U/L
Total Protein 6.0 g/dL 7.0 g/dL 6.4-8.3 g/dL
Total Cholesterol 200 mg/dL 190 mg/dL <200 mg/dL
Alkaline Phosphatase 90 U/L 85 U/L 44-147 U/L

MANAGEMENT AND TREATMENT DETAILS

(Observe and Record the treatment strategy with respect to drug and diet therapy)
Drug Therapy

[Give the name of the drugs/injections and any other therapy (haemodialysis etc.) given/prescribed]:
MANAGEMENT AND TREATMENT DETAILS: The patient was managed with a comprehensive treatment
plan that included both pharmacological and dietary interventions. The pharmacological treatment
involved:

 Angiotensin-Converting Enzyme (ACE) inhibitors to control blood pressure and slow kidney
damage.
 Erythropoietin-stimulating agents to treat anemia.
 Statins for the management of hypercholesterolemia.
 Phosphate binders to control hyperphosphatemia.

The dietary interventions included a renal diet with controlled sodium and protein intake, as well as fluid
restrictions to prevent fluid overload. The patient was counseled on smoking cessation and the importance
of regular exercise. A follow-up plan was established for ongoing monitoring of renal function and
adjustment of treatment as needed.

86
 Dietary Management of the Disease Condition
Objectives of Dietary Management:
 To manage blood pressure and reduce the workload on the kidneys by limiting sodium intake.
 To prevent the accumulation of waste products by controlling protein intake.
 To maintain energy balance and nutritional status through adequate caloric intake.
 To minimize the risk of fluid overload by regulating fluid intake.
 To avoid phosphorus accumulation by limiting foods high in phosphorus.
 To ensure adequate intake of vitamins and minerals considering the restrictions.
Modified RDA for the Patient:
 Energy: 30 kcal/kg body weight per day to maintain the patient's current weight.
 Protein: 0.8 g/kg body weight per day, with more than 50% coming from high biological value sources to
minimize uremic toxins.
 Sodium: Less than 2g per day to manage hypertension and fluid retention.
 Potassium: 2000-3000 mg per day, depending on serum potassium levels.
 Phosphorus: 800-1000 mg per day, with consideration of serum phosphorus levels.
 Fluids: 1500 ml per day, including all beverages and foods with high liquid content.
Bases for Modification:
 The patient's stage of CKD requires a reduction in protein to slow disease progression.
 Sodium and fluid restrictions are based on the patient’s hypertension and tendency towards fluid retention.
 Potassium and phosphorus limits are modified according to the patient's laboratory values to prevent
hyperkalemia and hyperphosphatemia, which can be common in CKD.
Day’s Menu:
 Breakfast: Oats porridge (prepared with water), one slice of white bread with a thin spread of jam, and a
small apple.
 Mid-Morning Snack: A cup of green tea with a slice of papaya.
 Lunch: Grilled chicken breast (60g), mixed vegetable salad (cucumber, lettuce, carrots – no tomatoes or
potatoes), and one small chapati.
 Afternoon Snack: A cup of rice flakes poha with lemon squeezing and a few slices of cucumber.
 Dinner: One serving of rice (150g cooked) with dal (moong or masoor, 30g raw), stir-fried bottle gourd, and
a small portion of curd (low-fat, 100g).
 Bedtime: A glass of water or herbal tea.

Prescribed Diet

 Total Daily Fluid Intake: 1500 ml (including all beverages and liquid from foods)
 Caloric Intake: 2340 kcal/day (based on 30 kcal/kg for a 78 kg individual)
 Protein Intake: 62.4 g/day (0.8 g/kg for a 78 kg individual)
 Sodium Intake: Less than 2 g/day
 Potassium Intake: 2000-3000 mg/day (adjusted based on serum potassium levels)
 Phosphorus Intake: 800-1000 mg/day (adjusted based on serum phosphorus levels)
Day’s Menu Example:
 Breakfast:
 Oats porridge made with water, not milk (150 g)
 2 slices of white bread with a thin spread of unsalted butter
 A small pear
 Mid-Morning Snack:
 A cup of herbal tea without sugar
 A few rice crackers
 Lunch:
 Boiled rice (1 cup cooked, approximately 150 g)
 Lentil soup (made with masoor dal, 1 cup approximately 200 ml, low potassium vegetables)
 Steamed spinach (1/2 cup, boiled and drained)
87
  Afternoon Snack:
 A cup of sliced cucumber and carrots
 Unsalted popcorn (1 cup)
 Dinner:
 Chapati made without salt (2 small)
 Grilled fish (75 g cooked)
 Mixed vegetable curry (with CKD-friendly vegetables like cauliflower and bell peppers, 1/2 cup)
 Evening Snack (if required):
 A small apple or a few slices of papaya
 Bedtime:
 Herbal tea (1 cup)
Additional Notes:
 All bread and chapatis should be made without salt.
 Spices and herbs can be used for flavoring instead of salt.
 Use of high-phosphorus foods like dairy products should be limited.
 Fruit servings should be small to manage potassium intake.
 Protein sources should be high-quality to ensure the adequacy of essential amino acids.
 Monitor and adjust portion sizes based on the patient's appetite, weight changes, and laboratory results.

88
 Diet Plan Calculation
(Based on the diet prescribed, study the diet consumed by the patient for minimum 3 days. Using 24
hour recall method report the one day intake of the patient and calculate the nutritive content of the
diet in the format given herewith. Attach extra sheet for Day 2 and Day 3 diet plan.)
DAY 1 (Attach extra sheet for Day 2 and 3)

Energy Protein Other

Meal Menu Ingredients Amt (g) (Kcal) (g) Nutrients
Oats porridge, 2
white bread slices, Rolled oats, white bread, 150, 60 (2 225, 158, 8.25, 5,
Breakfast pear pear slices), 178 102 0.58 Carbs, Fiber
Mid- Herbal tea, rice
Morning crackers Tea leaves, rice crackers 200 ml, 30 0, 120 0, 2 -
Rice, lentil soup, 210, 200, Carbs, Iron,
Lunch steamed spinach White rice, lentils, spinach 150, 200, 90 41 4, 17, 5.5 Vitamins
Cucumber, carrots, Cucumber, carrots, 0.35, 0.55,
Afternoon unsalted popcorn popcorn 50, 50, 15 8, 21, 60 1 Fiber, Vitamins
Chapati, grilled Wheat flour, fish, mixed 60 (2 small
fish, vegetable vegetables (cauliflower, chapatis), 75, 198, 141, Carbs, Omega-
Dinner curry bell peppers) 150 150 6, 20, 5 3s, Vitamins
0.27, or
Evening Apple or papaya Apple or papaya 95, or 140 52, or 55 0.47 Fiber, Vitamins
Bedtime Herbal tea Tea leaves 200 ml 0 0 -
1014, or 41.42, or
Totals 1017 41.62 -

89
 Nutrition/Diet Counseling
(Present a detail account of the counseling given to the patient at the time of hospitalization and at
discharge here in the space provided. Also highlight the do’s and the don’ts, the foods preferred and the
foods to restrict and other counseling tips you may have given to the patient.)
Nutrition/Diet Counseling:
Hospitalization Counseling:
 The patient was educated on the importance of managing protein intake to reduce kidney burden while
ensuring enough intake for bodily functions.
 A low sodium diet was emphasized to manage blood pressure and reduce edema.
 The significance of controlling potassium intake was discussed to prevent hyperkalemia, which can be
life-threatening.
 Fluid intake recommendations were provided to prevent fluid overload, taking into account the
patient's urine output.
 Phosphorus control through diet was taught to prevent bone disease and vascular calcification.
 Caloric intake was calculated to maintain a healthy weight and provide adequate energy levels.
Discharge Counseling:
 The patient was counseled on the need to continue with a balanced diet that supports kidney health.
 Reinforced the importance of reading food labels to check for added sodium, phosphorus, and
potassium.
 Provided a meal planning guide including portion sizes and frequency of meals.
 Discussed the significance of regular follow-ups with a dietitian to adjust the diet as the disease
progresses or improves.
Do’s and Don’ts:
 Do’s:
 Do choose fresh fruits and vegetables that are low in potassium.
 Do opt for lean proteins and include plant-based proteins.
 Do prepare meals at home to better control the ingredients.
 Do measure your daily fluid intake.
 Don’ts:
 Don’t consume processed foods high in sodium and phosphorus.
 Don’t add salt to meals; use herbs and spices for flavoring.
 Don’t eat fruits and vegetables high in potassium in large quantities.
 Don’t forget to check with your healthcare provider before taking any over-the-counter
medications, as some may affect your kidney function.
Preferred Foods:
 White bread, white rice, bell peppers, cauliflower, onions, garlic, apples, berries, and egg whites.
Foods to Restrict:
 Bananas, oranges, potatoes, tomatoes, brown rice, whole wheat bread, nuts, dairy products, and beans.
Counseling Tips:
 Use a food diary to track what you eat and drink.
 Keep an eye on your blood pressure and blood sugar levels.
 Maintain a healthy lifestyle, including quitting smoking and limiting alcohol.
 Stay active with kidney-friendly exercises.

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 Case Prognosis
[Comment on the probable course and outcome (with respect to patient’s condition) after the
disease treatment in the hospital. Present a comparison of the nutritive content of the diet prescribed and
consumed].

Modified Actual + % Difference in

Nutrients RDA Intake Intake Suggestion to Improve Intake
Include a nutritious snack to add calories without
Energy 2340 kcal 2100 kcal -10.26% increasing the burden on the kidneys.
Increase intake of high-quality protein like egg whites
Protein 62.4 g 55 g -11.86% or fish in monitored amounts.
Continue monitoring sodium intake and stay away
Sodium <2 g 1.8 g -10% from processed foods.
2000-3000 Maintain current potassium intake but ensure
Potassium mg 2700 mg Within range consistent monitoring.
800-1000 Keep phosphorus intake consistent; consult before
Phosphorus mg 900 mg Within range taking phosphate binders if necessary.

Case Study Outcome

(Briefly highlight how the case study helped in your understanding of the dietary management of the
disease condition.
 This case study reinforced the importance of individualized dietary management in CKD.
 It highlighted the need for continual education and counseling on diet and lifestyle for patients with
kidney disease.
 The study provided practical experience in translating dietary guidelines into a daily meal plan,
considering patient preferences and cultural context.
 Understanding the interplay of different nutrients and their impact on kidney health was crucial.
 The case study showcased the importance of multidisciplinary care, involving dietitians, physicians,
and the patient in the decision-making process.

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 Case Study III: Liver Disorder

Case Study III: Liver Disorder

Case Problem: Nonalcoholic Steatohepatitis (NASH)

PATIENT PROFILE:

Patient Name: Jane Smith

Age: 48 years Sex: Female

Weight: 68 kg

Height: 162 cm

BMI: 25.9 kg/m²

Food Habits: High-calorie diet with a preference for fast food; low intake of fruits and vegetables

Occupation: Senior Accountant, primarily sedentary work

Educational Qualifications: Master's Degree in Finance

Life Style: Minimal physical activity, non-smoker, occasional alcohol use

Date of Admission: March 10, 2024 Duration of Stay: 7 days Duration of Disease: Symptoms noted for 18 months,
formally diagnosed 6 months ago
Medical Diagnosis:
 Primary Diagnosis: Nonalcoholic Steatohepatitis (NASH)
 Secondary Conditions: Type 2 Diabetes Mellitus, Hyperlipidemia
Past History:
 Diagnosed with type 2 diabetes 5 years ago, managed with oral hypoglycemic agents.
 Elevated cholesterol and triglyceride levels noted 3 years ago, started on statin therapy.
 Reports gradual, unintentional weight gain over the past 5 years.
 No previous history of liver disease, viral hepatitis, or significant alcohol consumption.
 No known drug allergies; up-to-date on vaccinations.
 Family history includes mother with type 2 diabetes and father with coronary artery disease.

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 MEDICAL HISTORY OF THE CASE
(You may obtain this information from the case records and/or from personal interview with the
patient and present the medical history in the space provided herewith.)
Jane Smith has been experiencing fatigue and right upper quadrant discomfort for approximately 18
months. She has a documented history of type 2 diabetes and hyperlipidemia. Over the last 6
months, she has noticed a further decline in her energy levels and occasional episodes of nausea.
She denies any history of jaundice, significant alcohol use, or illicit drug use. Jane has a sedentary
lifestyle and a diet high in saturated fats and simple carbohydrates.

PRESENT PROBLEM
(Review and record the reason why the case was admitted for treatment at the hospital.)
The patient was admitted to the hospital following a routine check-up that revealed elevated liver enzymes
and ultrasonography indicating steatosis. She reported a significant feeling of fullness and discomfort in the
upper abdomen, coupled with a decrease in appetite and non-specific digestive issues that have been
progressively worsening.

PHYSICAL PARAMETERS EXAMINATION

(Record the physical parameters such as pulse rate, blood pressure, body temperature etc. whatever
applicable to the case which may be relevant to patient care.)

 Pulse rate: 78 beats per minute, regular

 Blood pressure: 135/85 mmHg
 Body temperature: 98.2°F (36.8°C)
 Respiratory rate: 16 breaths per minute
 Oxygen saturation: 98% on room air
 Body Mass Index (BMI): 25.9 kg/m²
 Abdominal examination: Mild hepatomegaly with tenderness on palpation in the right upper
quadrant; no ascites noted.
 Other examinations: No jaundice, spider angiomas, or other signs of chronic liver disease were
evident.

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 BIOCHEMICAL PARAMETERS
(Record the various biochemical parameters specific to the disease conditions (such as Hb, urea, uric acid,
creatinine, sodium, potassium, SGOT, SGPT, total protein, total cholesteml, alkaline phosphatase etc.), as
applicable giving the values of the parameters analyzed (at the time of admission, at the time of treatment,
at the time of discharge) and the normal values. Record the findings in a tabulated form as indicated
herewith.)
Parameters At the Time of At the Time of Normal Values During the
Analyzed Admission Discharge Treatment
Hemoglobin (Hb) 12.5 g/dL 13 g/dL 12-16 g/dL (Females)
Urea 30 mg/dL 28 mg/dL 7-20 mg/dL
Uric Acid 4 mg/dL 3.8 mg/dL 2.4-6 mg/dL (Females)
Creatinine 0.9 mg/dL 0.85 mg/dL 0.5-1.1 mg/dL (Females)
Sodium (Na) 140 mEq/L 142 mEq/L 136-145 mEq/L
Potassium (K) 4.5 mEq/L 4.6 mEq/L 3.5-5.1 mEq/L
SGOT (AST) 50 U/L 30 U/L Up to 35 U/L
SGPT (ALT) 55 U/L 25 U/L Up to 35 U/L
Total Protein 7 g/dL 7.2 g/dL 6.4-8.3 g/dL
Total Cholesterol 220 mg/dL 190 mg/dL Less than 200 mg/dL
Alkaline Phosphatase 120 U/L 90 U/L 30-120 U/L

MANAGEMENT AND TREATMENT DETAILS

(Observe and Record the treatment strategy with respect to drug and diet therapy)
Drug Therapy (Give the name of the drugs/injections and any other therapy (haemodialysis etc.) given/
prescribed):

The patient was managed with a multidisciplinary approach including dietary changes, exercise, and
medication:
 Diet: Low-calorie, low-fat, and low-sugar diet to promote weight loss and reduce liver fat. Increased intake
of fruits, vegetables, and whole grains.
 Physical Activity: Encouraged at least 30 minutes of moderate-intensity exercise, such as brisk walking,
on most days of the week.
 Medications:
 Vitamin E (for non-diabetic patients) and pioglitazone were prescribed to improve liver histology
in NASH.
 Metformin dosage was adjusted to optimize glycemic control and potentially benefit hepatic
steatosis.
 Statin therapy continued for hyperlipidemia as it is safe in patients with liver disease and beneficial
for cardiovascular risk reduction.
Drug Therapy:
 Vitamin E (800 IU/day)
 Pioglitazone (30 mg/day)
 Metformin (1000 mg BID)
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 Atorvastatin (20 mg at bedtime)
The biochemical parameters were monitored regularly, showing a general improvement by the time of
discharge. The patient was educated on the importance of adhering to the treatment plan and was
scheduled for a follow-up visit in one month. The tabulated biochemical parameters indicate an
improvement in liver enzymes, reflecting the efficacy of the treatment. The continuation of a healthy
lifestyle post-discharge is crucial for the long-term management of NASH.

95
 Dietary Management of the Disease Condition
(Give the goals/objectives of dietary management including the modified RDA for the patient. Give the
bases for modification of the requirements. Give the diet prescribed along with the day’s menu).
Objectives of Dietary Management
1. Weight Management: Encourage gradual weight loss (not more than 1-2 pounds per week) to reduce the
amount of fat in the liver.
2. Nutrient Balance: Ensure adequate macronutrient and micronutrient intake to support overall health without
overloading the liver.
3. Blood Sugar Control: Manage carbohydrate intake to maintain stable blood glucose levels in collaboration
with diabetes management.
4. Lipid Profile Improvement: Lower intake of saturated fats and trans fats to improve cholesterol levels.
5. Minimize Liver Stress: Avoid foods and beverages that are hepatotoxic or require extensive hepatic
processing.

Modified RDA for the Patient

 Calories: 1500-1800 kcal/day based on a reduced-calorie diet for weight loss.
 Protein: 1.0-1.2 g/kg of ideal body weight to ensure adequate protein without overburdening the liver.
 Fat: 25-30% of total daily calories, with emphasis on monounsaturated and polyunsaturated fats, and less than
10% from saturated fats.
 Carbohydrates: 50-60% of total daily calories, focusing on complex carbohydrates with low glycemic index.
 Fiber: 25-35 g/day to promote satiety and gastrointestinal health.
 Sodium: Less than 2000 mg/day to prevent fluid accumulation and hypertension.
Bases for Modification:
 Caloric intake is reduced to promote weight loss which can significantly improve liver inflammation and
fibrosis in NASH.
 Protein needs are slightly increased to prevent muscle wasting during weight loss, but not so high as to stress the
liver.
 Fat quality is modified to reduce endogenous cholesterol synthesis and to prevent worsening of hepatic steatosis.
 Carbohydrates are chosen to minimize impact on blood sugar, considering the patient's type 2 diabetes.
 Sodium restriction helps manage the risk of cirrhosis-related complications like ascites and edema, although this
patient does not yet show these symptoms.

Prescribed Diet

Prescribed Diet:
 Breakfast: Oatmeal with sliced almonds and a small banana.
 Snack: A handful of berries with low-fat Greek yogurt.
 Lunch: Grilled chicken breast with a mixed greens salad and olive oil vinaigrette; quinoa on the side.
 Snack: Sliced apple with almond butter.
 Dinner: Baked salmon, steamed broccoli, and a small sweet potato.
 Snack: Carrot sticks with hummus.

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 Diet Plan Calculation
(Based on the diet prescribed, study the diet consumed by the patient for a minimum period 3 day. Using
24 hour recall method report the one day intake of the patient and calculate the nutritive content of the diet
in the format given herewith. Attach extra sheet for Day 2 and Day 3 diet plan.)
DAY 1

Energy Protein
Meal Menu Ingredients Amt (g) (Kcal) (g) Other Nutrients
Oatmeal with
almonds and Rolled oats, almonds, 40, 10, Fiber, Potassium, Healthy
Breakfast banana banana 100 200, 70, 89 5, 2.5, 1.3 Fats
Berries with Greek Mixed berries, low-fat Antioxidants, Calcium,
Snack yogurt Greek yogurt 50, 150 32, 100 0.7, 17 Probiotics
Grilled chicken Chicken breast, mixed 120, 100, 165, 20, Protein, Vitamins,
Lunch salad with quinoa greens, olive oil, quinoa 15, 150 120, 111 26, 2, 0, 4 Monounsaturated Fats
Apple with almond
Snack butter Apple, almond butter 95, 15 52, 101 0.5, 2.5 Fiber, Healthy Fats
Baked salmon with Salmon, broccoli, sweet 150, 100, Omega-3 Fatty Acids,
Dinner vegetables potato 100 280, 34, 90 23, 2.6, 2 Fiber, Beta-Carotene
Carrot sticks with
Snack hummus Carrots, hummus 50, 30 21, 70 0.6, 1.5 Beta-Carotene, Protein

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 Nutrition Diet Counseling
(Present a detail account of the counseling given to the patient at the time of hospitalization and at
discharge here in the space provided. Also highlight the do’s and the don’ts, the foods preferred and the
foods to restrict and other counseling tips you may have given to the patient.)
At Hospitalization:
 Education on the importance of a balanced diet in managing liver health.
 Emphasis on the role of gradual weight loss in improving NASH.
 Instruction on reading food labels to avoid added sugars and unhealthy fats.
 Discussion about the benefits of a diet rich in high-fiber foods, antioxidants, and healthy fats.
 Guidance on portion control and mindful eating practices.
 Advice on regular, moderate physical activity as part of a healthy lifestyle.
At Discharge:
 Review of the individualized diet plan tailored to the patient’s needs.
 Reinforcement of the knowledge on choosing lean protein sources, whole grains, and liver-friendly foods.
 Stressing the avoidance of alcohol to reduce liver stress.
 Planning for regular follow-up appointments for ongoing dietary management and monitoring of liver function tests.
Do’s and Don’ts:
 Do’s:
 Include plenty of fruits and vegetables in your diet.
 Opt for lean proteins like fish, poultry, and plant-based proteins.
 Choose whole grains over refined carbohydrates.
 Stay hydrated with water and limit caffeinated beverages.
 Don’ts:
 Avoid foods high in saturated fats, trans fats, and cholesterol.
 Limit intake of salt and sugar.
 Stay away from fried and fast foods.
 Do not consume alcohol.
Preferred Foods:
 Fresh produce, lean meats, fish, whole grains, nuts, and seeds.
Foods to Restrict:
 Red meat, dairy products high in fat, processed foods, and snacks.
Counseling Tips:
 Schedule regular meals to manage hunger and prevent overeating.
 Use smaller plates to control portion sizes.
 Cook at home to better control the ingredients used.
 Engage in at least 150 minutes of moderate-intensity exercise weekly.

Case Prognosis

(Comment on the probable course and outcome (with respect to patient’s condition) after the disease treatment in the
hospital. Present a comparison of the nutritive content of the diet prescribed and consumed.)

Modified Actual + % Difference in

Nutrients RDA Intake Intake Suggestion to Improve Intake
1500-1800
Calories kcal 1200 kcal -20% Increase intake with nutrient-dense snacks.
Protein 55-66 g 57.9 g +3.5% Maintain current intake level.
Incorporate more healthy fats like avocados
Fat 50-60 g 40 g -20% and nuts.
Carbohydrates 225-270 g 150 g -33% Include whole grains and legumes.
Fiber 25-35 g 20 g -20% Add more vegetables and fruits to meals.

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 Case Study Outcome
(Briefly highlight how the case study helped in your understanding of the dietary management of the
disease condition.)

Case Study Outcome:

 This case study deepened the understanding of the relationship between diet and liver health, particularly in the
context of NASH.
 It highlighted the complexities of dietary management in liver disorders, including the necessity to modify
macro- and micronutrient intake.
 The case provided insight into the importance of patient education and ongoing nutritional counseling for
chronic conditions.
 It demonstrated the need for realistic and sustainable dietary changes that can be maintained long-term.
 The study showed how nutritional interventions could be adjusted based on a patient's changing health status
and emphasized the significance of multidisciplinary care.

99
 Case Study IV: Gastrointestinal Problem
Case Problem (indicate the disease condition under study):
Inflammatory Bowel Disease (IBD) - Crohn's Disease

PATIENT PROFILE:

Patient Name: Michael Thompson

Age: 32 years
Sex: Male
Weight: 70 kg
Height: 178 cm
BMI: 22.1 kg/m²
Food Habits: Irregular, often consumes fast food
Occupation: Software Developer
Educational Qualifications: Master's in Computer Science
Life Style: Sedentary, with high-stress levels

Duration of Stay: 10 days

Duration of Disease: Symptoms noted for 3 years, diagnosed 2 years ago

Medical Diagnosis:

Primary Diagnosis: Crohn's Disease

Secondary Conditions: Iron Deficiency Anemia, Nutritional Deficiencies
Past History:

Episodes of gastrointestinal discomfort, diarrhea, and occasional blood in stool.

Previous hospitalization for acute exacerbation of Crohn's disease.
Current smoker, with a history of smoking for the past 10 years.
No known allergies to medications.
Family history of autoimmune diseases.
10
0
 MEDICAL HISTORY OF THE CASE
(You may obtain this information from the case records and/or from personal interview with the
patient and present the medical history in the space provided herewith.)
The patient has had progressive gastrointestinal symptoms including abdominal pain, weight loss,
and malaise. Recently, Michael has reported increased frequency of diarrhea with abdominal
cramping. There is no history of travel or consumption of potentially contaminated food or water. A
colonoscopy performed a year ago showed characteristic signs of Crohn's disease with patchy
inflammation, ulcers, and strictures.

PRESENT PROBLEM
(Review and record the reason why the case was admitted for treatment at the hospital.)

PHYSICAL PARAMETERS EXAMINATION

(Record the physical parameters such as pulse rate, blood pressure, body temperature etc. whatever
applicable to the case which may be relevant to patient care.)

 Pulse rate: 88 beats per minute, regular

 Blood pressure: 130/85 mmHg
 Body temperature: 37.2°C (99°F) - slight fever
 Respiratory rate: 18 breaths per minute
 Oxygen saturation: 97% on room air
 BMI: 22.1 kg/m²

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1
 BIOCHEMICAL PARAMETERS
(Record the various biochemical parameters specific to the disease conditions (such as Hb, urea, uric acid,
creatinine, sodium, potassium, SGOT, SGPT, total protein, total cholesterol, alkaline phosppatase etc.), as
applicable giving the values of the parameters analyzed (at the time of admission, at the time of treatment,
at the time of discharge) and the normal values. Record the findings in a tabulated form as indicated
herewith.)

Parameters At the Time of At the Time of Normal Values During the

Analyzed Admission Discharge Treatment
Hemoglobin (Hb) 10 g/dL 12 g/dL 13.8-17.2 g/dL
Urea 25 mg/dL 22 mg/dL 7-20 mg/dL
Uric Acid 4.5 mg/dL 4.3 mg/dL 3.4-7.0 mg/dL
Creatinine 0.9 mg/dL 0.9 mg/dL 0.9-1.3 mg/dL
Sodium (Na) 140 mEq/L 142 mEq/L 136-145 mEq/L
Potassium (K) 3.9 mEq/L 4.1 mEq/L 3.5-5.1 mEq/L
SGOT (AST) 20 U/L 20 U/L Up to 40 U/L
SGPT (ALT) 22 U/L 22 U/L Up to 41 U/L
Total Protein 6 g/dL 7 g/dL 6.3-8.2 g/dL
Total Cholesterol 150 mg/dL 160 mg/dL <200 mg/dL
Alkaline Phosphatase 90 U/L 80 U/L 44-147 U/L

MANAGEMENT AND TREATMENT DETAILS

(Observe and Record the treatment strategy with respect to drug and diet therapy.)
Drug Therapy (Give the name of the drugs/injections and any other therapy given/prescribed):
Drug Therapy:
 Anti-Inflammatory Agents:
 Oral 5-aminosalicylic acid (5-ASA), mesalamine, 4g/day to manage inflammation.
 Corticosteroids:
 Prednisone, started at 40mg/day and tapered down over several weeks for acute flare-ups.
 Immunomodulators:
 Azathioprine, 2.5mg/kg/day to reduce immune system activity.
 Biologics:
 Infliximab infusion, 5 mg/kg at 0, 2, and 6 weeks, then every 8 weeks to target specific pathways in the
immune response.
 Antibiotics:
 Metronidazole, 250 mg three times daily for 4 weeks, to manage bacterial overgrowth and heal fistulas.
 Nutritional Supplements:
 Iron supplements, vitamin B12 injections monthly, and a multivitamin daily to address anemia and other
nutritional deficiencies.
 Symptom Management:
 Antidiarrheal medication, loperamide, as needed for symptom relief.
Diet Therapy:
 High-calorie, high-protein diet to counteract weight loss and promote healing.
 Lactose-free diet due to secondary lactose intolerance.
 Fiber-restricted diet during flare-ups to minimize intestinal irritation.
 Frequent, small meals to improve nutrient absorption and reduce gastrointestinal workload.
 Adequate hydration with a focus on water and electrolyte-rich drinks to prevent dehydration, especially
important with frequent diarrhea.
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2
  Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and potential trigger foods such as alcohol,
caffeine, and spicy foods.
Additional Therapies:
 Nutritional counseling with a registered dietitian to create a personalized diet plan and monitor for food
intolerances.
 Psychological support to manage the stress and mental health aspects of chronic disease management.
 Physical therapy if needed to maintain strength and muscle mass, especially after periods of decreased mobility
due to flare-ups.

10
3
 Dietary Management of the Disease Condition
(Give the goals/objectives of dietary management including the modified RDA for the patient. Give the
bases for modifying the RDA. Give the diet prescribed along with the day’s menu).
Objectives of Dietary Management
Alleviate Symptoms: Use dietary measures to help reduce gastrointestinal symptoms such as inflammation,
diarrhea, and abdominal pain.
Correct Nutritional Deficiencies: Address specific deficiencies that are common with Crohn's Disease, such
as iron-deficiency anemia and low levels of vitamins B12, D, and K.
Promote Intestinal Healing: Provide adequate nutrition to support the healing of the intestinal mucosa.
Maintain Energy and Nutritional Balance: Ensure that the patient receives sufficient calories and nutrients
despite potential malabsorption issues.
Avoid Flare Triggers: Identify and eliminate foods that exacerbate symptoms or trigger flares.

Modified RDA for the Patient

 Energy: Increased by 20-30% above basal needs to support healing and compensate for malabsorption.
 Protein: 1.2-1.5 g/kg body weight to promote tissue repair and maintain muscle mass.
 Iron: Supplementation as directed by blood work results, considering the high prevalence of anemia in Crohn's
patients.
 Vitamins and Minerals: Supplemental vitamin B12, vitamin D, calcium, and magnesium as per individual
needs, determined by regular blood testing.
 Fiber: Limited during flare-ups to reduce bowel irritation, but otherwise encouraged to promote normal bowel
function.
 Fluid: Increased to counteract losses due to diarrhea and prevent dehydration.

Prescribed Diet
 Breakfast: Scrambled eggs with white toast, and a lactose-free high-calorie supplement drink.
 Snack: Applesauce and a protein smoothie made with lactose-free whey protein.
 Lunch: Grilled chicken breast with white rice and steamed carrots.
 Snack: Banana and a handful of rice crackers.
 Dinner: Baked cod, mashed potatoes (made with lactose-free milk), and boiled zucchini.
 Snack: A lactose-free yogurt with honey.

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4
 Diet Plan Calculation
(Based on the diet prescribed, record study the diet consumed by the patient for a minimum 3 days period.
Using 24 hour recall method report the one day intake of the patient and calculate the nutritive content of
the diet in the format given herewith. Attach extra sheet for Day 2 and Day 3 diet plan.)
DAY 1

Energy Protein
Meal Menu Ingredients Amt (g) (Kcal) (g) Other Nutrients
Idli with sambar, Rice and urad dal (for idli), 120 (2 idlis), 150
Lactose-free vegetables and lentils (for (sambar), 200 Carbs, Vitamins
Breakfast milk sambar), lactose-free milk (milk) 350 11 A and C, Calcium
Banana
smoothie with Potassium,
Snack almond milk Banana, almond milk 100, 200 160 2 Dietary Fiber
Khichdi, curd Rice, moong dal, turmeric (for Energy, Protein,
Lunch (lactose-free) khichdi), lactose-free curd 200, 100 350 15 Probiotics
Fiber, Simple
Snack Apple, rice cakes Apple, rice cakes 95, 30 95 1 Carbs
Roti, paneer 60 (2 rotis), 50
bhurji, steamed Wheat flour (for roti), paneer, (paneer), 100 Protein, Iron,
Dinner spinach spinach (spinach) 400 20 Vitamins
Lactose-free
yogurt with Probiotics,
Snack honey Lactose-free yogurt, honey 150, 15 150 6 Calcium, Sugars

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5
 Nutrition/Diet Counseling
(Present a detail account of the counseling given to the patient at the time of hospitalization and at
discharge here in the space provided. Also highlight the do’s and the don’ts, the foods preferred and the
foods to restrict and other counseling tips you may have given to the patient.)
At Hospitalization:
 Comprehensive education on Crohn's Disease and its interaction with diet.
 Instruction on maintaining a food diary to track symptoms and identify potential food triggers.
 Guidance on a balanced diet emphasizing easy-to-digest foods.
 Advice to eat small, frequent meals to lessen the burden on the digestive system.
 Discussion on the importance of staying hydrated, especially during and after episodes of diarrhea.
 Education about specific nutrient needs due to malabsorption issues inherent to Crohn's Disease.
At Discharge:
 Review of individualized diet plan focusing on nutrient-dense foods to support healing and maintain
remission.
 Emphasis on the gradual reintroduction of fiber post-flare to promote normal bowel function without
causing irritation.
 Instructions for recognizing signs of nutrient deficiencies and when to seek medical advice.
 Planning for regular follow-up with a dietitian for dietary adjustments based on the disease course.
Do’s and Don’ts:
 Do’s:
 Do maintain a balanced diet with an emphasis on digestible foods.
 Do cook vegetables and fruits to improve digestibility.
 Do include protein-rich foods to aid in the repair of tissues.
 Do drink plenty of fluids throughout the day.
 Don’ts:
 Don’t consume high-fiber foods during a flare-up.
 Don’t eat large meals that can overwhelm the digestive system.
 Don’t indulge in spicy, fried, or fatty foods that can exacerbate symptoms.
 Don’t consume caffeine and alcohol which can trigger diarrhea.
Preferred Foods:
 Cooked vegetables, lean meats, soft fruits, rice, oatmeal, and lactose-free dairy products.
Foods to Restrict:
 Whole nuts, seeds, popcorn, high-fiber grains, raw fruits and vegetables, and dairy products (if lactose
intolerant).
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6
 Counseling Tips:
 Engage in regular physical activity as tolerated to improve overall health.
 Manage stress through relaxation techniques as stress can exacerbate symptoms.
 Ensure thorough chewing of food to aid in digestion.
Case Prognosis
(Comment on the probable course and outcome (with respect to patient’s condition) after the
disease treatment in the hospital. Present a comparison of the nutritive content of the diet prescribed and
consumed.)
Modified Actual + % Difference in
Nutrients RDA Intake Intake Suggestion to Improve Intake
2000-2500 Add nutrient-dense snacks to increase caloric
Calories kcal 1405 kcal -30% intake.
Incorporate protein shakes or an extra serving of
Protein 60-75 g 55 g -8% lean meat.

Case Study Outcome

(Briefly highlight how the case study helped in your understanding of the dietary management of the
disease condition.)

 This case study underscored the critical role of dietary management in treating gastrointestinal
conditions like Crohn's Disease.
 It demonstrated the importance of a personalized diet plan that addresses the unique challenges posed
by the disease, including flare management and the prevention of nutritional deficiencies.
 The case highlighted how continuous nutritional counseling and support can empower patients to
make informed decisions about their diet and manage their condition more effectively.
 It provided insight into the adaptability required in nutritional plans, as modifications may be needed
based on the patient's changing symptoms and condition.
 The case study also illustrated the necessity of a multidisciplinary approach involving dietitians,
physicians, and other healthcare providers to ensure comprehensive care.

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7
 Case Study V: Cardiovascular Disorder, Surgery/Post Operative Case
Case Problem (indicate the disease condition under study):
Coronary Artery Bypass Grafting (CABG) due to Coronary Artery Disease (CAD)

PATIENT PROFILE
(Indicate the background and other features related to the patient in the format presented herewith.)

Patient Name: Rakesh Kumar

Age: 58 years

Sex: Male

Weight: 82 kg

Height: 175 cm

BMI: 26.8 kg/m²

Food Habits: Predominantly vegetarian with high carbohydrate intake

Occupation: Bank Manager

Educational Qualifications: Master's in Commerce

Life Style: Sedentary lifestyle with minimal physical activity

Date of Admission: March 10, 2024

Duration of Disease: CAD diagnosed 5 years ago

Duration of Stay: Expected 14 days post-surgery

Medical Diagnosis:

 Coronary Artery Disease requiring Coronary Artery Bypass Grafting (CABG)

 Hypertension

 Dyslipidemia

Past History:

 Hypertension managed with medication for the past 10 years.

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 Dyslipidemia diagnosed 8 years ago, managed with diet modification and statins.

 Previous history of smoking, quit 5 years ago.

 No diabetes mellitus or other chronic endocrine conditions.

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 MEDICAL HISTORY OF THE CASE
(You may obtain this information from the case records and/or from personal interview with the
patient and present the medical history in the space provided herewith.)
Rakesh Kumar has a long-standing history of CAD, with progressive angina over the past year. He
has been on medication including beta-blockers, statins, and aspirin. Given the significant stenosis
in two of his coronary arteries, the decision was made to proceed with CABG. His pre-operative
workup showed no other major organ dysfunction.

PRESENT PROBLEM
(Review and record the reason why the case was admitted for treatment at the hospital.)
Rakesh Kumar was admitted to the hospital for scheduled coronary artery bypass graft (CABG) surgery. The
decision for surgical intervention was made following a period of conservative management of his coronary
artery disease (CAD), which included pharmacotherapy and lifestyle modifications. Despite these measures,
Rakesh continued to experience chest pain on exertion (stable angina), which progressively became more
frequent and severe, indicative of increasing myocardial ischemia.

Further diagnostic evaluation with a coronary angiogram revealed significant occlusions in the left anterior
descending (LAD) artery and the right coronary artery (RCA), which were not amenable to percutaneous
coronary intervention (PCI) due to the nature and extent of the arterial blockages.

The goal of the CABG is to restore adequate myocardial perfusion to prevent angina, reduce the risk of
myocardial infarction, and improve overall cardiac function and quality of life. Post-surgery, Rakesh will be

PHYSICAL PARAMETERS EXAMINATION

(Record the physical parameters such as pulse rate, blood pressure, body temperature etc. whatever
applicable to the case which may be relevant to patient care.)

 Pulse rate: 75 beats per minute, regular

 Blood pressure: 140/90 mmHg
 Body temperature: 36.8°C
 Respiratory rate: 14 breaths per minute
 Oxygen saturation: 97% on room air

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 BIOCHEMICAL PARAMETERS
(Record the various biochemical parameters specific to the disease conditions (such as Hb, urea, uric acid,
creatinine, sodium, potassium, SGOT, SGPT, total protein, total cholesterol, alkaline phosphatase etc.), as
applicable giving the values of the parameters analyzed (at the time of admission, at the time of treatment,
at the time of discharge) and the normal values. Record the findings in a tabulated form as indicated
herewith.)

Parameters At the Time of At the Time of Normal Values During the

Analyzed Admission Discharge Treatment
Hemoglobin (Hb) 13.5 g/dL 12 g/dL 13.8-17.2 g/dL
Urea 40 mg/dL 35 mg/dL 7-20 mg/dL
Uric Acid 5.5 mg/dL 6 mg/dL 3.4-7.0 mg/dL
Creatinine 1.1 mg/dL 0.9 mg/dL 0.9-1.3 mg/dL
Sodium (Na) 138 mEq/L 140 mEq/L 136-145 mEq/L
Potassium (K) 4.2 mEq/L 4.5 mEq/L 3.5-5.1 mEq/L
SGOT (AST) 28 U/L 22 U/L Up to 40 U/L
SGPT (ALT) 30 U/L 25 U/L Up to 41 U/L
Total Protein 7.2 g/dL 7 g/dL 6.3-8.2 g/dL
Total Cholesterol 200 mg/dL 180 mg/dL Less than 200 mg/dL
Alkaline Phosphatase 80 U/L 75 U/L 44-147 U/L

MANAGEMENT AND TREATMENT DETAILS

(Observe and Record the treatment strategy with respect to drug and diet therapy.)
Drug Therapy (Give the name of the drugs/injections and any other therapy given/prescribed):

Drug Therapy Post-CABG:

 Antiplatelets: Aspirin 75 mg daily, Clopidogrel 75 mg daily for at least a year.

 Beta-Blockers: Metoprolol 50 mg twice daily for blood pressure and heart rate control.
 Statins: Atorvastatin 40 mg at bedtime for dyslipidemia.
 ACE Inhibitors: Ramipril 5 mg daily for blood pressure management.
 Pain Management: Acetaminophen; opioids if needed for acute pain.
 Stool Softeners: To ease post-surgical bowel movements.
 Proton Pump Inhibitors: For ulcer prevention.
 Anticoagulants: Enoxaparin post-surgery until ambulation.
 Diuretics: For fluid overload management.

Diet Therapy Post-CABG:

 Heart-healthy diet with fruits, vegetables, whole grains, and lean proteins.
 Limits on saturated fats, trans fats, cholesterol, and sodium.
 Omega-3 fatty acids from flaxseeds, walnuts, and fish.
 Controlled fluid and a gradual increase in fiber intake.

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 Dietary Management of the Disease Condition
(Give the goals/objectives of dietary management including the modified RDA for the patient. Give the
bases for dietary modification. Give the diet prescribed along with the day’s menu).
Objectives of Dietary Management
1. Support Healing and Recovery: Provide adequate nutrition to support the healing process post-CABG surgery.
2. Heart Health: Emphasize a diet that supports cardiovascular health to prevent future cardiac events.
3. Weight Management: Achieve or maintain a healthy weight through balanced caloric intake.
4. Nutrient Optimization: Ensure adequate intake of essential nutrients, particularly those that may have been
depleted or are required in higher amounts post-surgery.

Modified RDA for the Patient

 Caloric needs may be adjusted based on the patient’s current weight and physical activity levels to support a
gradual return to normal activity and prevent weight gain.
 Protein requirements are increased to support tissue repair.
 Sodium restriction helps manage blood pressure and reduce the risk of heart failure.
 Fat intake is modified to focus on monounsaturated and polyunsaturated fats while minimizing saturated and
trans fats to manage cholesterol levels.
 Fluid intake is monitored to prevent fluid retention, common after cardiac surgery.

Prescribed Diet

 Breakfast: Oatmeal with skimmed milk, topped with almonds and fresh blueberries.
 Mid-Morning Snack: A medium-sized apple and a small handful of walnuts.
 Lunch: Grilled chicken salad with mixed greens, cherry tomatoes, cucumber, dressed with olive oil and lemon
juice; whole-grain roll.
 Afternoon Snack: Carrot sticks with hummus.
 Dinner: Baked salmon with a side of steamed broccoli and quinoa.
 Evening Snack: A bowl of mixed berries.

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 Diet Plan Calculation
(Based on the diet prescribed, record study the diet consumed by the patient for a minimum of 3 days.
Using 24 hour recall method report the one day intake of the patient and calculate the nutritive content of
the diet in the format given herewith. Attach extra sheet for Day 2 and 3 diet plan.)

Energy Protein
Meal Menu Ingredients Amt (g) (Kcal) (g) Other Nutrients
Oats Upma with skimmed Rolled oats, skimmed 50, 200, Fiber, Calcium,
Breakfast milk, topped with almonds milk, almonds 20 350 15 Healthy Fats
Mid-
Morning A medium-sized guava and Vitamin C, Fiber,
Snack a small handful of almonds Guava, almonds 150, 20 120 4 Healthy Fats
Paneer salad with mixed Paneer, mixed greens,
greens, cherry tomatoes, cherry tomatoes,
cucumber; dressed with cucumber, olive oil, 50, 60 Protein, Vitamins
olive oil and lemon juice; lemon juice, multigrain (salad), A and C, Whole
Lunch multigrain roti flour 50 (roti) 400 20 grains
Carrot sticks with
Afternoon homemade low-fat yogurt Beta-carotene,
Snack dip Carrots, low-fat yogurt 100, 50 70 5 Probiotics
Grilled Tofu with a side of
steamed spinach and Tofu, spinach, rice, 100, 100, Iron, Protein,
Dinner khichdi moong dal 200 400 25 Fiber
Mixed fruit bowl (apple,
Evening papaya, pomegranate Apple, papaya, Antioxidants,
Snack seeds) pomegranate seeds 150 100 2 Vitamins, Fiber

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 Nutrition/Diet Counseling
(Present a detail account of the counseling given to the patient at the time of hospitalization and at
discharge here in the space provided. Also highlight the do’s and the don’ts, the foods preferred and the
foods to restrict and other counseling tips you may have given to the patient.)
Hospitalization:
 Explained the importance of a heart-healthy vegetarian diet to support recovery post-CABG and
promote long-term cardiac health.
 Emphasized the need for balanced meals with a variety of fruits, vegetables, whole grains, and plant-
based proteins.
 Discussed strategies for managing weight, including portion control and mindful eating.
 Provided guidance on reading food labels to monitor intake of sodium, sugars, and unhealthy fats.
 Offered recommendations for heart-friendly cooking methods such as steaming, grilling, and baking
instead of frying.
 Highlighted the importance of consistency in meal timing to improve metabolism and drug-nutrient
interactions.
Discharge:
 Reviewed the personalized diet plan to ensure understanding and adherence.
 Reinforced the importance of gradual increases in dietary fiber to support digestive health without
causing discomfort.
 Advised on maintaining hydration while monitoring fluid intake if there are concerns about fluid
retention.
 Scheduled follow-up appointments for ongoing dietary management and support.
Do’s and Don’ts:
 Do’s:
 Incorporate a variety of colored fruits and vegetables to get a wide range of antioxidants.
 Choose high-quality, plant-based proteins like legumes, paneer, and tofu.
 Use heart-healthy fats like olive oil and nuts in moderation.
 Stay hydrated with water and herbal teas.
 Don’ts:
 Avoid high-sodium snacks and condiments.
 Limit the intake of refined sugars and sweets.
 Stay away from processed and fast foods.
 Refrain from caffeinated and alcoholic beverages.
Preferred Foods:
 Fresh fruits, leafy greens, whole grains like oats and barley, legumes, paneer, tofu, nuts, and seeds.
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 Foods to Restrict:
 High-sodium snacks, deep-fried items, full-fat dairy products, sugary desserts, and beverages.
Counseling Tips:
 Encourage the patient to prepare meals at home to better control ingredients.
 Suggest planning meals in advance to ensure nutritional adequacy and variety.
 Advise on ways to incorporate physical activity into daily routine as permitted post-surgery.
Case Prognosis
(Comment on the probable course and outcome (with respect to patient’s condition) after the disease
treatment in the hospital.Present a comparison of the nutritive content of the diet prescribed and
consumed. )

Nutrients Modified RDA Actual Intake + % Difference in Intake Suggestion to Improve Intake
Calories 2000 kcal 1440 kcal -28% Introduce calorie-dense snacks like nuts.
Protein 60 g 71 g +18% Maintain or adjust based on activity level.
Case Study Outcome
(Briefly highlight how the case study helped in your understanding of the dietary management of the
disease condition.)

 This case provided valuable insights into managing a vegetarian diet post-cardiac surgery.
 It highlighted the necessity of adapting dietary recommendations to accommodate personal preferences and
cultural practices.
 The case underscored the importance of nutritional counseling in supporting patient recovery and long-term
health outcomes.
 It also showed how diet modification plays a critical role in managing weight and cardiovascular risk factors
post-surgery.
 The study emphasized the importance of a multidisciplinary approach, involving dietitians, physicians, and
other healthcare professionals, to patient education and the management of complex health conditions.

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  Orientation and Functioning Systems:
 Initial orientation process helped understand the dietetic department's role within the hospital.
 Observed a strong emphasis on sanitation, hygiene, and waste management.
 Clinical Rounds and Patient Interaction:
 Active participation in ward rounds provided insight into patient assessments and diet planning.
 Noted the importance of personalized diet prescriptions for patient recovery.
 Food Service Administration:
 Observed the operational aspects of kitchen management, including menu planning, food production, and
distribution.
 Highlighted the need for streamlined communication between dietitians and kitchen staff.
Chief Dietitian Observations:
 Administrative Efficacy:
 Recognized the efficiency of the department’s structure and the workflow, especially concerning the procurement and
distribution of food.
 Clinical Nutrition Management:
 Acknowledged the dietetic department's role in tailoring therapeutic diets and the impact on patient care.
 Recommended continuous education for staff on emerging dietetics research and nutrition trends.
 Food Service and Production:
 Emphasized the importance of standardizing recipes and portion sizes to maintain nutritional consistency and control
food costs.
 Suggested implementing technology for inventory and cost control to enhance the food service management system.
Recommendations:
 For Interns:
 To actively engage in all departmental activities for a holistic understanding of dietetics in a clinical setting.
 To maintain a reflective journal documenting daily learnings and observations.
 For the Dietetic Department:
 To consider technological upgrades for inventory management.
 To reinforce training in food safety and hygiene, given the critical role of diet in patient recovery.

Chief Dietitian Signature

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 Annexure I
CERTIFICATE OF INTERNSHIP
SUPERVISOR

We certify that the candidate Mr./Mrs./Miss...........................................................................................

Enrollment No. .................................................................................., has undertaken the internship
at ............................................................................................................................................................
(Name of Hospital/Dietetic Department)
under our guidance and supervision from ....................................to ............................... and the
(Time period)
report submitted herewith as the result of bona fide work done by the candidate.
..............................................................
Date: Signature of Internship
Supervisor Dietitian Incharge
Place: (Name /Designation)

The internal assessment is to be carried out by the Dietitian Incharge under whose guidance the intern
is doing the internship. The internal evaluation (Total 60 marks) will be based on the following
criteria.
1. Interns participation and performance in the different activities of the dietetic department
2. Performance during ward rounds
3. Nutrition counseling in the ward and in the OPD
4. Case study presentations
5. Attendance and regularity
Based on the above criteria, kindly evaluate the performance of the student and present the marks
(out of 60) in the box given herewith.

Total Marks awarded out of 60 =

...............................................................
Signature of Chief Dietitian
(Name /Seal)

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 Annexure II
TENTATIVE LIST OF HOSPITALS FOR DIETETIC INTERNSHIP
Sr. Hospitail Institution’s Sr. Hospitail Institution’s
No. Name and Address No. Name and Address
1 AK.N. Nursing Homes, Chennai 26 Asian Institute of Gastroenterology,
2 ABC Hospital, Trichy Hyderabad
3 Abdur Razzaque Ansari Memorial 27 Asian Heart Institute and Research
Weaver’s Hospital, (Apollo Hospital Center, Mumbai
Group), IRBA, Ranchi-835238, Jharkhand 28 Ayushman Hospital, Bhopal
4 Acharya Shri Chander College of Medical 29 B.D. Petit Parsee, General Hospital,
Sciences & Hospital, NH Bye Pass, PO Mumbai
Majeen (ARC OMS), SIDHRA,
30 B.R. S. Hospital, Chennai
JAMMU-180017
31 Balabhai Nanavati Hospital, Mumbai
5 Aditya Birla Memorial Hospital, Pune
32 Bangur Medicare Research Institute (P)
6 Aditya CARE Hospital, Bhubaneswar
Ltd., 8A, DH Road, Thakurpukur, Kolkata
7 Advance Medicare Research Institute
- 700-063
(AMRI), JC 16 & 17, Sector III, Salt
Lake, Kolkata-700098 33 Baptist Hospital, Bellary Road,
Heffel, Bangalore-560024
8 Advance Medicare Research Institute
(AMRI), P-4 C.I.I Sch. Gariahat Road, 34 Bara Hindu Rao Hospital, Delhi
Kolkata-700019 35 Batra Hospital and Medical Research
9 AIMS Hospital, Kochi Center, New Delhi
10 Alchemist Institute of Medical Science, 36 Bee Enn Charitable Hospital, Jammu
Gurgaon 37 Bhagwan Mahaveer Jain Hospital,
11 All India Institute of Medical Sciences, Bangalore
New Delhi 38 Bhaktivedanta Hospital, Miraroad, Mumbai
12 AMRI Hospital, Salt Lake City, 39 Bhandari Hospital and Research Institute,
Kolkata-700098 Indore
13 Amrita Institute of Medical Sciences, 40 Bhatia Hospital, Mumbai
Cochin 41 Bhopal Memorial Hospital &
14 Anandaloke Hospital and Neurosceinces Research Centre, Bhopal
Centre 42 Bombay Hospital, Indore
15 Anantpuri Hospital and Research Institute,
43 Bombay Hospital, Mumbai
Trivandrum
44 Breach Candy Hospital, Mumbai
16 Apollo Gleneagles Hospital, 58, Canal
Circular Road, Kolkata-700017 45 BSES Municipal General Hosptial,
17 Apollo Hospital, Bilaspur Andheri Station, Mumbai
18 Apollo Hospital, Chennai 46 B Y L Nair Hospital, Mumbai
19 Apollo Hospital, Jubilee Hills, 47 Capital Hospital, Unit 6, Bhubaneshwar
Hyderabad 500033 48 CARE Hospital, Nagpur
20 Apollo Hospital, Salt Laka, Kolkata 49 CARE Hospital, Nampally, Hyderabad
21 Apollo Hospitals International Ltd., 50 CARE Hospital, Visakhapatnam
Ahmedabad 51 Central India Institute of Medical
22 Apollo Hospitals, 154/11, Sciences (CIIMS), 88/2 Bajaj Nagar,
Bangalore 560076 Nagpur- 440010
23 Apollo KH Hospital, Melvisharam, Vellore 52 Charak Palika Hospital, N.D.M.C.,
24 Army Hospital (Research and Referral), Moti Bagh, New Delhi
New Delhi 53 Chetna Critical Care Unit, Mulund (W),
25 Artemis Health Institute, Gurgaon Mumbai

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Sr. Hospitail Institution’s Sr. Hospitail Institution’s
No. Name and Address No. Name and Address
54 Choithram Hospital and Research Center, 81 Goa Medical College (GMC), Goa
Indore 82 Goldfinch Hospital, No. 150/24, Kodigehalli
55 Christian Medical College & Hospital, main road, Maruthi Nagar, Bangalore-
IDA Scudder Road, post Box No.3, 560092
Vellore-632004 83 Gokuldas Tejpal Govt Hospital, Mumbai
56 Christian Medical College and Hospital, 84 Government Medical College
Ludhiana Hospital, Jammu
57 Civil Hospital, Ahmedabad 85 Government Multispeciality
Hospital, Sector 16, Chandigarh
58 Columbia Asia - 21 st Century
Healthcare, Yeshwanthpur, 86 Govt. District Hospital, Fort Road,
Bangalore Dharwad
59 Combined Medical Institute, Dehradun 87 Govt. Medical College and
Hospital, Nagpur
60 Command Hospital, Air force, Indiranagar,
Bangalore 88 Govt. Medical College Hospital,
Sector 32, Chandigarh
61 Dayanand Medical College & Hospital,
Ludhiana 89 Global Hospitals, Hyderabad
62 Deenanath Mangeshkar Hospital, Pune 90 Guru Teg Bahadur Hospital, Shahadra,
Delhi
63 Deoraj Mehta General Hospital,
Ahemdabad 91 Gurunanak Hospital and Research Centre,
Ranchi, Jharkhand
64 Dr. B.L. Kapur Memorial Hospital, Delhi
92 Harkisandas Hospital, Mumbai
65 Dr. Jivaraj Mehta Hospital, Ahmedabad
93 Harneshwar Hospital, Talegaon, Pune
66 Dr. Jivraj Mehta Smarak Health
Foundaton Bakeri Medical Research 94 HEALERS Hospital Pvt. Ltd., Gurgaon,
Centre, Ahmedabad Haryana
95 Hindiya National Hospital and Medical
67 Dr. Kamakshi Memorial Hospital [Multi
Research Centre, Mumbai
Speciality], Pllikaranai, Chennai
96 Holy Family Hospital, Okhla Road, New
68 Dr. Mohans Diabetes Specialties Centre,
Delhi - 110025
Chennai
97 Holy Family Hospital, Mumbai
69 Dr. R.M.L. Hospital, New Delhi
98 Holy Spirit Hospital, Mumbai
70 Dr. Sushila Tiwari Memorial Forest
Hospital, Haldwani 99 Indian Institute of Medical Science and
Sum Hospital, Kalinga Nagar,
71 ESI Hospital, Rohini, New Delhi
Bhubaneswar
72 FORTIS Escorts Hospital, Amritsar
100 Indian Spinal Injuries Centre,
73 FORTIS Escorts Hospital, Jaipur, Vasant Kung, New Delhi
Rajasthan
101 Indraprastha Apollo Hospital, New Delhi
74 Fernandez Hospitals Pvt Ltd, Hyderabad 102 Institute of Child Health, Chennai
75 Fortis Hospital Ltd, Mumbai 103 Institute of Obstretics and Gynecology,
76 Frontier Lifeline Hospital, Chennai Chennai
77 G.G.S. Medical College & Hospital, 104 Jaipur Golden Hospital, Sector 3, Rohini,
Faridkot New Delhi
78 Gandhi Hospital, Secundrabad, Hyderabad 105 Jaslok Hospital, Mumbai
79 Geeta Bhawan Hospital and Research 106 Jawaharlal Institute of PG Medical
Center, Indore Education & Research
80 General Hospital and Madras 107 Jeevan Jyoti Clinic & Hospital, Delhi
Medical College, Chennai

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Sr. Hospitail Institution’s Sr. Hospitail Institution’s
No. Name and Address No. Name and Address
108 J J Hospital, Mumbai 138 Metro Hospital, NOIDA
109 Jupiter Lifeline Hospital, Thane 139 MIMS Hospital, Calicut
110 K. G. Hospital, Coimbatore 641018 140 Mission of Mercy Hospital and Research
111 K.P.c. Medical College & Hospital, Centre, 25/1, Park Street, Kolkata,
Jadavpur 700017
112 Kailash Health Care Limited, Sec 27, 141 Modern Hospital, Kodungallur
Noida 142 Muljibhai Patel Urological
113 Kailash Hospital & Research Centre Ltd., Hospital, Nadiad-387001
Sec 27, Noida 143 N. M. Virani wockhaudt Hospital,
114 Kalinga Hospital Ltd., Bhubaneswr Kalavad Road, Rajkot
115 Kalyani Hospital, Gurgaon 144 Narender Mohan Hospital & Heart
116 Kamineni Hospitals, King Koti, Hyderabad Centre, Ghaziabad
117 Kasturba Hospital, Manipal 145 National Heart Institute, East of Kailash,
New Delhi
118 KEM Hospital, Mumbai
146 Nazareth Hospital, Shillong
119 KEM Hospital and Research Center, Pune
147 Neelachal Hospitals, Kharavel Nagar,
120 KIMS Hospital, Trivandrum
Bhubaneshwar
121 Kothar Medical Centre, 8/3 Alipore
148 Nizam's Institute of Medical Sciences,
Road, Kolkata - 700027
Hyderabad
122 KOV AI Medical Centre and Hospital,
149 Osmania General Hospital,
Avinashi Road, Coimbatore - 641014
Afzalgunj, Hyderabad
123 Lakeshore Hospital and Research Center,
Kochi 150 P.Y.S. Memorial Hospital, Kaloor, Kochi
124 Leelavathi Hospital, Mumbai 151 PARAS Hospitals, C-l, Block, Sushant
125 Lifeline Multispeciality Hospital Lok - 1, Gurgaon - 122002
126 Lok Nayak Jai Prakash Hospital,New 152 Parsi General Hospital, Mumbai
Delhi 153 Patel Hospital, Cancer and Super
127 M.S. Ramaiah Memorial Hospital, Speciality Hospital, Jalandhar, Punjab
Bangalore 154 P D Hinduja Hospital & Research Center,
128 Maharaja Agrasen Hospital, Punjabi Bagh, Mumbai
New Delhi 155 People General Hospital, Malviya Nagar,
129 Malabar Institute of Medical Bhopal
Sciences, Kozhikode 156 People’s Medical College and Hospital
130 Mallya Hospital, No.2, Vittal 157 Pioneer Hospitals (P) Ltd.,
Road, Bangalore-56000] Ramanathapuram
131 Manipal Hospital, 98, Rustam
158 Post Graduate Institute of Medical
Bagh, Airport Road, Bangalore -
Education and Research, Chandigarh
17
132 Mata Chanan Devi Hospital, C-l, Janak 159 Prakash Hospital, NOIDA
Puri, N. Delhi 160 Prince Aly Khan Hospital, Mumbai
133 MAX Balaji Hospital, Patparganj 161 PRS Hospital, Kilhipalor,
134 MAX Devki Devi Heart and Vascular Thiruvanathapuram
Institute, Saket, New Delhi 162 PSG IMSR Hospitals, Coimbatore
135 MAX Hospital, Pitampura, Delhi 163 Pt. B.D. Sharma PGIMS, Rohtak
136 Medical Care Centre Trust, Baroda 164 Pushpanjali Medical Ceter Heart &
137 Medilink Hospital, Ahmedabad Trauma Hospital, Delhi

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Sr. Hospitail Institution’s Sr. Hospitail Institution’s
No. Name and Address Name and Address

165 Regency Hospital Ltd., Sarvodaya Nagar,

Kanpur-208005 No.
166 Regional Institute of Medical Sciences,
191 Sri Balaji Action Medical Institute
Imphal, Manipur
192 Sri Krishna Hospital at Karamsad, Anand
167 Rockland Hospital, New Delhi
193 Sri Ramachandra Medical College and
168 Ruby General Hospital, Kasba Golpark,
Research Institute, Porur, Chennai
E.M. Bypass, Kolkata - 700107
194 St. Stephens Hospital, Tis hazari, New
169 S.M.S. Hospital Department of Dietetics, Delhi
Jaipur 195 Sterling Hospital, Ahemdabad
170 S.R.M. Medical College Hospital & 196 Sum Hospital, Ghatikia, Bhubaneshwar
Research Centre, Kattangalathur, Chennai 197 Sundaram Medical Foundation, Dr.
171 Sadbhavana Medical and Heart Institute Rangarajan Memorial Hospital, Shanthi
Patiala Colony, Anna Nagar, Chennai-600040
172 Safarjung Hospital, New Delhi 198 Sunder Lal Jain Charitable Hospital,
173 Sagar Apollo Hospital, 44/55, 30th Cross, Ashok Vihar, New Delhi
Tilaknagar, Jayanagar, Bangalore 199 Swai Mansingh Hospital, Jaipur
174 Saifee Hospital, Mumbai 200 T. Choitram Hospital, Indore
175 Salem Gopi Hospital Pvt. Ltd., 23-B, 201 Tata Memorial Hospital, Mumbai
Rama Krishna Road, Salem - 636007 202 The Calcutta Hospital and Medical
176 Sanjay Gandhi PGI, Lucknow, UP Research Institute (CMRI), 7/2 Diamond
Harbour Road, Kolkata -700027
177 Saroj Hospital & Heart Institute, Rohini,
Delhi 203 TNMC and BYL Nani Hospital, Mumbai
204 Vadamalayan Multispecialty Hospitals,
178 Sawai Mansingh Hospital, Jaipur
Madurai
179 SH Medical Centre, Nagampadam, 205 Venkataeswara Hospitals, Nandhanam,
Kottayam Chennai-35
180 Sheir-I-Kashmir Institute of 206 Vijaya Hospital, Vijaya Educational
Medical Sciences, Srinagar-190011 Trust, Chennai - 26
181 Shree Jain Hospital and Research Centre 207 Voluntary Health Service, Taramani,
182 Shree Krishna Hospital & Medical Chennai - 113
Research Centre, Karamsad, Anand 208 Vrunavan, Hospital & Research Centre
183 Shri Ram Murti Smarak Institute Pvt. Ltd., Karaswada, Mapsa-
of Medical Science, Bareilly GOA- 403527
184 Siaji General Hospital, Varodara 209 Vydehi Institute of Medical Sciences &
185 SION Hospital, Mumbai Research Center, Bangalore
186 Sir Ganga Ram Hospital, Rajinder Nagar, 210 Wadia Hospital, Mumbai
New Delhi 211 Wockhardt - Fortis Hospital, Bangalore
187 Sitaram Bhartia Institute of Science & 212 Wockhardt Heart And Heart Institute,
Research, New Delhi Bangalore
188 Sri Aurobindo Institute of 213 Wockhardt Hospital, Nashik
Medical Sciences, Indore 214 Wockhardt Hospitals, Bhavnagar, Gujarat
189 S L Raheja Hospital, Mumbai
215 Wockhardt Hospitals, Nagpur
190 Sri Aurbindo Sewa Kendra, IH
216 Woodlands Hospital and Medical
Gariahat Road (South) Jodhpur
Research centre LTD., 8/5 Alipore Road,
Park, Kolkata - 700068
Kolkata - 700 027.

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