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We will be looking at an electronic health record and gathering information for a nutrition
assessment. Using the NCP as a guideline, review the information in this document, as well as
information on the following website.
The website is practicefusion.com . Go to login. Username: kcole207@gmail.com (my email in
case anyone has a question)
Password: Olivea34 (case sensitive)
The patient we are looking at is named Eric GastroDemo.
Eric D. was admitted to the hospital on 1/31 with a chief complaint of dark blood in his stool,
abdominal pain, and lightheadedness. His diagnosis on your census report just says GI bleed. You learn
from attending the morning meeting that he has a history of CHD, stomach ulcers, colon polyps and an
acute case of colitis. He is scheduled for an endoscopy later in the day. He is currently NPO. He will
most likely be in the hospital for 3-4 days. Before going to interview Mr. D gather all pertinent
information you will need by going over his chart.
Try to incorporate what you know of the NCP.
Steps:
1. Assessment. Include the medical history, medications/supplements, personal and social history and
food and nutrition history. Write down only what you can find in the charts and history. Include lab
values that are out of normal limits, anthropometrics, etc. I think a good place to always start when
looking at a chart is the BMI. It will automatically give you an indication of nutritional status. I think
its a good starting point.
2.Diagnosis: Even though dietetic technicians cannot make a nutrition diagnosis, what do you think
would be an appropriate diagnosis for this patient? We as DT's, can often still be part of the
conversation when it comes to nutritition diagnosing.
3. Nutrition Intervention/Goals:
12Tes t
13Normal
14Abnormal
15Flag
16Units
COMPLETE BLOOD COUNT
White Blood
6.9
K/mcL
Cell (WBC)
Red Blood Cell
(RBC)
1.8 L
M/mcL
Hemoglobin
(HB/Hgb))
6.5 L**
g/dL
Hematocrit
19.5 L**
%
(HCT)
Mean Cell
Volume (MCV)
109.6 H
fL
Mean Cell
Hemoglobin
(MCH)
36.5 H
pg
Mean Cell Hb
Conc (MCHC)
33.3
g/dL
Red Cell Dis t
Width (RDW)
16 H
%
Platelet count
180
K/mcL
Mean Platelet
7.9
fL
Volume
WBC Differential
Neutrophil
(Neut)
50
%
Lymphocyte
(Lymph)
36
%
Monocyte
8
%
(Mono)
Eos inophil
(Eos )
5
%
Bas ophil
(Bas o)
1
%
Neutrophil,
3.5
K/mcL
Abs olute
Lymphocyte,
Abs olute
2.5
K/mcL
Monocyte,
0.6
K/mcL
Abs olute
Eos inophil,
Abs olute
0.4
K/mcL
Bas ophil,
Abs olute
0.1
K/mcL
Flag Key: L= Abnormal Low, H= Abnormal High, **= critical value
Fasting
HDL
LDL
TGL
Gluc
Creat
Na
K
BUN
32
162
250
17Reference
Range
4.8-10.8
4.7-6.1
14.0-18.0
42-52
80-100
27.0-32.0
32.0-36.0
11.5-14.5
150-450
7.5-11.0
33-73
13-52
0-10
0-5
0-2
1.8-7.8
1.0-4.8
0-0.8
0-0.45
0-0.2
mg/dL
mg/dL
mg/dL
133
1.1
175
5
25
74-106 mg/dL
.7-1.3 mg/dL
136-146 Meq/L
3.5-5.1 mEq/L
6-20 mg/dL