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What do I document?

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:

4. Nutrition Monitoring and evaluation: Make sure pt is meeting his needs

5.Calculate estimated needs using ABW. Use these parameters:


25-30 kcals/kg
1 gram protein/kg
25-30 cc/kg of fluids
History and Physical
HISTORY OF PRESENT ILLNESS: Mr. D is a 64 year old advertising executive who presents to the
emergency room complaining of the passage of black stools x 3 days and an associated
lightheadedness. He also relates that he cannot keep up with his usual schedule because of fatigue
Upon further questioning he states that his stools are not only black, but are sticky and malodorous. He
further complains of recent worsening of a chronic epigastric burning which had been a problem off/on
for years. He takes NSAIDS as needed for back pain and recently started on one aspirin per day for
cardiac prophylaxis. He was told of an ulcer in the distant past but had no specific evaluation or
treatment for same. Pt also presents with a history of edema
PHYSICAL EXAMINATION: Examination reveals an alert, oriented, overweight male. He appears
anxious and somewhat restless. Vital sips are as follows. Blood Pressure 120/80 mmHg, Heart Rate
110/min - Supine; BP 90/60 mmHg; HR Thready - Standing (Patient complains of dizziness upon
standing). Respiratory Rate - 20 /minute; Temperature 98 F.
HE-ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity
are noted. No spider nevi are seen. The parotid glands appear full.
CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals regular rhythm with
an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak.
ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are hyperactive.
There is moderate tenderness in the epigastrium. The liver is percussed to 13 cm (mal); the edge feels
firm. The spleen was not felt and no masses were appreciated; the exam was felt to be suboptimal
secondary to the patient's obesity. Rectal examination revealed black, tarry stool, as well as some bright
red blood.

Borderline high triglycerides = 150 to 199 mg/dL.


High triglycerides = 200 to 499 mg/dL.
Very high triglycerides = 500 mg/dL or higher.
For total cholesterol:
200 milligrams per deciliter (mg/dL) or less is considered normal.
201 to 240 mg/dL is borderline.

Greater than 240 mg/dL is considered high.


HDL 60 mg/dL or higher is good -- it protects against heart disease.
HDL between 40 and 59 mg/dL are acceptable.
Less than 40 mg/dL HDL is low, increasing the risk of heart disease.
For LDL ("bad cholesterol"), lower is better:
An LDL of less than 100 mg/dL is optimal.
An LDL of 100 to 129 mg/dL is near-optimal.
LDL between 130 and 159 mg/dL is borderline high.
LDL cholesterol between 160 and 189 mg/dL is high.
An LDL of 190 mg/dL or more is considered very high.

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

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