Medical Record Note

Scores are listed in the left column.

Heading (1 point)
A
(6 points
total)

S
(2 points)

O
(4 points)

7:30 a.m. October 29, 2014 MNT 2- HIV/AIDS

- pt. reports that he is having difficulty eating and has a sore mouth
- Reports he is willing to try new therapies from a dietary standpoint
- pt. states that he usually eats out when at work and brings the leftovers home
- pt. requested information as to whether he should be consuming a multivitamin
- pt. requested information as to whether he should gain weight
- pt. reports two to three loose bowels a day
- pt. comments that his doctor recommends that he gain weight

Age: 35 y/o male C2 HIV

Ht: 185.42 cm
Wt: 72.72 kg
BMI: 21.1
UBW: 86.18 kg
UBW%- 84.2%
IBW- 83.64 kg
IBW%- 86.96%
TSF: 5.0 mm (7th percentile, below average)
Arm Circumference: 24.2 (5th percentile)
AMA: 40.77cm2
TAA: 46.63 cm2
AFA- 15.86 cm2 (37th percentile= Average)
TEE: 1716.08*1.3= 2230 kcal
DER (To gain one lbs. a week)- 2800 kcal
Protein Needs- .8*72.73= 58 g
Fluid Needs- 2800 mL (1ml per kcal)
Medical dx: HIV, Kaposi sarcoma, candidiasis, diarrhea, cramping, nausea
Medical Labs: Serum albumin 2.2 g/dL, CD4+: 238/mm
Nutritional Analysis- 962 kcal, 35.1 g protein, 37.98 g fat, 121 g CHO, 6.46 g fiber
Medications: Retrovir, Vincristine sulfate, mycostatin, medical marijuana

D
Dx:
____points

Dx:
____points

Dx:
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A
(9 points)
(Each
PES
statement
is worth 3
points,
unless you
had fewer
than
three.
One=9
points;
Two=4.5
points
each.)

Inadequate Protein-Energy Intake (NI-5.3) related to decreased ability to consume sufficient protein
and energy as evidenced by pt. comments that it has been difficult for him to eat, nutrition analysis,
TSF, and low serum albumin.

Intake of Unsafe Foods (NB-3.1) related to food and nutrition-related knowledge deficit concerning
potentially unsafe food, as evidenced by diarrhea, nausea, abdominal cramping, and intake of raw
meat.
Unintended Weight Loss (NC-3.2) related to decreased ability to consume sufficient energy, as
evidenced by UBW%, candidiasis, and nutrition analysis.

I (M/E)
I:
____points
M/E:
____points

P
(6 points)
(3 points
for
Intervention; 3
points for
M/E.)

Intervention:
Recommend commercial beverage (ND-3.1.1) to help increase protein and caloric intake in
addition to current diet.
2 8 oz cans daily of Abbott nutrition Hi-Cal, will provide 950 kcal, 39.6 g protein, 42.4 g fat,
102.6 g CHO, and 332 mL free water
Recommend nightly nasogastric continuous enteral feeding to encourage weight gain and prevent
wasting (ND-2.1)
Jevity 1 kcal to provide extra kcal and to provide extra protein, recommend 1000 mL of Jevity 1
kcal, 125 ml/hr for 8 hours, will provide 1060 kcal, 44.3 g protein, 34.7 g fat, 154.7 g CHO, and 835 mL
free water
Recommended Megace Oral Suspension to increase pt. appetite (ND-3.1)
Megace Oral Suspension can increase appetite to help with weight gain and prevention of muscle
wasting
Nutrition Education related to consumption of unsafe food (E-1.5)
Educate patient on proper storage of leftover foods
Educate patient on food safety and proper cooking of food
Educate patient on why food safety is important, especially in HIV patients.
Nutrition Education related to weight loss and pt. questions (E-1)
Inform patient that I do not have enough information to answer question regarding multi-vitamin,
will request a longer food log from patient to access normal micronutrient intake and request
micronutrient lab test from physician to check micronutrient levels and utilization.
Educate patient on the importance of weight gain/maintenance and adequate food intake to
prevent wasting.
Discuss ways to consume sufficient energy with candidiasis, explain the importance of the
commercial beverage and nightly tube feedings.
Monitor/Evaluation
Monitor tolerance to commercial beverage (FH-1.2.1.1) and tolerance to enteral feeding
(FH-1.3.1.1) through session with pt. asking how he is handling the nutrition support, monitoring
stool patterns, and monitoring pt. weight. Monitor enteral feeding by checking the tube feeding
residual volume.
Monitor how the Megace Oral Suspension is effecting pt. appetite (FH-3.1.1) through follow up
session with pt.

Evaluate pt. understanding of proper food storage and food preparation (FH-4.1.1)
Evaluate pt. understanding of proper storage of food and food preparation, by asking the patient if
his diarrhea and abdominal cramps have subsided

Monitor patients weight (AD-1.1.2)

Evaluate patient food consumption through a food log

If patient does not tolerate the commercial beverage or tube feeding we will discuss different
beverages he can take or another type of tube feeding. If patients weight continues to decline we
will discuss increasing commercial beverage intake, increasing oral intake based on pt. ability to
eat, or discusses a permanent tube feeding.

Signature (1 point)

Writing Style
(2 points)

Brandon Cavinee

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