General Medicine I

Intern: Allana Boone

Preceptor: Mrs. Haarburger
MED1

Client History
Veteran: A.B.
Ward 4B
Attending Physician:
__ Y.O. AA male
PMH: Hep C, left eye prosthesis, LBP and psych

Hx of
Depression, Polysubstance use (cannabis, opioid, etoh)
Admission Dx: Opioid and ETOH abuse

Substance Abuse/Dependence

Medications

Anthropometric Measures
Height: 5 11 (180 cm)
Weight: 115.7lb (53.6 kg)
BMI: 16.2
UBW: 138 lb (62.7 kg)
IBW: 172 lb (78.2 kg)

% weight change: 13%

% UBW: 84%
% IBW: 67%

Biochemical Data, Medical Tests and

Procedures

Paste in laboratory data.

Food/Nutrition-Related History

Comparative Standards
Energy: 1736 kcal/kg
Protein: 58 g/d
Fluid: 1736 ml/d
Estimated needs calculated using actual body weight and
caloric factor of 33kcal/kg

Nutrition Diagnosis
Unintentional weight loss
Related to poly-substance abuse
As evidenced by significant weight loss x 1mo (17#, 13%),
Veterans statement

Nutrition Intervention
Diet: Recommend pt remain on current recommended diet.

(Regular)
Supplements: Recommend pt remain on Hi Cal Liquid
Supplement (Inpatient)
Coordination of Care: Upon d/c, refer to outpatient care RD
Education: Educated pt on importance of consuming all of his
sup (look at note from today)

Nutrition Monitoring & Follow-Up

See patient on meal rounds, adjust diet as needed

Nutritional Goals

Weight gain and/or maintenance

Continued consumption of >/= 75% of meals