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First Office Call

DOB: 5/29/1958

Client Name: DC

Age: 56
Appointment length: 60 minutes

Client History

Reason for visit/HPI: Referred by MD for nutritional education for stage 4 colon CA support.
Willing to do whatever she can to fight CA, get healthy, and lose weight.
PMH: Surgical resection of tumor 6w ago with 6 of transverse colon and small wedge portion of
liver removedpt healed and normal eating resumed. Started chemo tx 2 wks ago and will
continue q other wk for next 6m-1yr at least. Mild s/s so far. Has hx of hypothyroidism, HTN, and
Family Med Hx: Pts father and grandfather died of colon CA. Pts mother had HTN and died of
Environmental and Medication Allergies: NKA
Tobacco / Drug use: n/a
RX/OTC: fluorouracil, oxaliplatin, avastin, prilosec, lisinopril, levothyroxine, simvastatin, MVI
Doctors Choice for Women (Enzymatic Therapy), Vitamin E 400 IU

Physical activity: Little PA in past; generally busy. Doesnt enjoy sitting around, but dislikes gym.
Walked 2x this wk for almost 1mi. Just got a dog to help motivate her to walk outside more
Social Hx: Married to supportive husband. Critical care nurse for 20 yrs. Used to being busy,
reports difficulty slowing down. Self-reported Type A. Positive outlook, family is worried.
Other client hx notes: n/a

Food and Nutrition History

24 hour recall/ Typical day: B: 8 oz black tea, c FF Fage Greek yogurt, c honey nut cheerios,
c FF milk. L: 6 Subway club, 12 oz iced tea with lemon. D: 10 oz Stouffers cheese lasagna, 8 oz
water. Doesnt eat past 7:30 pm.
Nutrition Intake Analysis Results - ESHA: Deficient in most nutrients: Energy 832 kcal (43%);
Protein 58 g (88%); Fiber 10.5 (50%); Fluids 564 mL (24%); vitamin A (22%); vitamin C (34%);
folate (54%); vitamin K (0.5%); Ca (74%); w-3 FA (1.8%). Caffeine 2,000 mg.
Food and Nutrition History: Enjoys cooking, willing to try new recipes.
Dietary preferences: Likes most foods, nothing I wont eat.
Food allergies / intolerances: NKA
ETOH: Drinks wine 2-3x/wk.
Weight History: Skinny in 20s, early 30s. Gained wt mid 30s. Highest wt (185 lbs) when dx
with CA.
Meals away from home: Eats out 2-3x/wk.
Restaurant Type: Greek, Thai
Who prepares food: Pt cooks, friends & family willing to help.
Where shops for food: QFC, TJs, sometimes PCC
Other nutrition notes: Financially secure

Physical Findings

GI Function: Loose BMs 4x/day, stomatitis
Sleep hx: 7-8 hrs/nt
Energy level: 2.5/5. Feels tired and weak often. Pt appears to have high energy during apt.
Stress level: 3.5/5.

Overall clinic observation: Pt speaks quickly, laughs easily, has high energy. Highly motivated.

Biochemical Data (Pertinent Labs):

Sodium 135 mEq/L (low); BUN 28 mg/dL (high); GFR 78 mL/min (low); HCT 29.5% (low); Hgb 9.6
g/dl (low); TC 215 mg/dl (borderline high); LDLc 129 mg/dl (above optimal); all other labs WNL.


Height: 64 (162.56 cm)
Weight: 178 lbs (80.91 kg)
BMI: 30.6 (Obese)

Ideal weight (Hamwi): 120 lbs (108-132 lbs)
%ideal weight: 148%
Usual weight: 185 lbs

%usual weight: 96.2%
% Wt change: 4% decrease in 6 wks.
Weight change classification: of concernmonitor throughout tx
Desired weight: n/a; pt expresses desire to lose wt.
Adjusted BW: 132 lbs (60 kg); Upper end of IBW range

Estimated Needs / Nutrition Prescription

REE/ Kcals:
Mifflin St. Jeor: 1,388 kcal REE
REE x AF (1.1 - 1.2; obese) x IF (1.3 - 1.4; cancer) = 2,000-2,165 kcal

Protein (g/kg): 60-72 g
Adj. BW (kg) * 1.2-1.4 g/kg = 72-84 g

Fluids (ml/kg): 2.4 L/d
BSA (M2) = [the square root of (Wt (kg) x Ht (cm)] 60

= [the square root of (60 kg x 162.56 cm)] 60

= 1.646

BSA x 1500 = ml fluid needs

1.646 x 1500 = 2,469 ml; 2.4L

Fiber (g/day): <10 g/d (Low Residue)
Other: n/a

Nutrition Diagnosis

Problem: Undesirable food choices (NB-1.7)
Etiology: Food and nutrition-related knowledge deficit of how to support GI health during
chemotherapy tx to alleviate diarrhea
Signs and Symptoms: referral from doctor, typical intake reflects consumption of potential gut
irritants (caffeine, dairy, occ ETOH), and loose stool up to 4x/day.

Problem: Inadequate fluid intake (NI-3.1)
Etiology: knowledge deficit about appropriate fluid intake for chemo tx
Signs and Symptoms: typical intake 23.5% of calculated fluid needs per BSA calculation

Nutrition Intervention and Professional Goals

Intervention 1: Nutrition EducationContentRecommended Modifications (E1.5)
Educated pt about how to support GI health during chemotherapy tx to alleviate diarrhea.
Introduced pt to the Low-Residue diet and discussed possible meal suggestions to comply with
Low-Residue diet while maintaining nutrient needs. Provided Low-Residue handout.
Goal: at f/u apt in 2 wks, pts diet will show compliance with Low-Residue diet and pt will report
daily reduction in diarrhea occurrences to improve management of chemotherapy for colon CA.

Intervention 2: Nutrition EducationContentPriority Modification (E1.2)
Educated pt about increasing fluid intake to maintain hydration with diarrhea throughout
chemotherapy tx. Discussed ways to incorporate liquid into meals via smoothies, soups, and
beverages. Encouraged pt to increase fluid intake b/w meals by keeping a water bottle
throughout the day. Suggested fruit-infused water to improve palatability and enjoyment.
Goal: on f/u pts diet will show consumption of 2.4 L/d of fluids to maintain hydration with
diarrhea due to chemotherapy tx.

Follow up: address super dose intake of vitamins E (1,500% RDI) and C (500%), assess calorie
intake (currently 54% of needs), wt loss goals, PA, omega-3s, PRO, bioactives, glutamine,
Handouts provided: Low-Residue/Low-Fiber Diet handout, Diarrhea handout, smoothie recipes,
fruit-infused water recipes
Involvement in appointment: Active