Medical Record Documentation Form

Progress Notes
02/14/16
11:30 am

Nutrition Consult Note

Pt is a 45 y.o. male admitted to the hospital for tests related to abdominal
pain & ascites. Diagnosed over 6 months ago with hepatitis with a fatty
liver. Wt. 68.2kg, Ht. 71 in. BMI 20.9. IBW 78.2kg, %IBW 87%. Labs
ALT 260, AST 320, Alk Phos 470, Total Bilirubin 2.5. Pt states he
abstained from alcohol for 6 months and then started to drink again a few
weeks ago. Needs 2400 kcals & 102 g of protein. Current diet: Low
Sodium (1g) Diet. Pt does not like low sodium diet, oral intake has been
small over the past 2 days due to dislike of food and NPO status for tests.
Inadequate oral intake related to increased needs and lack of interest as
evidenced by NPO status, Pt dislike of low sodium diet, and little intake
compared to a need of 2400 kcals.------------------------------------------------Provide education on low sodium diet for ascites. Send salt-free seasoning
with all meals. Send ensure & high protein jello with each meal. Consider
advancing diet to 2g of sodium. --------------------------------------------------Monitor pt oral intake. F/U in 2 days to assess pt intake of food and
supplements.--------------------------------------------------------------------------Sarah Fennewald, Dietetic Student