Nutrition Assessment Reason for assessment: Consult request: unplanned wt loss, poor PO intake prior to admit Subjective: Pt states

she has lost about 20 lbs in the past few weeks secondary to quitting weed. he states she does not ha!e an appetite to eat if she is not on weed. "er parents want her to get a medical mari#uana card, but she is not sure if she will be able to afford it. $old pt we will discuss other options for meeting her caloric needs once she is no longer %PO. Objective: &ge: 2' y.o. "t: ()2.) cm *)+,- e.: /emale &dmit 0t: 12.3 kg &dmit 456: 2(.3 *no edema mentioned in chartDiet Orders: Procedures 7 8iet %PO Pt has been %PO since admit &llergies: %o known food allergies. Other &llergies: 9ortab asa: Penicillins: Prednisone: ;ancomycin analogues: and <osyn &dmission 8iagnosis: &bdominal pain =2>3.00? 8iagnosis: %O5@8 C$*A1. Abdominal pain Pt found to ha!e small bowel obstruction Pt is on third week of treatment for pneumonia Past Medical Histor 8iagnosis 7 Brinary tract infection 8ate (333 Normal renal US 7 ;ascular in#ury 20(' of left popliteal &48O56%&9 P&6%

artery Vascular injury to the left popliteal artery discovered on hospitalization 2009. She had a popliteal endarterectomy in January 2010 y !r. ". #resuma ly occurred $ith sno$ oardin% accident 7 8epression 20(+ .&istory of !epression on #rozac. 'n 2012( Suicide attempt $ith slittin% $rists. &ospitalized in )*12. !ru% and alcholol a use. +ollo$ed y !r. , !- N-" US. /0V-1 2'"& #3-/4,. &istory of alcohol use 7 Cilbert syndrome 20(0 .levated iliru in $ith normal liver function tests in the past. She is on ursodiol. &er elevated iliru in $as thou%ht to e due to 5il ert syndrome. 7 C/ *cystic fibrosis200+ She has %ro$n Staphylococcus aureus( pseudomonas in the past. &er last pseudomonas $as in July 2009. She didhave a sputum culture $hich %re$ phaeococcomyces dermatitides in 6arch of 2011. 'n the past( she has had a reaction to cefazolin and ceftazidime( $hich caused an elevation in her liver function tests( ut in !ecem er of 2010( $hen she developed an aller%y to /osyn( she did not have a reac 7 Pancreatic insufficiency 20(' #ancreatic insufficiency. She has developed hi%h su%ars on admissions( associated $ith prednisone use( and has een re7uired to e on insulin. -n her most recent hospitalization( she did not re7uire any insulin. &er su%ars have returned to normal $hen she has een ta8en off the prednisone. &er hemo%lo in 41, values have een normal in the past. 7 /atty li!er 20(2 +atty chan%es in her a dominal ultrasound in Novem er 2009( pro a ly consistent $ith cystic fi rosis. She had repeat ultrasound in 200: and 200;( $hich sho$ed

sta le spleen and liver size. 4s mentioned a ove( she $as started on ursodiol in 200). She has had ne%ative hepatitis serolo%ies( 4N4( 4N,4( 4S,4. 2ith on%oin% a dominal pain( she has had an upper 5' $ith a normal terminal ileum se%ment. . 7 5igraine 20(2 She had 63' and ," done in 200:( $hich sho$ed impacted sinuses. She has een follo$ed y !r. + in 200:. She has een seen y !r. 6. She $as felt to have classic mi%raines $ith visual aura precedin% her headaches. She has %otten her est response from #hener%an. 7 O!arian cyst 20(2 <ar%e ovarian cyst removed in 2012 7 C@A8 *gastroesophag eal reflu. disease5igraine &llergic rhinitis 0eight loss Pneumonia Coughing up blood &n.iety $rouble in sleeping hortness of breath Chest pain

7 7 7 7 7 7 7 7 7

Past urgical "istory Procedure 9aterality 8ate

&ppendectomy

2002 Normal appendi=. She had si%nificant respiratory distress after anesthesia ut su se7uently has tolerated anesthesia $ell.

7 7

O!arian cyst remo!al Central !enous catheter insertion %asal sinus surgery inus surgery

20(2 20(2

7 7

!ab Results Component %& E C9 CO2 C9B 4B% ;alue ('2 '.2 (0( 23.0 ((2F )F 8ateD$ime 20(+ ):22 &5 20(+ ):22 &5 20(+ ):22 &5 20(+ ):22 &5 20(+ ):22 &5 20(+ ):22 &5

Creatinine, erum: 0.11 20(+ 0):22 "emoglobin &(C: ).( 20(' 03:++ 5eds include: dulcola., cipro, Gofran %utrition risk factors: unplanned wt loss, poor PO intake prior to admit, C@A8, cystic fibrosis Assessment: "tDwt status:normal PO 6ntake is inadequate: pt has not had anything to eat since admit Aisk for nutritional deficit:high

8ue to wt loss of ('H usual body wt in #ust a few weeks, pt is at high risk for malnutrition. Plan: 5onitor PO intake and diet progression per nutrition protocol PO goal 21H of full liquids and solids Aecommendation: discuss supplements and calorie needs with pt once PO intake resumes

Nutrition "ollo# $p: Objective: Aesults for 20(+ 03:'2 'D2D20(+ 01:0+ odium: ('+ *9Potassium: +.( Chloride: (0' CO2 I Carbon 8io.ide: 2>.0 4B%: J( *99Creatinine, erum: 0.1( Clucose: (>' *"Current wt: )0 kg *('2 lb +.+ oG- *no edema notedDiet Orders: Procedures 7 8iet %PO Assessment: Pt remains %PO after laparoscopic cholecystectomy 2 days ago. Pt has been %PO since the +th and had poor intake and significant wt loss prior to admission. Pt is at high risk for malnutrition. Plan: 5onitor diet progression and tolerance per nutrition protocol PO goal 21H of full liquids and solids Aecommendation: pro!ide high calorie, high protein supplement once PO intake resumes

6f ileus continues for more than 2 days, consider $P%

Nutrition "ollo# $p: Subjective: Pt states she is eating ok and that she has some appetite now. he states that she ate Chinese food last night and that it tasted good and didnKt hurt her stomach. Pt states she does not like protein drinks because they are too sweet. $old pt 6 will send 2I' oral supplements with her lunch today for her to try. he knows to tell her nurse if she likes any of them so that it can be sent $68 with trays. &lso discussed beneprotein powder with pt and her dad as a good option for after discharge. PtKs dad sounds !ery interested and willing to purchase this for his daughter. 8iscussed that it is tasteless and can be added to soups and other foods to increase protein intake. Pt discussed con!ersation with physician about hemoglobin &(C le!el. 8iscussed with pt the importance of trying to eat carbohydrates with protein and fat to slow glucose absorption and reduce risk of high blood sugar. Objective: Aesults for20(+ 03:'3 'D>D20(+ 0+:22 odium: ('2 Potassium: '.3 Chloride: (02 CO2 I Carbon 8io.ide: '2.0 *"4B%: J( *99Creatinine, erum: 0.10 Clucose: (12 *""emoglobin &(C: ).' *"- 'D>D20(+ 0+:22 Current wt: )2.3(+ kg *('> lb ((.2 oGDiet Orders: Procedures 7 8iet Aegular: Les I patient to order food: C6 oft Assessment: Pt and ptKs father were !ery recepti!e to discussing ptKs increased calories and protein needs. $hey seem willing to try beneprotein after discharge. Pt would really benefit from taking an oral protein supplement

@le!ated hemoglobin &(C: pt will get blood sugar checked again after discharge to determine whether she has de!eloped cystic fibrosis related diabetes. /ortuity, pt does not show ob!ious physical signs of muscle or fat wasting in her face, arms, and collar bone area. Plan: Continue to monitor PO intake and labs per nutrition protocol PO goal 21H Can pro!ide further education on carbohydrates counting and meal planning upon request 0ill send no!asource renal *becasue it is not !ery sweet-, 4reeGe, and chocolate C64 with beneprotein with lunch tray for pt to try. Pt knows to tell nurse if she like any of them and to ha!e it sent $68.