LOCAL TITLE: CLINICAL NUTRITION STANDARD TITLE: NUTRITION DIETETICS NOTE DATE OF NOTE: APR 15, 2014@13:40 ENTRY

DATE: APR 15, 2014@13:40:32 AUTHOR: BLACK,CHELSEA EXP COSIGNER: SANGER,KIAH SUZANNE URGENCY: STATUS: COMPLETED CLINICAL NUTRITION NOTE The following document contains information generated by other SORCC staff and is included with attribution to help in completeness and maintain a cohesive document for later reference. ----------------------------------------------------------------------------[x]INITIAL ASSESSMENT [ ]FOLLOW-UP ASSESSMENT [x]CHART REVIEW, PATIENT NOT PRESENT ----------------------------------------------------------------------------ADMISSION DATE:4/9/14 ANTICIPATED DISCHARGE DATE:UNKNOWN REASON FOR ADMISSION:ETOH CURRENT DIET ORDER: N/A PREVIOUS NUTRITION STATUS LEVEL: N/A - ASSESSMENT ANTHROPOMETRICS: ---------------------AGE:53 SEX:MALE HEIGHT:72 in [182.9 cm] (04/09/2014 09:41) WEIGHT (current): 169 lb [76.8 kg] (04/09/2014 09:41) BMI:23.0 IBW:178(+/-10%) IBW%:95% WEIGHTS HISTORY: SVSO - Vital Select Outpat. Measurement DT WEIGHT LB(KG)[BMI]

01/30/2014 12:55 12/09/2013 12:49 12/11/2012 08:24

177(80.29)[24] 181(82.10)[25] 191(86.64)[26]

Nutrition-Focused Physical Findings -----------------------------------Food Allergies:No Ethnic/Religious Food Preferences:No Skin Breakdown/Concerns: No Chewing/Swallowing Issues: No Nausea or Vomiting:No Diarrhea or Constipation: No NUTRITION RELATED MEDICAL DX/PMH: N/A ACTIVE NUTRITION RELATED MEDICATIONS: SEE MED LIST Active Inpatient and Outpatient Medications (including Supplies): LABORATORY DATA: [X]REVIEWED, SEE "LABS" TAB IN CPRS BP:123/76 (04/09/2014 09:41) HgA1C: HEMOGLOBIN A1C, DIAMAT 1/28/14 15:51 5.7 7/8/13 07:38 5.7 ------------------------------------------------------------------------------ PROVIDER SECTION OF H&P "COPIED" BELOW, DATED (4/10/14): Plan: 1.medications reviewed, side effects and efficacy discussed 2. At the patient's request she will be started on Wellbutrin for help in smoking cessation and will be given some mirtazapine for insomnia as he says trazodone gives him side effects and hydroxyzine at this time is not working. He will also begin some triple antibiotic ointment for his apparent needle inflammation 3. Mental health consult for evaluation of the patient's history of depression 4. As noted the patient strongly advised to completely stop smoking.

------------------------------------------------------------------------------------------------------------------------------------------------------------ NUTRITION DIAGNOSIS & INTERVENTIONS [x]NO NUTRITION DIAGNOSIS AT THIS TIME NUTRITION STATUS LEVEL: I (MCM 11-006 Attch-A) SECTION-A: NUTRITION HISTORY None of the above(1) SECTIONS-B: RECENT UNINTENTIONAL WT LOSS: < 10% in 6 mo(2) SECTION-C: WEIGHT AS A % OF IBW OR BMI Current BMI: 18.5-24(1) % IBW: 90-119(1) HT:72 in [182.9 cm] (04/09/2014 09:41) WT (current): 169 lb [76.8 kg] (04/09/2014 09:41) BMI:23.0 SECTION-D: DIET ORDER Regular (heart healthy)(1) SECTION-E: DIAGNOSIS Substance abuse, recent within past 30 days(2) SECTION-F: ALBUMIN Alb > or equal to 3.4g/dL OR PreAlb 17-42(mg/dL)(1) NUTRITION STATUS RISK FACTORS: unintentionial wt loss - MONITORING & EVALUATION SUMMARY/EVAL: - Wt status reveals steady wt loss since 12/11/12. Pt has lost 15-20 lbs in the last 6 months. Plan on seeing pt to discuss recent wt loss. Labs reviewed: - No signs of diabetes evidenced by normal A1c and gluc levels. - Documented BP is WNL - LDL 139; chol 206

- No signs of anemia - No signs of electrolyte imbalances - Alb WNL PLAN & FOLLOW-UP: 1. Monitors: weight 2. Diet Order: regular 3. Assigned nutrition status level I, pt will be seen by RD to discuss wt gain. /es/ CHELSEA BLACK OHSU Dietetic Intern Signed: 04/15/2014 15:43 /es/ Kiah Sanger, B.S., R.D. Clinical Dietitian Cosigned: 04/15/2014 15:55