Professional Documents
Culture Documents
Study
October 9, 2015
Amanda Lambrechts
Illinois State University Dietetic Intern
Objectives
Patient Introduction
Age: 57 y.o.
Height: 51
Weight: 86#
Family Responsibility:
independent,
widowed
Date of Admission:
9/14/15 at 2310
Attending
Physician(s): Dr.
Jaydev Jani and Dr.
Jerry Antonini
Vertigo
Diverticular ds
Asthma
Diverticulosis
Pancreatitis
Non-compliance
Osteopenia10/13
COPD
Cholecystectomy, laparoscopy2010
Cataract removal
Present Admission
Diagnosis/Problem List:
Physical Examination
Cachexia
Pt is a current 1 ppd smoker who comments that she has cut back a lot recently
Potassium
15-Sep
125
4.1
16-Sep
133
4.6
25-Sep
135
5.1
Normal Ranges:
Creatinine
15-Sep
11
0.6
18
16-Sep
0.58
14
0.56
14
25-Sep
Normal Ranges:
BUN/Cr Ratio
Albumin
3.5
9/15
0511
0817
1316
1752
2122
81
133
159
141
97
0814
0838
1248
1756
2132
63
126
135
173
0854
0917
0933
1243
1703
9/16
0819
1321
1629
2112
66
82
164
211
132
9/18
65
82
88
145
118
Hypoglycemic Consults
PharmacyNoted Metformin d/cd on 9/16 and thought should add back in since
doesnt significantly contribute to hypoglycemia, plus pt is on steroid
Pharmacysame recommendations
78% IBW
Barriers: c/d, SOB while eating secondary to COPD, difficulty chewing food
Estimated needs
1750-2000kcal/day (35-40kcal/kg)
So-so appetite, pt does shopping and lives alone, unintentional wt loss post 2010 surgery
Malnutrition Diagnosis:
Other protein malnutrition given Alb 3.5 and 99% UBW. BMI is 16.28 which is severe
underweight, which appears to be normal for pt.
Follow-up: 9/18
Consistent wt
Constipation
Hopeful that rescheduled appointment will help solve chewing difficulties and
enjoy food more
Occurrence
COPD (continued)
Etiology
Symptoms:
Related Diseases
Emphysema
Chronic bronchitis
18 studies reviewed
Six studies
Eight studies
Six report reduced serum and/or tissue levels of vitamins A, C and/or E in people
with COPD
Medications:
PT 5x week
Respiratory Therapy
General progress:
Follow-up Plans
References
American Thoracic Society / European Respiratory Society Task Force. (2004). Standards for the
diagnosis and management of patients with COPD (Version 1.2). New York: American Thoracic
Society.
Centers for Disease Control and Prevention. (2012). 6.3% of U.S. adults report having COPD.
Retrieved from http://www.cdc.gov/Features/COPDAdults?
Centers for Disease Control and Prevention. (2013). Deaths and mortality. Retrieved from
http://www.cdc.gov/nchs/fastats/death/htm
National Heart, Lung, and Blood Institute. (2013). How is COPD treated?. Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment.
National Heart, Lung, and Blood Institute. (2014). What causes COPD?. Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/copd/causes
Questions??