CLINICAL:

74 yo M with biliary obstruction. GI surgery is planned February. PMH: Gout, HTN, aortic stenosis, several months of vertigo symptoms SUBJECTIVE: Patient is alert, speaking clearly, and looking forward to possible discharge tomorrow. MEDICATIONS OF SIGNIFICANCE: 1) Acetaminophen tab 325-650mg po q4h prn indication: for pain. hold while patient taking vicodin (hydrocodone/acetaminophen) 2) Aluminum/magnesium/simeth susp,oral 30 ml po bid prn for acid suppression/gas 3) Calcium carbonate tab 325mg po tid prn indigestion 4) Dextrose 50% inj,soln 1 (50ml) syringe ivp prn indication: for treatment of hypoglycemia per hypoglycemia protocol. 5) Docusate cap,oral 100mg po bid 6) Fentanyl patch 50 mcg patch pa q72h 7) Glucagon inj 1mg/1vial sc prn indication: for treatment of hypoglycemia per hypoglycemia protocol. 8) Glucose gel,oral contents of 1 tube po prn indication: for treatment of hypoglycemia per hypoglycemia protocol. 9) Insulin regular (human) inj supplemental sc wm&bedtime for pre-meal/bedtime hyperglycemia. give mealtime suppl scale dose at cbg check time even if pt does not eat, or npo dose if npo. medium dose (bmi 25-29.9 or tdd 40-80 units/day) 10) Lidocaine patch 5% pa qday please cycle on for 12 hours and off for 12 hours. for back pain resistant to oral pain meds. * inpatient use only * 11) Omeprazole cap,ec 40mg po qam ac 12) Ondansetron inj,soln 4mg/2ml ivp q6h prn for nausea 13) Oxycodone soln,oral 5-15mg po q4h prn pain 14) Piperacillin/tazobactam inj piperacillin/tazobactam 3.375 gm in iso-osmotic 50 ml infuse over 30 minutes ivpb q6h 15) Polyethylene glycol powder,oral 1 packet (17 gm) po daily prn dissolve in 4 to 8 oz of liquid of choice; hold for loose stools. LABS: ALBUMIN 3.3 L 01/17/2013 05:30 PREALBUMIN 6.6 L 01/15/2013 05:30 CHEM 7 PANEL 01/17/2013 05:30 GLUCOSE 105 UREA NITROGEN 6 L

 CREATININE 0.6 L SODIUM 135 POTASSIUM 4.0 CHLORIDE 98 CO2 25 ANION GAP 16 EGFR 132 PHOSPHATE 2.4 L 01/14/2013 04:16 MAGNESIUM 2.5 01/17/2013 05:30 WBC 9.1 01/17/2013 05:30 HGB 9.4 L 01/17/2013 05:30 HCT 28.6 L 01/17/2013 05:30 LIVER FUNCTION PANEL 01/17/2013 05:30 PROTEIN,TOTAL 6.8 ALBUMIN 3.3 L BILIRUBIN, TO 0.6 ALKALINE PHOS 235 H SGOT (AST) 35 SGPT (ALT) 77 H CBGS: 1/17/2013 107 mg/dL 1/16/2013 123 mg/dL ANTHROPOMETRICS: Weight:198 lb [90.0 kg] Ht:70 in [177.8 cm] Wt hx: 198.8# 12/14/2012 212# 11/14/2011 BMI: 28.5 IBW = 166 lbs 75.5 kg %IBW = 119.28 PHYSICAL ASSESSMENT/FUNCTIONAL STATUS: Overall Appearance: Patient is alert with good color, speaking clearly. DIETARY/ALIMENTATION/ELIMINATION: Current Diet: Listed Items diet with full liquids and progressing PO Intake = Pt ate oatmeal and Boost drink this morning. Diet History: NPO to Full liquid diet - soft foods as tolerated IV FLUIDS:600 mL I/O: 2340/2945 (-600mL) N/V: No report of N/V

 NUTRITION DIAGNOSIS: Suboptimal enteral nutrition related to lack of appetite and poor GI function as evidenced by low prealbumin labs and poor PO intake. NUTRITION STATUS: Moderately compromised ESTIMATED NUTRITION NEEDS: Calories = 1967 kcals (MSJ x 1.2 AF) Protein = 108 g (kg x 1.2) Fluid = 2000 mL (1 mL/kg) NUTRITION RECOMMENDATIONS/INTERVENTIONS: 1. Spoke with patient regarding foods available and ability to eat at home if discharged tomorrow. Patient reported his wife will be cooking and assisting him with ADL's. He stated he felt he could eat soft, high protein items such as: canned tuna, canned white meat chicken, eggs, and lean ground beef. Recommended he avoid high fiber foods to help from having early satiety and fullness. Patient also said applesauce and mashed potatoes would be an option he could tolerate. Patient was concerned about his CBG's and wanted to avoid all sugary items. Changed his supplement to Boost Chocolate Glucose Control to assist with controlling his blood sugars. 2. Recommended patient drink a complete supplement such as Ensure or Impact prior to surgery. Recommended he drink Ensure each day going forward or order Impact from local pharmacy and drink 3 boxes each day for 5 days prior to scheduled surgery to help with pre-surgery nutrition and post-surgery healing. NUTRITION MONITORING: 1. Continue to monitor for timely nutrition and adequacy of nutrition received, labs and I/O's. NUTRITION GOALS: 1. Increase PO nutrition as tolerated to goal of 2000 kcals per day and 108g protein. 2. Maintain and improve current nutrition status prior to surgery in February. F/U: RD to monitor as needed.