Patient Medical History

Patient Medical History

Patient Medical History

Mr. Tyler, a 55-year-old accountant, has had a “drinking problem” throughout most of his adult life. He drinks a case of beer each day. He has lost several jobs over the years for drinking at the workplace or showing up for work drunk. He lost his driver’s license for drunk driving, and his drinking has placed a considerable strain on his marriage. He has tried several self-help programs as well as Alcoholics Anonymous, all with little success. He has been hospitalized on several occasions over the years. Mr. Tyler has a severe tremor in his hands (probably a result of excessive alcohol intake), which makes it very difficult for him to use a spoon, fork, and knife to eat.
It’s your first day on the job as a CDM/DSS/NA, and you are consulted by his physician to see him for “Feeding Problems” and “Malnutrition”. The physician is wondering if there is any way to help Mr. Tyler with eating.
You review his medical record (which is quite extensive) and begin to work through your nutrition assessment for Mr. Tyler.
Past Medical History
First Hospitalization:
You note that Mr. Tyler was first hospitalized 15 years ago at age 40 with a complaint of vomiting up blood after a binge drinking episode that lasted seven days. He had excessive and repeated vomiting episodes at that time. The vomitus was bright red.
The hospital chart listed an admitting diagnosis of “Upper GI bleed” due to repeated vomiting.

 

How do you write a medical history for a patient?

Patient Medical History

Second Hospitalization
At age 45 (10 years ago), Mr. Tyler was hospitalized again this time with complaints of upper abdominal pain and noted to have “coffee-ground” emesis. He also complained of “heartburn” (a burning sensation in the area of the sternum), which was partially relieved with antacids. A diagnosis of “upper GI bleed due to gastritis and reflux esophagitis” is noted in the chart.

Third Hospitalization
At age 55, Mr. Tyler entered the hospital with complaints of a high fever, nausea, loss of appetite, and a dull, continual pain in the left side of the back. In addition, he had diarrhea of a particularly foul odor and yellow color. He had also lost 15 pounds over the last month and a half. He lost his appetite and sometimes he has some difficulties chewing and swallowing his regular foods. He is noted to have fluid accumulation (aka edema).
Anthropometrics:
Height: 5’11
Weight: 150 lbs
Labs: Albumin 2.1 (low)
Show your work/calculations, and the formula that you used for full credit.
1. Calculate his BMI. (2 points)
2. Calculate percent weight loss. (2 points)
3. Calculate his calorie, protein and fluid needs that are appropriate for his current diagnosis. (3 points)
4. What therapeutic diet do you think is the best recommendation for Mr. Tyler? (2 points)
5. Name two guidelines that Mr. Tyler should follow on the prescribed diet. (2 points)
6. List 4 beverages that may cause distress and should be avoided on his diet. (2 points)
7. List four food items that may cause distress and should be avoided on his diet. (2 points)
8. List four food items that may beneficial and could help Mr. Tyler. (2 points)

Nutrition Care Assessment and Recommendations

 

Patient Medical History

9. Briefly explain your nutritional assessment of Mr. Tyler such as: timing of meals, consistency of foods, any social support, and supplement recommendations. What can you recommend to help him increase his nutritional intake? (4 points)

10. Design a day meal plan for Mr. Tyler (Breakfast, Lunch, Dinner, and Snack) based on dietary guidelines, therapeutic dietary recommendations and the USDA My Plate. Don’t forget to write each food item with an appropriate portion size. What is the consistency/texture of the food items? What overall texture modification, if any, do you think Mr. Tyler might need? (10 points)
Overall texture recommendation for Mr. Tyler and why: _______________________

Table is worth 8 points

Meal
Portion Size AND Food Item
Food Group
Example
½ cup oatmeal
½ cup apple juice
1 cup coffee
Grains
Fruit
Free Food
Breakfast

Lunch

Snack

Dinner

11. Complete a Medical Record Entry for the Case Study Medical Record Documentation
ADIME format charting

Nutrition Assessment

Estimated Nutrient Needs:

Nutrition Diagnosis

PES Statement:

Intervention
Nutrition Prescription Recommendations:

Interventions:

Goals:

Monitoring/Evaluation