A-Assessment 10/17 Reason for Nutrition Assessment: JUSTIN THYME WAS REFERRED TO THE RDN FOR A NUTRITION ASSESSMENT AND FORMULA FEEDING EDUCATION Client History (CH): note which diagnosis is the primary or admitting diagnosis Patient chief nutrition complaint: WORRIED ABOUT SON NOT GAINING WEIGHT (PER MOTHER REPORT) Age: 6 MONTHS CH-2.1.1 CH-1.1.1 CH-113 Sex: MALE CH-1.14 Race: AFRICAN-AMERICAN Patient/Client/Family Medical/Health History: CH-2.1.1 CH 213 CH-3.1.4 Patient chief nutrition complaint: WORRIED ABOUT SON NOT GAINING WEIGHT (PER MOTHER REPORT) Endocrine/metabolism: FAILURE TO THRIVE Social and medical support: MOTHER SAYS SHE WAS BREASTFEEDING FOR FIRST THREE MONTHS WHILE ON MATERNITY LEAVE BUT SWITCHED TO FORMULA Social History: CH-3.1.2 Living/housing situation (specify): PT LIVES WITH MOTHER Anthropometric Measurements (AD): AD-1.1.1.1 Measured Height: 19" AD-1.1.2.1 Measured Weight: 2.7 KG (6#) AD-1.1.6.9 Stature for age percentile: 1 AD-1.1.6.10 Stature for age z score:-11 AD-1.1.6.13 Weight for age percentile: 1 AD-1.1.6.14 Weight for age z score: -9.6 Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.1.10 PD-1.1.13 PD-1.1.3.9 PD-1.1.14.6 QUADRICEPS) Digestive system: PT WITH GOOD APPETITE; MOTHER SAYS HE FINISHES ALL OF HIS BOTTLES Hair: THIN HAIR Mouth: DRY MUCOUS MEMBRANES Clavicle abnormal prominence: MILDLY APPARENT CLAVICLE Quadriceps muscle atrophy: ANTERIOR THIGH DEPRESSION LINE NOTICEABLE (MODERATE MUSCLE LOSS TO PD-1.1.14.11 Pectoral muscle atrophy: MILD MUSCLE LSOS TO PECTORALIS PD-1.1.2.5 PD-1.1.2.7 REGION Loss of subcutaneous triceps fat: MILD FAT LOSS TO TRICEP Loss of subcutaneous fat overlying the ribs: MILDLY APPARENT RIB CAGE, MILD FAT LOSS TO MID-AXILLARY Vital signs: PD-1.1.21.8 PD-1.1.21.9 Pulse rate: 90 BPM Respiratory rate: 25 Food/Nutrition Related History (FH): FH-1.2.2.1 Estimated amount of food: 100% OF BOTTLES AT HOME (FIVE BOTTLES/DAY, 2 SCOOPS OF ENFAMIL PREMIUM WITH 6 OZ WATER) FH-1.2.2.2 Types of food/meals: FORMULA (AT HOME) Interview: Patient interview in narrative format: PER MOTHER REPORT PT WAS FOUND LYING IN CRIB WITH MOTHER SITTING NEXT TO CRIB. PT IS WITH GOOD APPETITE AND FINISHING ALL PROVIDED BOTTLES; PT SPITS UP A LITTLE BIT WHEN BURPED, BUT NOT A LARGE AMOUNT; PT HAS AROUND 4-6 WET DIAPERS PER DAY AND 1-2 DIRTY DIAPERS; PT DOES NOT HAVE UNUSUAL DIRTY DIAPERS "I DON'T THINK HIS ARE ANY WORSE THAN OTHER BABIES" PT MOTHER AGREES TO DIET EDUCATION ON PREPARING FORMULA AND INTRODUCING BABY FOOD. Diet Hx: PT MOTHER REPORTS PT WAS SWITCHED TO FORMULA AFTER THREE MONTHS OF BREASTFEEDING; PT MOTHER REPORTS PT IS WITH GOOD APPETITE AND FINISHES ALL HIS BOTTLES AT HOME; PT MOTHER SAYS THEY FEED HIM AROUND FIVE BOTTLES PER DAY; PT MOTHER REPORTS MIXING TWO SCOOPS OF ENFAMIL PREMIUM WITH 6 OZ WATER; PT SOMETIMES SPITS UP A LITTLE BIT WHEN HE IS BURPED, BUT NOT A LARGE AMOUNT.