DM2 Case Study Patient Data Anthropometrics Height: 6'2" Weight: 225 lbs Mr. Abdullah Oblongata DOB: 05/05/1955 New Mexico State University Dietetic Internship Labs Glucose Diet Meds Intake Consistent -Lantus 100% of tray Carbohydrate Day 1: 350, 287,250, -Novolog 2,300-2,500 300 Sliding Scale mL/day Day 2: 285, 220, 230, 215 ase read the clinical patient record, all the sections, and complete the purple lavender sections throughout the dinical record. A-Assessment 9/10 Reason for Nutrition Assessment: 65 YOM ADMITTED FOR HYPERGLYCEMIA. REFERRED TO RDN FROMP PCP FOR DIABETES NUTRITION EDUCATION. Client History (CH): note which diagnosis is the primary or admitting diagnosis CH-2.11 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-1.1.1 CH-1.1.3 CH-114 CH-1.16 Age: 65 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-2.1.3 Endocrine/metabolism: DM2 DIAGNOSED UPON ADMISSION Social History: CH-3.1.2 CH-3.14 CH-3.15 Living/housing situation (specify) UVES WITH WIFE Social and medical support (specify): WIFE DOES COOKING Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): AD-1117 AD-1.12.1 Stated Height: 188 CM (6'2") Measured Weight: 102 KG (225#) AD-1.15.1 BMI 28.9 OVERWEIGHT Nutrition Focused Physical Findings (PD) PD-115 PD-1.1.5.21 Digestive system: PT WITH GOOD APPETITE AND REPORTED EATING ALL OF HIS MEALS Increased appetite: PER PATIENT REPORT PD-1.1.13.16 Excessive thirst: PER PATIENT REPORT Vital signs: PD-1.1.21.5 PD-1.1.21.6 PD-1.1.21.7 Pulse rate: 85 BPM Respiratory Rate: 15 BREATHS PER MINUTE Temperature: 37 CELSIUS Food/Nutrition Related History (FH) Oral fluid estimated intake in 24 hours: 2300-2500 ML FLUID/DAY Estimated amount of food: 100% OF TRAY FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 Types of food/meals: PRE-SELECT MENU FH-1.2.2.3 FH-2.11.2 Modified diet order: CONSISTENT CARB ON 04/25 Meal/snack pattern: 3-5 MEALS PER DAY AT HOME
DM2 Case Study Patient Data Anthropometrics Height: 6'2" Weight: 225 lbs Mr. Abdullah Oblongata DOB: 05/05/1955 New Mexico State University Dietetic Internship Labs Glucose Diet Meds Intake Consistent -Lantus 100% of tray Carbohydrate Day 1: 350, 287,250, -Novolog 2,300-2,500 300 Sliding Scale mL/day Day 2: 285, 220, 230, 215 ase read the clinical patient record, all the sections, and complete the purple lavender sections throughout the dinical record. A-Assessment 9/10 Reason for Nutrition Assessment: 65 YOM ADMITTED FOR HYPERGLYCEMIA. REFERRED TO RDN FROMP PCP FOR DIABETES NUTRITION EDUCATION. Client History (CH): note which diagnosis is the primary or admitting diagnosis CH-2.11 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-1.1.1 CH-1.1.3 CH-114 CH-1.16 Age: 65 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 Patient chief nutrition complaint: HUNGRY/THIRSTY AND WANTS MORE FOOD AND DRINKS EVEN AFTER EATING/DRINKING CH-2.1.3 Endocrine/metabolism: DM2 DIAGNOSED UPON ADMISSION Social History: CH-3.1.2 CH-3.14 CH-3.15 Living/housing situation (specify) UVES WITH WIFE Social and medical support (specify): WIFE DOES COOKING Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): AD-1117 AD-1.12.1 Stated Height: 188 CM (6'2") Measured Weight: 102 KG (225#) AD-1.15.1 BMI 28.9 OVERWEIGHT Nutrition Focused Physical Findings (PD) PD-115 PD-1.1.5.21 Digestive system: PT WITH GOOD APPETITE AND REPORTED EATING ALL OF HIS MEALS Increased appetite: PER PATIENT REPORT PD-1.1.13.16 Excessive thirst: PER PATIENT REPORT Vital signs: PD-1.1.21.5 PD-1.1.21.6 PD-1.1.21.7 Pulse rate: 85 BPM Respiratory Rate: 15 BREATHS PER MINUTE Temperature: 37 CELSIUS Food/Nutrition Related History (FH) Oral fluid estimated intake in 24 hours: 2300-2500 ML FLUID/DAY Estimated amount of food: 100% OF TRAY FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 Types of food/meals: PRE-SELECT MENU FH-1.2.2.3 FH-2.11.2 Modified diet order: CONSISTENT CARB ON 04/25 Meal/snack pattern: 3-5 MEALS PER DAY AT HOME
Chapter14: Cpt Surgery Iv
Section: Chapter Questions
Problem 8MC
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You reviewed the patient's medical chart. Now, conduct a nutrition assessment and nutrition focused physical exam on this patient. Keep in mind possible issues this patient might face based on diagnosis lab values. You might want to review your patient assessment template. You will also need to be familiar with lactose-free shakes to recommend to the patient.
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