UHU UNIVERSITY HOSPITAL BED # 1 DATE: 8/30 TIME: 1700 ADMISSION DATABASE Yellow PRIMARY PERSON TO CONTACT: Name: Maria Rodriguez DOB: 12/19 (age 38) Physician: A. Gustaf, MD ☐ Green ☐White Name: Emilio Santiago (brother) TRIAGE STATUS (ER ONLY): ☐ Red Initial Vital Signs Home #: 555-212-7890 TEMP: 102 RESP: 32 SAO2: HT (in): WT (lb): 110 5'2" UBW 145 B/P: 78/60 PULSE: 68 LAST TETANUS 5 years ago LAST ATE yesterday LAST DRANK water 1 hour ago Work #: 555-213-4563 ORIENTATION TO UNIT: ☑Call light ☑Television/telephone ☑Bathroom ☑Visiting ☑ Smoking ☑Meals ☑Patient rights/responsibilities CHIEF COMPLAINT/HX OF PRESENT ILLNESS "I found out I had an ulcer 2 weeks ago. Last night I seemed to have gotten worse. I have been vomiting, and I have diarrhea. My pain is terrible. I think I have blood in my vomit and my diarrhea." ALLERGIES: Meds, Food, IVP Dye, Seafood: Type of Reaction Codeine causes nausea and vomiting. PREVIOUS HOSPITALIZATIONS/SURGERIES For delivery of her two daughters only PERSONAL ARTICLES: (Check if retained/describe) ☐ Contacts ☐ R ☐ L ☑Jewelry: wedding band ☐ Other: VALUABLES ENVELOPE: Valuables instructions ☐ Dentures ☐ Upper ☐ Lower INFORMATION OBTAINED FROM: ☑ Patient ☑Family ☐ Previous record ☐ Responsible party Maria Rodriquez Home Medications (including OTC) Medication bismuth subsalicylate metronidazole tetracycline omeprazole Signature Codes: A Sent home Dose B=Sent to pharmacy Frequency Time of Last Dose Code C=Not brought in Patient Understanding of Drug 525 mg 4 x daily this AM C yes 250 mg 4 x daily this AM C yes 500 mg 4 x daily this AM C yes 20 mg 2 x daily this AM C yes Do you take all medications as prescribed? ☑ Yes ☐ No If no, why? PATIENT/FAMILY HISTORY ☐ Cold in past two weeks ☐ Hay fever ☐ Emphysema/lung problems TB disease/positive TB skin test ☐ Cancer ☐ Stroke/past paralysis Heart attack ☐ Angina/chest pain ☐ Heart problems RISK SCREENING Have you had a blood transfusion? ☐ Yes ☑ No ☑ Yes ☐ No ☐ High blood pressure ☐ Arthritis Claustrophobia Circulation problems Easy bleeding/bruising/anemia Sickle cell disease ☐ Liver disease/jaundice ☐ Thyroid disease ☑ Diabetes Maternal grandmother ☐ Kidney/urinary problems ☑ Gastric/abdominal pain/heartburn Patient Hearing problems Glaucoma/eye problems Back pain ☐ Seizures ☑ Other Father and grandfather had ulcer disease FOR WOMEN Ages 12-52 Do you smoke? Is there any chance you could be pregnant? ☐ Yes ☑ No If yes, how often? If yes, how many pack(s)? 1.5/day for 15 years Does anyone in your household smoke? ☑ Yes ☐ No Do you drink alcohol? ☐ Yes When was your last drink? If yes, expected date (EDC): Gravida/Para: 2/2 ☑ No ALL WOMEN How much? Do you take any recreational drugs? Yes ☑ No Date of last Pap smear: Feb. of this year Do you perform regular breast self-exams? ☑ Yes ☐ No If yes, type: Route: ALL MEN Frequency: Date last used: Do you perform regular testicular exams? ☐ Yes ☐ No Additional comments: × Sophia MaMillan, t Signature/Title V. Nutrition Intervention 30. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 31. What nutrition education should this patient receive prior to discharge? 32. Do any lifestyle issues need to be addressed with this patient? Explain.

UHU UNIVERSITY HOSPITAL BED # 1 DATE: 8/30 TIME: 1700 ADMISSION DATABASE Yellow PRIMARY PERSON TO CONTACT: Name: Maria Rodriguez DOB: 12/19 (age 38) Physician: A. Gustaf, MD ☐ Green ☐White Name: Emilio Santiago (brother) TRIAGE STATUS (ER ONLY): ☐ Red Initial Vital Signs Home #: 555-212-7890 TEMP: 102 RESP: 32 SAO2: HT (in): WT (lb): 110 5'2" UBW 145 B/P: 78/60 PULSE: 68 LAST TETANUS 5 years ago LAST ATE yesterday LAST DRANK water 1 hour ago Work #: 555-213-4563 ORIENTATION TO UNIT: ☑Call light ☑Television/telephone ☑Bathroom ☑Visiting ☑ Smoking ☑Meals ☑Patient rights/responsibilities CHIEF COMPLAINT/HX OF PRESENT ILLNESS "I found out I had an ulcer 2 weeks ago. Last night I seemed to have gotten worse. I have been vomiting, and I have diarrhea. My pain is terrible. I think I have blood in my vomit and my diarrhea." ALLERGIES: Meds, Food, IVP Dye, Seafood: Type of Reaction Codeine causes nausea and vomiting. PREVIOUS HOSPITALIZATIONS/SURGERIES For delivery of her two daughters only PERSONAL ARTICLES: (Check if retained/describe) ☐ Contacts ☐ R ☐ L ☑Jewelry: wedding band ☐ Other: VALUABLES ENVELOPE: Valuables instructions ☐ Dentures ☐ Upper ☐ Lower INFORMATION OBTAINED FROM: ☑ Patient ☑Family ☐ Previous record ☐ Responsible party Maria Rodriquez Home Medications (including OTC) Medication bismuth subsalicylate metronidazole tetracycline omeprazole Signature Codes: A Sent home Dose B=Sent to pharmacy Frequency Time of Last Dose Code C=Not brought in Patient Understanding of Drug 525 mg 4 x daily this AM C yes 250 mg 4 x daily this AM C yes 500 mg 4 x daily this AM C yes 20 mg 2 x daily this AM C yes Do you take all medications as prescribed? ☑ Yes ☐ No If no, why? PATIENT/FAMILY HISTORY ☐ Cold in past two weeks ☐ Hay fever ☐ Emphysema/lung problems TB disease/positive TB skin test ☐ Cancer ☐ Stroke/past paralysis Heart attack ☐ Angina/chest pain ☐ Heart problems RISK SCREENING Have you had a blood transfusion? ☐ Yes ☑ No ☑ Yes ☐ No ☐ High blood pressure ☐ Arthritis Claustrophobia Circulation problems Easy bleeding/bruising/anemia Sickle cell disease ☐ Liver disease/jaundice ☐ Thyroid disease ☑ Diabetes Maternal grandmother ☐ Kidney/urinary problems ☑ Gastric/abdominal pain/heartburn Patient Hearing problems Glaucoma/eye problems Back pain ☐ Seizures ☑ Other Father and grandfather had ulcer disease FOR WOMEN Ages 12-52 Do you smoke? Is there any chance you could be pregnant? ☐ Yes ☑ No If yes, how often? If yes, how many pack(s)? 1.5/day for 15 years Does anyone in your household smoke? ☑ Yes ☐ No Do you drink alcohol? ☐ Yes When was your last drink? If yes, expected date (EDC): Gravida/Para: 2/2 ☑ No ALL WOMEN How much? Do you take any recreational drugs? Yes ☑ No Date of last Pap smear: Feb. of this year Do you perform regular breast self-exams? ☑ Yes ☐ No If yes, type: Route: ALL MEN Frequency: Date last used: Do you perform regular testicular exams? ☐ Yes ☐ No Additional comments: × Sophia MaMillan, t Signature/Title V. Nutrition Intervention 30. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 31. What nutrition education should this patient receive prior to discharge? 32. Do any lifestyle issues need to be addressed with this patient? Explain.