Progress Report Overview

Student: William McGinty

Activity: Richard Goldman

Start Time: 10/24/2019 21:03:42

End Time: 10/30/2019 14:09:46

Total Time: 03:36:55

Actions

Note at 10/30/2019 14:07:19

Richard Goldman Documentation
Student: William McGinty
Activity Start: 10/24/2019 21:03:42
Activity Completion: 10/30/2019 14:09:46
Activity Completion: 03:36:55

Patient Data

Patient: Richard Goldman DOB: 03/30/1958

Age/Sex: 61 yo M MR#: MR620390
Location: General Hospital ER Admit Date: 10/24/2019

Notes

Note at 10/30/2019 08:22:51

ADIME Note

Basic Information

Date:

10/30/2019 08:22:51

Author:
William McGinty

Location:
General Hospital ER

Patient name:

Richard Goldman

Date:

10/30/19

Assessment

Diagnosis:

Rule out Myocardial Infarction

Age:

61
Gender:

Race:

Caucasian

Ethnicity:

N/A

Client History

Medical history:

Pt has Hypercholesterolemia, Borderline Hypertension, Sleep Apnea. Pt involved in a motor vehicle accident 23 years ago
where he sustained a fractured clavicle, left side atelectasis and fractured sternum. There have been no further
complications from these injuries.

Medical diagnoses:

Rule out Myocardial Infarction

Family history:

Pt has a family history of cardiovascular disease on his paternal side. Pt has a family history of breast cancer on his
maternal side.

Social history:

Pt has a long history of obesity, lives a sedentary lifestyle, and is inactive. Pt is not a smoker and drinks alcohol at social
gatherings. He is recently divorced with 3 children who are 12, 15, and 17 years old. The children do not live with him, but
they live in the same town. Pt only sees them 2-3 times a month. Pt is a newspaper editor and is under a lot of stress at
work. The company the Pt works for is under financial duress and there are rumors of potential layoffs.

Current medications:

dextrose 5 % / sodium chloride 0.45 % Injectable Solution

heparin sodium, porcine 10,000 UNT per 100 ML Injectable Solution
heparin sodium, porcine 5000 UNT per 0.5 ML Prefilled Syringe

Nutrition-related medications:

N/A

Current supplements:
 N/A

Anthropometric history

Height:

73in/185.42cm

Weight at admission:

275lbs/125kg

Current Weight:

N/A

BMI:

36.3 (Obese-class II)

% Weight change:

N/A

IBW:

184lbs

% IBW:

149% (Obesity)

UBW:

N/A

% UBW:

N/A

Weight assessment:

Pt reports no significant changes in weight changes. Pt is obese per BMI/IBW.

Biochemical history, medical tests, labs, and procedures:

Glu - 120 H Possibly due to stress/obesity

HDL - 33 L Possibly due to family hx of cardiovascular dz/obesity
LDL - 150 H Possibly due to family hx of cardiovascular dz/obesity
Triglycerides - 175 H Possibly due to family hx of cardiovascular dz/obesity
Nutrition Focused Physical Exam

Edema
+1

Feeding Ability

Independent

Oral Motor

Intact

If other, please explain:

Trace bilateral ankle edema - unknown classification

Food and Nutrition History

Current diet order:

Regular

Assessment of usual intake:

Pt reports no changes in appetite. Usually has a good appetite.

Assessment of current intake:

N/A

Supplements/herbals:

N/A

Food allergies and intolerances:

NKA

Intake and digestive problems:

N/A

Assessment of Nutritional Status/Nutrition Risk

 No malnutrition noted

Malnutrition criteria met per current malnutrition guidelines:

N/A

Specify:

N/A

Specify:

N/A

Specify:

N/A

Specify:

N/A

Fluid accumulation

Specify:

Trace bilateral edema in the ankles - unknown classification

Specify:

N/A

Nutrition Recommendations

kcal/day based on:

1375-1750 kcal/day Based on 11-14 kcal/kg (ABW 125kg)

g protein/day based on:

 150-175 g/day Based on 1.2-14 g/kg (ABW 125kg)

mL fluid/day based on:

1375-1750 mL based on 1ml/kcal

Nutrition assessment summary:

Pt has a family history of cardiovascular dz on his paternal side. Has a medical history of Hypercholesterolemia, borderline
hypertension, and sleep apnea. Pt has a history of obesity, lives a sedentary lifestyle, and consumes fast food on a regular
basis. Pt is divorced and sees his children 2-3 times per month. He has a high stress job as a newspaper editor and has heard
rumors of the financial distress the company is in. Pt noted layoffs may occur in the future.

Diagnosis

Nutrition Diagnosis:

Obesity

PES Statement:

Obesity related to sedentary lifestyle with inactivity as evidenced by BMI of 36.3 (Class II Obesity)

Nutrition Intervention

Nutrition education:

Nutrition education via the importance of regular exercise/physical activity

Coordination of care:
 Refer to outpatient RD for further counseling/education

Monitoring and Evaluation

Food and nutrient intake:

Cardiac Diet
Pt will meet 100% of needs via cardiac diet within 48 hours.

Anthropometric measurements

Measured wt
Pt will lose 2lbs within 1 week.

Biochemical data:

Glucose profile
Glucose will be WNL within 5 days

Nutrition focused physical findings:

Edema
Pt will not exhibit trace bilateral ankle edema within 1 week.

Signature/credential/date:

William McGinty, DPD student, 10/30/19