Progress Report Overview
Actions
Student: Oscar Solorzano
Patient Data
DOB: 11/09/1966
MR#: MR11130
Admit Date: 02/26/2018
Notes
Note at 02/26/2018 15:19:59
ADIME Note
Basic Information
Assessment
Dale Mer
...
Progress Report Overview
Actions
Student: Oscar Solorzano
Patient Data
DOB: 11/09/1966
MR#: MR11130
Admit Date: 02/26/2018
Notes
Note at 02/26/2018 15:19:59
ADIME Note
Basic Information
Assessment
Dale Merrick Basic Documentation
Student: Oscar Solorzano
Activity Start: 02/26/2018 14:19:53
Activity Completion: 03/12/2018 14:25:24
Activity Completion: 03:56:50
Patient: Dale Merrick
Age/Sex: 51 yo M
Location: General Hospital
Date:
02/26/2018 15:19:59
Author:
Oscar Solorzano
Location:
General Hospital
Diagnosis:
Ascites
S/p Paracentesis w/ spontaneous bacterial peritonitis
Anthropometric history
Client history:
Chronic Liver Failure
Hepatic Encephalopathy
Confusion
HTN
ETOH abuse x 25y
Nutrition-related medications:
Aldactone (K+ sparing diuretic) - Avoid high K intake, supplements, salt substitutes; may increase
Zn excretion.
Lasix (Loop diurectic) maintain adequate intake of K+, Mg, Ca; avoid natural licorice.
Inderal (Beta-blocker) monitor glucose, avoid natural licorice.
Lactulose (non-absorb-able disaccharide to retain ammonia induce diarrhea)
MVI (Multivitamin)
Height:
5'11"
Weight at admission:
172 lb
Current Weight:
163 lb
BMI:
23
Weight assessment:
Pt current wt following paracentesis 163 lbs (172 lbs upon admission)
Normal BMI
Feeding Ability
Independent
Oral Motor
Intact
Skin Assessment
Intact
Nutrition Recommendations
Biochemical data, medical tests and procedures:
Glucose: High (201mg/dL) - Liver dz; beta blocker Inderal.
Sodium: Low (133 mEq/L) - Edema
Potassium: Low (3.3 mEq/L) - Edema; diuretics
Chloride: High (111 mEq/L)
Albumin: Low (1.9 g/dL) - Liver dz, effect on Alb production.
ALT: High (79 IU/L) - Liver dz.
AST: High (178 IU/L) - Liver dz.
PT: High (18) - Liver dz, effect on clotting factors.
Platelet: Low - clotting factor
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