ADIME ASSESSMENT: Food/Nutrition- Related History/ Client History/ Nutrition-Focused Physical Findings: Chief complaint(s) and information pertaining

to reason for hospitalization 51 y/o M, HIV+, a/w on/off fever x 1 wk and difficulty swallowing Pt c/o painful swallowing and dysphagia and is unable to tolerate food or liquids due to vomiting. Pt reports feeling something is stuck in throat, but denies reflux like symptoms. Also reports coughing X 2 wks with white sputum. Pt denies diarrhea, + 2 BMs today. Pt reports weakness and inability to get out of bed or walk on his own uses motor wheel chair. Pts wife reports pt did not take meds for past 4 days due to inability to swallow them and also wont take them crushed in applesauce. SLP consult (11/28): Puree diet w/ thin liquids. Pt requested liquid diet then denied it when learned he would not receive yogurt. Pt found to have missing teeth and N/V/D. Has experienced wt loss of 33 pounds (130 lbs 97 lbs ) over past 3 months. No diet PTA, NKFA, no vit/herbal supplements. Pt occasionally drinks Nutrimen. Food prefs: no applesauce, yogurt in am, 4 Resource frt bevs /day and broth. Pt willing to try Boost Diabetic (reports Ensure + causes diarrhea for him). Pt lives with wife, quit smoking 10 yrs ago, before he smoked 2 p/d for 35 yrs. Quit crack, marijuana and alcohol 12 yrs ago. PMH: list mainly those that are pertinent to hospitalization Biochemical Data, Medical Tests, and Procedures and Anthropometric Measurements Ht: 172.7 cm Wt: 44 kg Wt Hx: 10/17: 58.64 kg, 7/28: 57.3 kg, 6/22: 57.3 kg, 6/14: 57.3 kg, 4/20: 53.7 kg, 4/10: 57.5 kg, 3/30: 59 kg % most recent wt: 74% IBW: 63 kg 77 kg Labs: Trends 11/28: Na: 129 L, K: 3.8, Cl: 99, CO2: 22 L, BUN: 17, Glucose: 100, Protein: 8.3, alb: 3.5, T. Bil: 0.8, Ca: 8.7, creat: 0.5, sgpt: 81 H, sgot: 169 H, alk phos: 203 H, amylase: 380 H, D bili: 0.3 H Diet Order: Puree Skin: N/A Pert. Meds: HAART (tenofovir, abacavir/lamivudine), fluconazole, valacyclovir, bactrim, minocycline, filgastrim, azithromycin Estimated needs based on current weight: Calories: 1,540 kcal1,760 kcal (35 - 40 kcal/kg) Pro: 66 g 88 g (1.5 - 2 g/kg) % wt change: 25% in one month BMI: 15.2 %IBW: 57-70%

Fluid: 1,320 1,540 ml (30 35 ml/kg) Nutrition status: Pt is at high nutritional risk 2 HIV/AIDS and clinically significant weight loss. Estimated calories are adequate to replete weight, protein also appropriate for wt gain and muscle building, a protein supplement may help with this, and fluid levels appropriate to replenish losses from vomiting. Current diet of puree is appropriate per SLP recommendation if pt can tolerate and keep down sufficient foods to meet his needs. He may benefit from antiemetic PRN. Will provide oral supplements, MVI and honor pt food preferences as able to optimize PO intake/nutrition status and monitor food intake. May need to consider nutrition support if pt is unable to meet needs via PO. Labs reviewed. Noted values for WBC, RBC, HGB, HCT, MCV, MCH, MPV, Neut %, Neut #, Lymph #, mneut %, mlymph are low, c/w AIDS progression and possibly neutropenia. Low RBC, HGB, HCT, and MCV possible anemia? Na and CO2 low, likely r/t vomiting. All other labs wnl. NUTRITION Dx: Can fall into three domains intake, clinical, behavioral/environmental NI-1.4 Inadequate energy intake related to N/V/D and painful swallowing as evidenced by significant unintentional wt loss of 25% over past month. NC-3.1 Underweight related to decreased energy intake as evidenced by BMI of 15.2. INTERVENTION: Can involve: Food and/or Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care 1. Continue puree diet as tolerated 2. Recommend Boost Diabetic oral supplement x BID and Juven protein supplement 2 packets x TID (with meals)

3. RD to communicate pt food preferences to foodservice dept to optimize PO intake

4. Recommend anti-emetic and/or appetite stimulant as medically appropriate (e.g. Marinol) 5. RD to initiate 3-day calorie count, and monitor wt, diet tolerance and labs/lytes 6. Recommend change diet to EN formula if pt cannot meet 75% of needs on PO diet; RD to f/u with TF recs PRN

7. Recommend MVI with minerals to optimize nutrition status

8. Provided verbal and written education on medicine compliance, protein supplementation and light wheelchair-based strength-training. Pt demonstrated good understanding and indicated willingness to comply.

9. Will refer to outpt RD for reinforcement of diet ed after d/c MONITORING and EVALUATION: 1. Monitor PO intake/ability to meet 75% of needs PO, daily wts. Goal: prevent further wt loss; promote gradual weight gain of 0.5-1.0kg/week. 2. Begin meds again, via PO or crushed and mixed with food. Goal: 100% compliance with med regimen. 3. Simple wheelchair exercises at home after wt gain should see strength improve as weight improves 4. Monitor GI distress/resolution of N/V