Initial Nutrition Consult

Chief Complaint

Consult Letter Template

Template

History of Presenting Illness: [Provide a concise narrative of the patient's presenting illness, including age, gender, diagnosis, and timeline of symptoms. Include any significant weight changes, upcoming procedures, Symptom Frequency and Patterns, Timing and Duration, Symptom Onset, patient's visit goal. In narrative paragraph format.] Current Vitamins and Nutritional Supplements: [List all current vitamins and nutritional supplements the patient is taking, including dosages, frequency, and any relevant history of changes or discontinuation.] For example: • [Supplement Name]: [Dosage and Frequency]; [Reason for use or discontinuation] Medications: [List all current medications the patient is taking, including dosages, frequency, and any relevant notes about their usage or effectiveness.] For example - • [Medication Name]: [Dosage and Frequency]; [Notes on usage or effectiveness] Laboratory Work: [Document any pending or recent lab work, including the tests ordered and their purpose.] For example - • [Test Name]: [Purpose or reason for testing] Weight Status: [Provide a detailed account of the patient's weight history, including current weight, recent fluctuations, usual weight, height, BMI, and any relevant observations about weight loss or gain. Include the patient's ideal weight and their perception of their weight status.] For example - • Current weight: [weight]. • Weight fluctuation: [weight_range] over the past [duration]. • Previous weight: [weight] [duration] ago. • Usual weight: [weight] approximately [duration] ago. • Height: [height(e.g., 5'10")] • BMI: [value(e.g., 23)]. • Total weight loss: [weight_loss] over the past [duration], including [weight_loss] during hospitalization in [month, year]. • Reports feeling weak and underweight, with an ideal weight of [weight]. Gastrointestinal Symptoms: [Describe patient's gastrointestinal symptoms in detail, including onset, duration, frequency, triggers, and associated symptoms. Include any patterns or observations related to meals, bowel movements, and pain management strategies.] For example - • Abdominal pain for the past [duration], worse over the last [duration]; starts in [location] and then moves to [location]; triggered by [triggers]; pain also present when they have BMs; [Pain management strategy] • Bloating/distension on [location], gets worse with eating • Persistent bloody diarrhea; [pattern of occurrence]; there has been a lot of blood present the last [duration] with every BM • Having [number] liquid BMs/24 hours; [pattern of occurrence]; frequency of BMs depends on [factors]; frequent tenesmus • No vomiting but feels nauseous regularly, especially [time] • Frequent and foul-smelling gas and has to be on the toilet anytime passing gas Lifestyle Notes: [Provide information about the patient's lifestyle, including occupation, physical activity, daily routines, and any changes due to their symptoms. Include details about their living situation and support system.] For example - • The patient has adjusted their work and physical activity due to symptoms • The patient lives with a supportive partner who assists with daily activities Allergies, Sensitivities, and Dietary Restrictions: [List any known allergies, sensitivities, or dietary restrictions the patient has. Include any observations or patterns related to food triggers and their effects on symptoms.] For example - • Hasn't been able to identify food triggers since they feel like eating anything causes pain • Has tried taking out [food items], only eating [food items], and none of these things helped Relationship with Food: [Describe the patient's relationship with food, including their feelings about eating, any challenges they face, and how their symptoms have impacted their eating habits.] For example - • Previously enjoyed eating but now feels forced to eat to prevent further weight loss. • Finds eating painful and challenging, especially during flare-ups Usual Diet: [Provide a detailed account of the patient's usual diet, including meal patterns, types of foods consumed, and fluid intake. Include any changes in diet due to symptoms and any specific foods or beverages that are well-tolerated or avoided.] For example - • Breakfast: [Foods typically consumed] • Snacks: [Foods typically consumed] • Lunches and Dinners: [Foods typically consumed] • Fluids: [Types and estimated daily intake. Include Alcohol intake, frequency & quantity and any noted effects on symptoms] Nutrition Assessment: [Provide a detailed assessment of the patient's nutritional status, including any recent weight changes, dietary intake limitations, and specific nutrient deficiencies such as calories, protein, fiber, calcium, fluid, and omega-3 fats.] For example - • Patient has lost X% of body weight over the last year. • Oral intake is limited due to abdominal pain. • Diet lacks in calories, protein, fibre, calcium, fluid, and omega 3 fats. Nutrition Recommendations: [Discuss the patient's current situation and any consultations with healthcare professionals. Include recommendations for dietary adjustments to address weight loss and nutrient deficiencies. Suggest meal frequency and types, such as small meals/snacks, high-calorie and protein soups/smoothies, and supplement drinks. Provide guidance on solid food choices, focusing on lean proteins, simple carbohydrates, and soft-cooked vegetables. Offer advice on fruit consumption and hydration strategies, including specific products and their availability.] For example - 1. I discussed patient's situation with healthcare team. Recommend presenting to ER if necessary. 2. Suggest 4-5 small meals/snacks daily, focusing on high-calorie and protein intake. 3. Recommend high-calorie soups/smoothies or supplement drinks like Boost/Ensure. 4. For solid meals, focus on lean proteins and simple carbohydrates. Recommend removing skins/peels from fruits to reduce pain. Suggest 2-3 cups of oral rehydration solution daily for hydration.