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] For example - Donald is a 34 year old male with colitis, possibly Crohn's disease that was diagnosed in 2024. He has been having severe and progressive symptoms with significant weight loss. He will be getting an urgent colonoscopy, which is scheduled for September 18th. Patient's goals for management [concise single statement on patient's goals] For example - His goals are learning how to manage his nutrition and foods he should be avoiding. 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.] - Current weight: [weight]. - Weight fluctuation: [weight_range] over the past [duration]. - Previous weight: [weight] [duration] ago. - Usual weight: [weight] approximately [duration] ago. - BMI: [value]. - 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: -Abdo pain for the past 4 years, worse over the last year; starts in upper abdo and then moves to rectum area and back; triggered by exercising, deep breathing, coughing, triggered by all meals within 10 min of eating; pain also present when he has BMs; cannabis to helps relieve the pain -Bloating/distension on left side, gets worse with eating -Persistent bloody diarrhea; he may have a few days per week that he doesn't see blood followed by a few days with frequent bleeding; there has been a lot of blood present the last 4 days with every BM -Having 6-7 liquid BMs/24 hours; last night he was up every 2 hours last night having BMs; frequency of BMs does depend on how much he's eating; frequent tenesmus -No vomiting but feels nauseous regularly, especially in the night when he's up -Frequent and foul smelling gas and has to be on the toilet anytime he's 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: -He works in construction but has been off work for several months due to his symptoms -Used to work out a lot up until a year ago; limited to short walks now and occasionally weight lifting because of pain -Mostly stays at home these days -He lives with his partner; his partner does the grocery shopping and cooking 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 he feels like eating anything causes pain -He feels like solid food causes more immediate pain but actually helps his BMs be a bit thicker; he feels liquids like soups and protein shake don't cause much immediate pain but causes more looser and painful BMs -Has tried taking out dairy and wheat, only eating cooked fruit and veg, all soup diet 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. 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]