HLTH

Smith, Jennifer Female, 61 y.o. Allergies: NFKA Pt. Location: Outpatient Oncology Clinic

Code: FULL Physician: M. Johnson

Isolation: None Admit Date: 7/8

Patient Summary: Jennifer Smith is a 61-year-old female who was diagnosed with breast cancer—Stage IIB Invasive Ductal Carcinoma T2N1miM0 18 months previously. She was treated with R mastectomy followed by radiation and chemotherapy. She received chemo- therapy with Docetaxel, doxorubicin, and cyclophosphamide every three weeks for six cycles. This was followed with radiation therapy to the chest wall. She has completed treatment and most recently completed reconstructive surgery.

History: Onset of disease: Dx: Stage IIB Invasive Ductal Carcinoma T2N1miM0 Medical history: Type 2 DM Surgical history: s/p Hysterectomy, s/p R mastectomy, s/p deep inferior epigastric perforator flap reconstructive surgery 6 weeks ago Medications at home: metformin Tobacco use: none Alcohol use: 1–2 3 per week—white and red wine Family history: Mother and sister—breast cancer; father—diabetes, CHD

Demographics: Marital status: Married Number of children: 4 children—ages 32, 30, 27, 24 Education: 4 years college Language: English only Occupation: Sales manager for national cosmetic company Hours of work: Currently not working but plans to return in the next few weeks Household members: Husband—youngest child home for summer Ethnicity: Caucasian Religious affiliation: Methodist

History/Physical: Chief complaint: Here for follow-up 3 months. Last treatment General appearance: Pleasant, overweight woman

Vital Signs: Temp: 98.6 Pulse: 73 Resp rate: 15 BP: 127/78 Height: 5’5” Weight: 175 lbs Heart: Regular rate and rhythm, normal heart sounds—no clicks, murmurs, or gallops HEENT: Head: WNL Eyes: PERRLA Ears: Clear Nose: WNL Throat: Moist mucous membranes without exudates or lesions Genitalia: Normal female Neurologic: Alert and oriented 3 3 Extremities: Noncontributory Skin: Smooth, warm, dry, excellent turgor, no edema Chest/lungs: Lungs clear Peripheral vascular: Pulse 41 bilaterally, warm, no edema Abdomen: Healing postsurgical wounds

Smith, Jennifer Female, 61 y.o. Allergies: NFKA Pt. Location: Outpatient Oncology Clinic

Code: FULL Physician: M. Johnson

Isolation: None Admit Date: 7/8

Nutrition: General: Patient reports that her usual weight prior to breast cancer diagnosis was 195 lbs. She experienced loss of appetite, nausea, vomiting, diarrhea, and mucositis during chemo treatments. She also states that she had ex- treme fatigue throughout both chemo and radiation. She states that she is feeling much better and appetite “un- fortunately” has returned to normal. She admits that she is glad she has lost weight and would like to continue to lose weight—“I know that this will keep me healthier”. Mrs. Smith is interested in changing her diet to try and keep her cancer from coming back and wants advice on how to do this. She has considered becoming a vegetarian and wonders if this will be a good thing for her. She is not exercising yet due to the recent reconstructive surgery but would like to start something besides just walking—which she does every day with her dogs. She walks her golden retrievers twice a day for about ½ mile each time.

24 hour recall: AM: 1 c coffee (brewed black) Cheerios—1 c with ½ c fresh strawberries Almond milk —1 c Snack: 2 c coffee (brewed black) Granola bar Lunch: Tuna salad—made with egg and mayonnaise—¾ c in a fresh tomato 20 wheat thins eaten with tuna salad 1 can diet cola PM: 8 oz filet mignon grilled 1 large baked potato with 2 tbsp butter, salt, and pepper Dinner salad with ranch-style dressing (3 tbsp)—lettuce, spinach, croutons, sliced cucumber 1 glass of Riesling white wine (~ 6 oz) HS snack: 1 glass of Riesling white wine (~ 6 oz)—3 oz cheese and ~ 10 wheat thin crackers

Food allergies/intolerances/aversions: No known Previous nutrition therapy? Yes. If yes, when: several years ago Where? Local diabetes association—attended diabe- tes classes. Food purchase/preparation: Self and husband Vit/min intake: Multivitamin/mineral daily

Laboratory Results

Ref. Range 7/1 0600 (fasting) Chemistry Sodium (mEq/L) 136–145 138

Potassium (mEq/L) 3.5–5.1 3.7

Chloride (mEq/L) 98–107 101

Carbon dioxide (CO2, mEq/L) 23–29 25

Bicarbonate (mEq/L) 23–28 24

BUN (mg/dL) 6–20 11

Creatinine serum (mg/dL) 0.6–1.1 F 0.9–1.3 M

0.8

(continued)

Smith, Jennifer Female, 61 y.o. Allergies: NFKA Pt. Location: Outpatient Oncology Clinic

Code: FULL Physician: M. Johnson

Isolation: None Admit Date: 7/8

Ref. Range 7/1 0600 (fasting) BUN/Crea ratio 10.0–20.0 13.75

Uric acid (mg/dL) 2.8–8.8 F 4.0–9.0 M

3.1

Est GFR, non-Afr Amer (mL/min/1.73 m2)

.60 82

Glucose (mg/dL) 70–99 137 ! Phosphate, inorganic (mg/dL) 2.2–4.6 3.8

Magnesium (mg/dL) 1.5–2.4 1.9

Calcium (mg/dL) 8.6–10.2 9.1

Anion gap (mmol/L) 10–20 13

Osmolality (mmol/kg/H2O) 275–295 288

Bilirubin total (mg/dL) #1.2 0.7

Bilirubin, direct (mg/dL) ,0.3 0.1

Protein, total (g/dL) 6–7.8 6.9

Albumin (g/dL) 3.5–5.5 3.8

Prealbumin (mg/dL) 18–35 30

Ammonia (NH3, µg/L) 6–47 8

Alkaline phosphatase (U/L) 30–120 42

ALT (U/L) 4–36 11

AST (U/L) 0–35 17

CPK (U/L) 30–135 F 55–170 M

44

Lactate dehydrogenase (U/L) 208–378 210

C-reactive protein (mg/dL) ,1.00 1.1 ! Cholesterol (mg/dL) ,200 210 ! HDL-C (mg/dL) .59 F, .50 M 72

VLDL (mg/dL) 7–32 31

LDL (mg/dL) ,130 107

LDL/HDL ratio ,3.22 F ,3.55 M

1.48

Triglycerides (mg/dL) 35–135 F 40–160 M

155 !

HbA1C (%) ,5.7 6.8 ! Hematology

WBC (3103/mm3) 3.9–10.7 5.2

RBC (3106/mm3) 4.2–5.4 F 4.5–6.2 M

4.3

Hemoglobin (Hgb, g/dL) 12–16 F 14–17 M

11.9 !

Hematocrit (Hct, %) 37–47 F 41–51 M

36 !

(continued)

Laboratory Results (continued)

Smith, Jennifer Female, 61 y.o. Allergies: NFKA Pt. Location: Outpatient Oncology Clinic

Code: FULL Physician: M. Johnson

Isolation: None Admit Date: 7/8

Ref. Range 7/1 0600 (fasting) Platelet count (3103/mm3) 150–350 201

Transferrin (mg/dL) 250–380 F 215–365 M

385 !

Ferritin (mg/mL) 20–120 F 20–300 M

55

Urinalysis

Collection method — Clean catch

Color — yellow

Appearance — clear

Specific gravity 1.001–1.035 1.005

pH 5–7 5.9

Protein (mg/dL) Neg Neg

Glucose (mg/dL) Neg Neg

Ketones Neg Neg

Blood Neg Neg

Bilirubin Neg Neg

Nitrites Neg Neg

Urobilinogen (EU/dL) ,1.0 Neg

Leukocyte esterase Neg Neg

Prot chk Neg Neg

WBCs (/HPF) 0–5 2

RBCs (/HPF) 0–2 1

Bact 0 0

Mucus 0 0

Crys 0 0

Casts (/LPF) 0 0

Yeast 0 0

Note: Values and units of measurement listed in these tables are derived from several resources. Substantial variation exists in the ranges quoted as “normal” and these may vary depending on the assay used by different laboratories.

Laboratory Results (continued)