High School

**Patient Information:**

- **Name:** Emily Montgomery
- **Date of Birth:** 10-13-1965
- **Physician:** Dr. Jack Wall

**History and Physical Examination:**

- Emily Montgomery is a 55-year-old woman admitted with a diagnosis of pneumonia and malnutrition.
- She was brought to the emergency department by a friend.
- Lives alone and does not work outside the home.
- Her husband of 30 years died about 1 year ago.
- She has a son and a daughter; both are married and live about 100 miles away.

**Physical Examination:**

- Appears thin and frail.
- Mild respiratory distress noted.
- Receiving oxygen at 2 L/min.
- On intravenous fluids: 5% dextrose in water with 40 mEq of potassium.
- On a full liquid diet with orders to increase oral fluid intake.
- Height: 5'6"
- Weight: 103 lb.
- Reports a poor appetite for the past year and usually eats one small meal daily.
- Reports a 40-lb weight loss.

**Laboratory Values:**

- Hemoglobin: 9.7 g/dL
- Hematocrit: 30.1%
- Albumin: 2.8 g/dL

**Admission Orders:**

1. **Diet:** Full liquid diet
2. **Dietary Consult**
3. **Vital Signs:** Every 4 hours
4. **Intake and Output:** Every 4 hours
5. **Oxygen:** 2 L/min via nasal cannula, titrate to maintain SpO2 above 92%
6. **Intravenous Fluids:** D5W + 40 mEq KCl at 80 mL/hour continuous
7. **Medication:** Levofloxacin 500 mg IV every 24 hours for 7 days
8. **Multivitamin:** 1 tablet orally daily
9. **Psychiatric Referral:** To rule out depression

Answer :

Mrs. Emily Montgomery is a 55-year-old woman who was admitted with a diagnosis of pneumonia and malnutrition. The patient has had a poor appetite for the past year and usually eats one small meal daily. She reports a 40-lb weight loss. She is receiving oxygen at 2 L/min, intravenous fluids of 5% dextrose, and water with 40 mEq of potassium added. She is on a full liquid diet with orders to push oral fluids. Mrs. Montgomery has a thin, frail-appearing physique in mild respiratory distress. She lives alone and does not work outside of the home. Her husband of 30 years passed away about 1 year ago. She has a son and a daughter both are married and live approximately 100 miles away.Hemoglobin levels are 9.7 g/dL, hematocrit is 30.1%, and albumin is 2.8 g/dL. Emily Montgomery was admitted to the Medical floor with the following orders:

  • 1. Diet: Full liquid diet
  • 2. Dietary consult
  • 3. Vital signs every 4 hours
  • 4. Intake and Output every 4 hours 5. 02 at 2 L/min via nasal cannula, titrate to maintain SpO2 above 92% 6. D5 W + 40 mEq KCl at 80 mL/hour continuous 7. Levofloxacin 500 mg IV every 24 hours X 7 days 8. Multivitamin 1tab po daily 9. Refer to psychiatrist to r/o depression

About Malnutrition

Malnutrition occurs when the body does not get enough nutrients. The cause can be a poor diet, digestive conditions, or other diseases. Symptoms of fatigue, dizziness and weight loss. Untreated malnutrition can lead to physical or mental disabilities.Treatment must address the underlying condition and replace lost nutrients.

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