Nutritional Assessment using Subjective Global Assessment Scoring Sheet Patient Name: Delos Santos, Estela V.________ Date:_November 7, 2009__Weight:_50kg______ Part 1: Medical History 1. Weight Change A. Overall change in past 6 months: ? kgs. B. Percent change: (X) gain - < 5% loss NOTE: d/t edema C. Change in past 2 weeks: (X) no change 2. Dietary Intake A. Overall change: (X) Change NOTE: feeding now via NGT B. Duration: ~4 weeks C. Type of change: (X) full liquid diet

Nutritional Assessment using Subjective Global Assessment Scoring Sheet 3. Gastrointestinal Symptoms (persisting for >2 weeks) : __?__none 4. Functional Impairment (nutritionally related) A.Overall impairment: (X) severe : bedridden, chronic metabolic/endocrine disease, severe, infection B. Change in past 2 weeks: (X) no change Part 2: Physical Examination 5. Evidence of: (X) Muscle wasting (X) Edema Part 3: SGA Rating: Mildly-Moderately Malnourished

Dietary Intake Assessment TER = BEE x stress factor x activity factor Where: TER – total energy requirement BEE – basal energy expenditure for females = (9.6 x wt in kg) + (1.85 x ht in cm) – (4.67 x age) Stress factor – 1.2 to 1.4 for severe infection Activity factor – 1.2 for sedentary TER = 1053kcal x (1.2 to 1.4) x 1.2 Total Enegy Requirement = 1516 to 1769 kcal/day Actual diet: 1600kcal/day (50% carbohydrates, 30% fats, 20% proteins) Divided into 6 equal feedings of 2:1 dilution + 1 bottle yakult 3x a day + Peptamen 5 scoops in ½ glass of water every other meal Dietary intake assessment: ADEQUATE