Print
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Nutritional Assessment

		54 Hgt: DOB: DOA: NMP:A Phy: [ ] Diet: Likes: DisLikes: Notes: [ RM ]


Diagnosis: Meds:

\|-\|REQ\|--\|--------------CW-----------------------------------------------------\| \|Kcal Adj: \| \| \|- Receiving -\|- Factors --\|---- BEE Calculations ---\| \|Calories:1584.3 kcal/day \| \|Actvity:1.3 \|655+(4.3130) \| Adj \| \|Protein :47.27 g/day \| \|Stress :1 \|+(4.766)-(4.765 )\| \| \|Fluid :1773 cc/day \| \|Protein:.8 \|1.3 *1 \|BMI:0 \| \| \|------------------------------------------------------------------------------\| \|TF: \| %RDA \|- Volume Calculations (cc)-\| \|Formula\| \| \| \| \| \| \|= \| \|Flush \| \| \| \| \| \| \|= \| \|---------------------------------------------- % \|----\|-\|----\|-\|----\|--------\| \| - - \|Dx: \| \|Dextrose\| \| \| \| \| \| \|= \| \|------------------------------------\|Amino A.\| \| \| \| \| \| \|= \|

Diagnosis:
Meds:

|-|REQ|--|--------------CW-----------------------------------------------------|
|Kcal Adj:       |     |  |- Receiving -|- Factors --|---- BEE Calculations ---|
|Calories:1584.3 kcal/day |             |Actvity:1.3 |655+(4.3*130)      | Adj |
|Protein :47.27  g/day    |             |Stress :1   |+(4.7*66)-(4.7*65 )|     |
|Fluid   :1773   cc/day   |             |Protein:.8  |*1.3 *1   |BMI:0   |     |
|------------------------------------------------------------------------------|
|TF:    |                                     %RDA |- Volume Calculations (cc)-|
|Formula|                                          |    | |    | |    |=       |
|Flush  |                                          |    | |    | |    |=       |
|----------------------------------------------  % |----|-|----|-|----|--------|
|  -  -  |Dx:                    |   |Dextrose|    |    | |    | |    |=       |
|------------------------------------|Amino A.|    |    | |    | |    |=       |


\| Date \|Weight\|% chg\| Kg \|Sc\| w*#< \| e+@> \|7days\|30 days\|90 days\|180 days\|CP\| \| - - \| . \| \| \| \|-------------\|-----\|-------\|-------\|--------\|--\| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \| \| - - \| . \| \| \| \| \| \| \| \| \| \|	\| Date \| Hb \| Hct \| Alb \| Glu \| Bun \| Cre \| K+ \|Chol\| Na+ \| Cl- \|mOsmK\| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| - - \| . \| . \| . \| . \| . \| . \| . \| \| \| \| \| \| \| Date \|w\| Location \|g\| L \| W \| D \|Wk\|PVECd\|OD\|TCodes\|Acquired\| Family \|M\| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| - - \| - - \| \| \| Date \|B\|L\|S\|11-7\|7-3 \|3-11\|1\|3\|H\|11-7\|7-3 \|3-11\|Total\|11-7\|7-3 \|3-11\|Total \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| \|

|  Date  |Weight|% chg| Kg  |Sc| w*#< | e+@> |7days|30 days|90 days|180 days|CP|
|  -  -  |   .  |     |     |  |-------------|-----|-------|-------|--------|--|
|  -  -  |   .  |     |     |  |             |     |       |       |        |  |
|  -  -  |   .  |     |     |  |             |     |       |       |        |  |
|  -  -  |   .  |     |     |  |             |     |       |       |        |  |
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|  Date  | Hb | Hct | Alb | Glu | Bun | Cre | K+ |Chol| Na+ | Cl- |mOsmK|      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
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|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |

|  Date  |w| Location  |g| L  | W  | D  |Wk|PVECd|OD|TCodes|Acquired| Family |M|
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
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|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  Date  |B|L|S|11-7|7-3 |3-11|1|3|H|11-7|7-3 |3-11|Total|11-7|7-3 |3-11|Total |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
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|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
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|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |


Dietitian Comments \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \|	CDM Comments \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \| \| - - \| \| \| \| \| \| \| \| \| \| \| \| \| \| \| - - \| \| \| \| \|

Dietitian Comments
|  -  -  |   |                                                  |   | |   | |   | |   | |   | |   | |  -  -  |   |   |   |                                     |
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CDM Comments
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54 Hgt: DOB: DOA: NMP:A Phy: [ ]Diet: Likes: DisLikes: Notes: [ RM ]

Diagnosis: Meds:

54 Hgt: DOB: DOA: NMP:A Phy: [ ]
Diet:
Likes:
DisLikes:
Notes: [ RM ]

Diagnosis:
Meds: