Medical Nutrition Therapy Consultation Template



Initial Progress Note—Case #1

Name: _____Alice Jones_____________________________

MR# _0596283________ DOB: _2/10/1939 ______ Date: _ 7/15/2005____________

Recommendations:

Physician encouragement of physical activity might move patient toward action in this area.

Please recheck lipid profile before her next nutrition therapy appointment on 9/9/2005

Nutrition Diagnosis:

Nutrition Diagnosis (Problem)

|√ | |√ | |

| |NI-1.5 Excessive energy intake | |NC-2.3 Food-medication interaction |

| |NI-2.2 Excessive oral food/bev. intake | |NC-3.3 Overweight/obesity |

| |NI-4.3 Excessive alcohol intake | |NB-1.1 Food, nutrition and nutrition related knowledge|

| | | |deficit |

|X |NI-51.3 Inappropriate intake of food fats- specify: |X |NB-1.3 Not ready for diet/lifestyle change |

| |NI-53.3 Inappropriate intake of types of | |NB-1.6 Limited adherence to nutrition-related |

| |carbohydrate—specify: | |recommendations |

| |NI-53.5 Inadequate fiber intake | |NB-2.1 Physical inactivity |

| |Other: | | |

Inappropriate intake of saturated and trans-fat (NI-51.3) related to food and nutrition knowledge deficit as evidenced by LDL cholesterol >130 mg/dL and reports of high saturated fat foods in 24-hour recall.

Additional Nutrition Diagnoses:

Not ready for diet/lifestyle change (NB-1.3) related to inability to focus as evidenced by unwillingness to commit to short term goals for lifestyle change.

Nutrition Assessment Recommendations and Nutrition Diagnosis are based on the following:

Patient is a 66 y/o white female referred by Dr. John Morgan for combined hyperlipidemia and metabolic syndrome.

This is a 45 minute Initial MNT encounter. Patient states she is depressed over recent loss of husband 6 months ago.

Client History (medication/supplement [cholesterol-lowering meds and folate, B6, B12, CoQ

10], social [smoking and alcohol habits], medical/health [S/P angioplasty or CABG] and personal):

Pertinent Meds: Levoxyl, Coumadin, Atenolol, Prozac

Social Hx: retired, lives in her own home with 2 grown sons.

Family Hx: premature CVD—father died after an MI at age 44

Medical Hx: Patient has been on statin therapy to lower LDL cholesterol, but it

was discontinued due to elevated LFT’s. Hypothyroidism, Depression

Pt has a mechanical tricuspid valve, placed 25 years ago

Baseline for Outcomes Monitoring:

Biochemical Data:

|Lipid Profile |Date: 7-10-05 |

|Total Cholesterol | 255 mg/dL |

|LDL calculated or X direct | 152 mg/dL |

|HDL | 25 mg/dL |

|TG | 386 mg/dL |

|Non HDL (if TG > 200 mg/dL) | 230 mg/dL |

|Other Labs |

|Glucose | 112 mg/dL |

|Others: | |

|ALT | 40 units/L |

|AST | 46 units/L |

|TSH | 4.16 uIU/mL |

Anthropometric Measurements:

Ht. 5’2” Wt. 159 lbs. BMI 29.1 WC 37”

Weight History: weight had been stable at 150 lbs. for years until 6 months ago when husband died Physical exam findings (oral health, physical appearance [abdominal obesity, xanthomas], muscle/fat wasting, affect):

Well nourished with abdominal obesity

BP_152/90__

Food and Nutrition History (food consumption [Intake of fat, % calories from fat, type, sources of fat, total and soluble fiber, fish, soy, plant sterols] nutrition/health awareness and management, physical activity/exercise, food availability):

She eats only one meal per day plus sugared tea throughout the day; frequent use of high fat meats and large servings of starch. She has limited fruit and vegetable intake.

Results of computerized nutrient analysis of a 24 hour recall.

|Nutrient |Patient’s Intake |Recommended Level |

|Kcalories |2343 |1720 |

|% Energy from Fat |27% | 25-35% |

|% Energy from Saturated and Trans Fat |10% | < 7% |

|Dietary cholesterol (mg) |342 | ................
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