Medical Nutrition Therapy Consultation Template



Initial Progress Note—Case #2

Name: ___Harry Woods_________________________

MR# _21007________ DOB: _08/06/1973_____ Date: _12/15/2005_

Recommendations request for labs, nutrition relationship to changes in meds, need for reinforcement of lifestyle changes

Please recheck lipid profile at 3 months (about 3/15/2006)

Nutrition Diagnosis:

Nutrition Diagnosis (Problem)

|√ | |√ | |

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

|X |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: | |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 intake of large portions of high-fat foods.

Additional Nutrition Diagnoses:

Excessive oral food intake (NI-2.2) related to inability to refuse food when dining out as evidenced by BMI above 25 and waist circumference >43.

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

Patient is a 32 y/o white male referred by Dr. Gary Smith for hyperlipidemia.

This is a 45 minute Initial MNT encounter. Patient states he wants to improve his blood pressure and lipid levels. He is concerned about his family history of CVD.

Client History (medication/supplement [cholesterol-lowering meds and folate, B6, B12, CoQ10],

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

Pertinent Meds: Altace; no dietary supplements

Social Hx: pharmacist with a pharmaceutical company; does not smoke;

Alcohol: 2-5 drinks/wk

Single, lives alone.

Family Hx: Cousin recently died of CVD at age 39

65 yo mother has HTN and hyperlipidemia treated with meds

Father has type 2 diabetes, NASH with cirrhosis, TIA at 55 and MI

at 65

Medical Hx: Hypertension x 13 years

No clinical evidence of CHD

Baseline for Outcomes Monitoring:

Biochemical Data:

|Lipid Profile |Date: 12/12/05 |

|Total Cholesterol | 200 mg/dL |

|LDL X calculated or  direct | 137 mg/dL |

|HDL | 44 mg/dL |

|TG | 90 mg/dL |

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

|Other Labs |

|Glucose | 90 mg/dL |

|Other: | |

|Lp (a) | 62 (high) mg/dL |

|hsCRP | 5.2 (high) mg/L |

Anthropometric Measurements:

Ht. 5’10” (178 cm) Wt. 212 lbs (96 kg) BMI 30.3 WC 43 “ Weight History: Weight gain from

190 to 210 over 1-2 years about 5 years ago. Current weight has been stable for the last year.

Physical exam findings (oral health, physical appearance [abdominal obesity, xanthomas], muscle/fat wasting, affect):

BP 148/94 (previous readings have been in the range of 140-160/90-100)

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):

Follows no specific diet.

Excessive dining out related to job with use of many foods high in saturated and trans fat

Saturated and trans fat intake exceeds 7% of energy intake

Based on stable weight, his current energy intake meets his needs, but supports obesity.

He was quite aware of the need to use diet and exercise to reduce risk of heart disease and that being overweight was detrimental for his hypertension. However, he had limited knowledge about how to make heart healthy choices, especially when eating out.

He was very receptive and interested in making healthier choices to reduce his risk of heart disease.

Additional Pertinent Information: n/a

Nutrition Intervention:

Food and/or Nutrient Delivery (meals/snacks, medical food supplements, vitamin/mineral supplement, bioactive substance supplement, feeding environment and nutrition-related medication management, [meal plan]):

1. Reduce saturated and trans fat to ................
................

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