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NUTRITION PROGRESS NOTE for INITIAL CONSULTATION

Student Name: Brittany Schneider Consultation Date: May 14, 2016 Consultation #: 1

ASSESSMENT: Age: 60 Gender: F Ethnicity: Caucasian Family History: high cholesterol, hypertension, cancer

Clients Desired Outcomes: Resolve food senstitivies, lose weight, maximize healthy food choices

Antecedents & Triggers: Criticism about weight, emotional eater when stressed, gets discouraged that she wont lose weight

Medical Diagnosis: Celiac Disease, Achalasia, Obesity, Hypothyroidism Health History: 2007
diagnosed with Celiac disease, 1994 achalasia (had sugrugy in 1998, hellermyotomoy & nissanfundoplicatoin), obesity,
hypothyriodsm diagnosed in 2013.

Ht: 54 Wt: 185 IBW: 145 IBW%: BMI: 31 Waist: 44.5 Fat%: Visceral: TBW%:

Estimated Needs: Calories: 1733 Protein: 116g Fluid: 123oz

Diet: Low quality calories. High in carbohydrates and sugar. Breakfast is usually good with a protein shake with spinach,
berries, almond butter, and unsweetened cashew milk. Lunch is low in calories usually a gluten free lean cusine. She likes
to snack on nuts and chocolate covered almonds or chocolate covered mangos. <2 servings vegetables per day. <1 or 2
servings fruit per day. 28oz of water over three days.

Laboratory Data: n/a

Nutrition Focused Physical Exam: Dry skin, brittle nails/have been splitting, hair is course/thinning, ridging on tongue, coating
on tongue, high waist/hip ratio, joint pain. Preference for hot beverages, body typically feels cold.

Symptom Burden/Biological Systems: BFrequency of GI symptoms: several times a day. Her biggest concern is bloating,
intermettient constipation (1x per week), intermettient diarrhea (4x per week), gas on a regular basis after she eats. Used to
get a lot of heartburn, now takes Nexium and doesnt have heartburn as much. Gallbladder removed in 1994. Doesnt really
eat fatty or fried foods very often. She sometimes get dark circles under eyes. She has many food sensitivities she had a
blood test for her food senstitivies done by Biotek a year ago: dairy, eggs, shellfish (crab) are high on the list. She also
sometimes has a coated tongue a couple times per week; wakes up in the morning with it.

Meds/Supplements: Liothyronine (25mg AM & 12.5mg PM), amour thryiod (180mg), progesterone (100mg), nexium (40mg
2x daily), Omega-3 fatty acids EPA&DHA 2000IU daily, probiotic, multivitamin, Vit D3.

Physical Activity: 2x week personal training (strength training). Sits at a desk most of the day for work.

Lifestyle/Stress: Lives in upper middle class neighborhood with husband. Husband, daughter, work friends, church friends
are all supportive. Work can be stressful, she is about to get a new job. Stress level is about a 3/10. Work is 5/10. Gets 7-8
hours of sleep per night.

Behavior, Beliefs, Readiness: Beliefs: She thinks that nutrition is important; its just hard to make healthy choices sometimes.
She has had many food sensitivies that makes it hard for her to put together meals that are good and satisfy her. She thinks
that she has a pretty good overall knowledge of nutrition. She doesnt understand why you get food senstitives, or what to
do about them b/c in the past she has had testing done and cut out the specific foods she was sensitive to but she still has GI
symptoms. Lowest weight before married was 130lbs (31 years old). Got married and slowly started gaining weight afer
she had her first child. Got up to 165lbs. In her previous marriage it was her partners opinion that she was never skinny
enough but it also became her belief. Her weight went up to 225lbs after seperations then divorce in 2007. She is very
frusterated about her current weight.. +8/9 on readiness scale, needs/wants guidance for healthy consistent choices.

Core Imbalances: Digestion, Neuro-Endocrine (thyroid)-Immue, Inflammation/oxidative stress, and Detoxification


Nutritional Status: Normal (not at risk) At Risk x Subclinical Deficiency

Clinical Deficiency Malnutrition Explanation:

NUTRITION DIAGNOSIS:
Main Nutritional Problem Altered GI function related to excessive carbohydrate intake and inadequate water intake

as evidenced by overweight, high waist/hip ratio, GI symtoms


(bloating, gas, and diarrhea after eating).

INTERVENTION: Overall Outcome Goals:

Increase fruit and vegetable intake to 6+ servings daily


Increase healthy fat intake (25-35g)
Support gastric digestion and brush board
Reduce weight to reach 145lbs
Increase water intake to 123oz per day
*See short-term interventions that support todays priority outcome goals on attached recommendations form.

MONTORING/EVALUATION: 1) Follow up 2) Assess compliance with short-term action

MOCK NUTRITION AND INTEGRATIVE HEALTH


RECOMMENDATIONS
Mock Consultation Date: 5/14/16 Student Name: Brittany Schneider

Todays Priority Goals: Increase water intake

DIETARY INTERVENTIONS Hand-Out

1) Increase water intake to 64oz of water per day

2) Increase to 4+ servings fruits/vegetables daily

3)

5) SUPPLEMENT INTERVENTIONS
Form Before Mid Before
Breakfast Afternoon Bed
Supplement Capsule Breakfast Lunch Dinner
Tablet
Powder
Liquid

l-glutamine (5g) powder 1

Special Instructions:

INTEGRATIVE HEALTH INTERVENTIONS Hand-Out

6)

7)

OTHER RECOMMENDATIONS/LAB WORK/REFERRAL

8) Biotek Food Sensitivity Test

9)

Recommended Follow Up Visit in ______2 weeks____________ *Kindly give your clinical student intern 24-hours notice for
appointment cancellations. Late cancellations and missed appointment fees apply to appointments cancelled with less than 24-hours
notice.