Write a note for your initial outpatient nutrition assessment and nutrition recommendations

Question

What will be an ideal response?

Answer 1

Jennifer Smith, 7/8/2015
61 yo, F, referral from oncology clinic
Onset of disease: Stage IIB invasive ductal carcinoma T2N1miM0
PMH: T2DM
PSH: s/p hysterectomy, s/p R mastectomy, s/p deep inferior epigastric perforator flap reconstructive surgery 6 weeks ago
Meds: metformin
Labs: Glucose 137; CRP 1.1; Chol 210; TG 155; HbA1C 6.8; Hgb 11.9; Hct 36; transferrin 385;
Diet Hx: lost weight 20 lbs d/t chemotherapy and RT; appetite is returning to normal "unfortunately"; wants to continue to lose weight; interested in changing diet to prevent cancer reoccurrence
Diet: 24-hr recall: 1 c coffee; 1 c Cheerios w/ 1/2 cup strawberries, 1 c almond milk; 2 c coffee, granola bar; 3/4 c tuna salad (with egg and mayo) in tomato, 20 wheat thins, 1 can diet cola; 8 oz grilled filet mignon, 1 lg baked potato (w/butter, salt, pepper), salad (lettuce, spinach, croutons, sliced cucumber) w/ 3 tbsp ranch dressing, 12 oz Riesling wine;3 oz cheese w/10 wheat thins (~2926 kcal, 117 g pro, 18 g fiber, 45% fat)
PA: walks dogs for 1/2 mile BID
Alcohol: 1-2/week (wine)
Ht: 5'5" Wt: 175# UBW: 195# %UBW: 89.7% IBW: 125# %IBW: 140% BMI: 29.2 kg/m2
EER: 1700-2000 kcal/d; EPR: 57-68 g/d; EER (for weight loss): 1300-1500 kcal/day
D: Excessive energy intake related to large portion sizes as evidenced by an estimated energy intake of ~2900 kcal/day per 24-hr recall (900 kcal more than estimated needs).
Undesirable food choices related to food- and nutrition-related knowledge deficit as evidenced by regular consumption of red meat and lower amounts of fruits and vegetables.
I: Nutrition counseling and education on portion control, increasing fruits and vegetables, reducing dietary fat intake and red/processed meat consumption.
Goals: Consume 1300-1500 kcal/day
Consume less than 18 oz red/processed meat per week (~2.5 oz/day).

M/E: Follow-up in 3-6 months
Monitor weight status, adherence to nutrition therapy
Monitor labs for glycemic control (BG, HbA1C - if available) and CVD risk (TG, Chol, LDL, HDL)
Reassess motivation level/acceptance to lifestyle changes (consider additional diabetes counseling if necessary)