Write an ADIME note for your initial nutrition assessment with your plans for education and follow-up

Question

What will be an ideal response?

Answer 1

Alicia Clarke (Nutrition consult for IBS)
7-10-12
A: 42 YOWF Dx: irritable bowel syndrome-Diarrhea (D); PMH: history of constipation and diarrhea, obesity, GERD, and hypothyroidism
Meds: Omeprazole 50 mg twice daily; Levothroxine 25 mcg; vitamin D 600 IU; 800 mg calcium; Lomotil prn. Elavil (25 mg daily), Metamucil (1 T in 8 oz. of liquid twice daily)
Skin: warm, dry
Abdomen: hyperactive bowel sounds x4; no organomegaly or masses - lower abdominal tenderness.
Labs: glu 115, Chol 201, Tg 171, HDL 42, HbA1C 6.1%, Urinalysis: WNL
Height: 5' 5" (65in.), Weight: 191 lbs. BMI: 32 (obese), IBW 125 +/- 10#, 153% IBW
Estimated energy requirements: 1250 -1420 kcal (22-25 kcal/kg IBW to facilitate weight loss)
Estimated protein requirements: 46-57 g per day
Diet Hx: diet reveals many fermentable oligosaccharides, disaccharides, monosaccharides, artificial sweeteners, and sugar alcohols are consumed (FODMAP assessment analysis). Snacks are high in fat as evidenced by cookies, cake, and ice cream. "Often" consumption of gas-producing foods including: asparagus, kidney beans, lentils, fruit juice, dried fruit, artificial sweeteners, and fructose, which may contribute to IBS symptoms. Daily high fiber sources include wheat, dried fruit, kidney beans, and lentils.
D: Nutrition-related knowledge deficit related to FODMAP food consumption as evidenced by FODMAP assessment with frequent consumption of asparagus, sugar alcohols, high-sugar foods, and lentils.
I: Goal: Identify food triggers that make symptoms worse and alleviate symptoms.
pt. will focus on elimination diet and re-introduction over 6-8 week trial.
pt. will be educated on the FODMAP foods to identify which foods may contribute to symptoms.
pt. will consider adding probiotics such as cheese, kefir, or yogurt to diet.
pt. may consider continuing weight reduction to improve overall health.
M/E: pt. will keep a food diary for six weeks to identify food patterns. Pt. should note when symptoms occur to identify food triggers. Pt. should note episodes of diarrhea.
Symptoms will be monitored as pt. eliminates FODMAP foods from diet over a period of time.