NUTRITION PROGRESS NOTES –
INITIAL CONSULTATION
Date
6/2/2016
Client
Janet
Intern
Assessment
Age
36
Gender
Female
Ethnicity
unknown
Family History
Family history unknown
Client’s Objectives
Client would like to balance her home and work life
Medical Diagnosis/
Health History
Patient presents with fatigue, insomnia, hypoglycemia, irregular menses, depression and dehydration
(drinks at least 8 glasses of water a day).
Anthropometric Data
Ht (inches, cm)
63 inches
Wt (lb/kg)
120 lbs
Ideal BW
(lb/kg)
118 lbs
Ideal
BW %
19%
BMI (kg/cm2)
21.3%
Waist (in,
cm)
25 - 25.3 in
Estimated needs:
Calories
1,446
Protein (cal, grams)
43.5g/day
Fluid (oz,
ml)
2.7 L/day
Current diet
3 meals a day, mainly processed foods, caffeine and soda. Drinks at least 8 glasses of water a day.
Relevant Laboratory
Data
Ferritin, Sodium,
T4, T3, Serum B12, Folate and DHEA all within normal limits.
Elevated levels of Potassium, BUN, Eosinophils, Diurnal Cortisol,
and TSH.
Nutrition Focused
Physical Exam
Early morning fatigue, better energy at 6-7pm, often feels worse/more tired after exercise, irregular
menses and dehydration.
Meds/Supplements
No meds/supplements.
Physical Activity
Does not exercise much it causes her to feel worse/more tired.
Lifestyle/Stress
Wife; mother; part-time consultant.
Often stays up late at night to get work done & struggles to get up
in the morning.
Beliefs, Attitude,
Readiness
Feels disengaged since leaving her job, husband is not around to help take care of her daughter, and
believes she is experiencing PMS symptoms.
Core Imbalances
Communication imbalances
Nutrition Diagnosis
Problem
Poor diet/lack of sleep
related to
Adrenal Insufficiency Syndrome
as evidenced by
fatigue, insomnia, hypoglycemia, irregular menses and depression, dehydration
Intervention
See case study questions below
Monitoring/Evaluation
See case study questions below
NUTRITION PROGRESS NOTES –
INITIAL CONSULTATION
CASE STUDY QUESTIONS/SUMMARY ASSIGNMENT
1)
Assess the patient’s story in the context of the Integrative and Functional Medicine Nutrition Therapy Model as
it relates to the:
Antecedents -
Environmental stressors of trying to balance her home and work life.
Triggers -
Psychological/physical stress worsened with pregnancy.
Mediators -
Ongoing psychological/physical stress and sleep deprivation.
2)
Identify any risk factors in this case.
Poor nutrition.
Diet consists of processed foods, caffeine and soda.
Insufficient sleep
. Often stays up until midnight and struggles to get up in the morning.
Poor circadian rhythm regulation
.
Low energy throughout the day, doesn't feel energized until around 6-7
pm.
Stimulants
- Drinks 2-3 cups of coffee for breakfast and a cola with her snack
Trauma/stressful event -
stressful events of losing work identity and pregnancy caused symptom to worsen.
