M4-Addison\u2019s disease Case Study - NUTRITION PROGRESS NOTES INITIAL CONSULTATION Date Client Janet Intern Assessment Age Family History Clients

M4-Addisonu2019s disease Case Study - NUTRITION PROGRESS...

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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
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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.
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