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NUTRITION PROGRESS NOTES – INITIAL CONSULTATIONDate6/2/2016ClientJanetInternAssessmentAge36GenderFemaleEthnicityunknown Family HistoryFamily history unknownClient’s ObjectivesClient would like to balance her home and work life Medical Diagnosis/ Health HistoryPatient presents with fatigue, insomnia, hypoglycemia, irregular menses, depression and dehydration (drinks at least 8 glasses of water a day). Anthropometric DataHt (inches, cm)63 inchesWt (lb/kg)120 lbsIdeal BW (lb/kg)118 lbsIdeal BW %19%BMI (kg/cm2)21.3%Waist (in, cm)25 - 25.3 inEstimated needs:Calories1,446Protein (cal, grams)43.5g/dayFluid (oz, ml)2.7 L/dayCurrent diet3 meals a day, mainly processed foods, caffeine and soda. Drinks at least 8 glasses of water a day. Relevant Laboratory DataFerritin, 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 ExamEarly morning fatigue, better energy at 6-7pm, often feels worse/more tired after exercise, irregular menses and dehydration. Meds/SupplementsNo meds/supplements.Physical ActivityDoes not exercise much it causes her to feel worse/more tired. Lifestyle/StressWife; mother; part-time consultant. Often stays up late at night to get work done & struggles to get up in the morning.Beliefs, Attitude, ReadinessFeels disengaged since leaving her job, husband is not around to help take care of her daughter, and believes she is experiencing PMS symptoms.Core ImbalancesCommunication imbalancesNutrition DiagnosisProblemPoor diet/lack of sleeprelated toAdrenal Insufficiency Syndrome as evidenced byfatigue, insomnia, hypoglycemia, irregular menses and depression, dehydration InterventionSee case study questions belowMonitoring/EvaluationSee case study questions below
NUTRITION PROGRESS NOTES – INITIAL CONSULTATIONCASE STUDY QUESTIONS/SUMMARY ASSIGNMENT1)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 snackTrauma/stressful event -stressful events of losing work identity and pregnancy caused symptom to worsen.