By Lani | Initial Nutrition Consultation Notes

<u>Overview</u> - Client Name: Sarah Jenkins - Age: 34 - Height: 165 cm - Occupation: Marketing Manager --- **PRIMARY COMPLAINT – **Chronic fatigue and unexplained weight gain • Location: Generalised throughout the body, primarily impacting energy levels - **Onset: **Started approximately 18 months ago, gradually worsening after a period of high work stress. - **Provocation: **Lack of sleep, high-stress periods at work, irregular meal times, consumption of sugary foods. **• Palliation: **Rest, short periods of vacation, mindful eating of whole foods, occasional B vitamin supplements. **• Quality: **Constant feeling of sluggishness, difficulty concentrating, brain fog, and a persistent dull ache in muscles. **• Severity: **7/10 at its worst, interfering significantly with daily activities and work productivity. **• Timing: **Worse in the afternoons and evenings, especially after lunch. Mornings are slightly better but still not optimal. **• Understanding: **Client believes it's related to chronic stress from her demanding job and poor eating habits developed during that time. **• History: **Has tried various over-the-counter energy supplements with no sustained improvement. Saw a GP 6 months ago who suggested lifestyle changes but no specific diagnosis was made. --- **ADDITIONAL COMPLAINTS – **Digestive discomfort (bloating, occasional constipation) • Location: Abdominal area - **Onset: **Coincided with the onset of fatigue, approximately 18 months ago. - **Provocation: **Eating large meals, particularly those high in processed foods or dairy. **• Palliation: **Smaller meals, drinking warm water, gentle exercise like walking. **• Quality: **Feeling of fullness, distension, and infrequent bowel movements (every 2-3 days). **• Severity: **5/10 when active, uncomfortable but not debilitating. **• Timing: **Most prevalent after meals, especially dinner. **• Understanding: **Client links it to her diet and stress affecting her gut. **• History: **No prior significant digestive issues. Has tried probiotics briefly but didn't notice a major change. --- **REVIEW OF SYSTEMS – ** **• GIT: **Bloating after meals, occasional constipation (bowel movements every 2-3 days, sometimes hard), no current heartburn or reflux. Reports some gas. Craves sugary foods. **• Reproductive / Menstrual Cycle: **Regular menstrual cycle (28 days), moderate flow, mild premenstrual symptoms (mood swings, slight bloating). Not currently on hormonal contraception. No fertility concerns. **• Nervous System: **Reports brain fog, difficulty concentrating, and occasional headaches. Sleep quality is poor, often waking up multiple times a night. Energy levels consistently low. **• Immune System: **Prone to catching colds more frequently in the last year (3-4 times a year). No known autoimmune conditions. **• Cardiovascular System: **No history of heart disease, palpitations, or high blood pressure. Occasional light-headedness upon standing quickly. **• Musculoskeletal: **Dull muscle aches, particularly in shoulders and neck, attributed to desk work and fatigue. No joint pain or swelling. **• Urogential: **No urinary tract infections. Normal frequency of urination. No discomfort. **• Integumentary System: **Skin is generally clear, occasional dry patches on elbows. Nails are brittle. Hair loss noticed in the last 6 months. **• Liver: **No history of liver issues or jaundice. Denies excessive alcohol intake. --- **LIFESTYLE – ** • Sleep: Typically goes to bed around 11:30 PM, wakes up around 7:00 AM. Struggles to fall asleep quickly (takes 30-60 mins), wakes up 2-3 times per night, and reports not feeling refreshed upon waking. Often uses phone before bed. **• Energy: **Energy level is typically 3/10. Experiences a significant dip in energy post-lunch, requiring caffeine to push through the afternoon. - **Stress: **Stress level is consistently 8/10 due to high work demands and personal commitments. Presents as irritability, anxiety, and jaw clenching. Better with weekend breaks and meditation practice (when she remembers). **• Mood: **Mood is generally 5/10. Often feels overwhelmed and low-spirited due to fatigue and perceived lack of control over her health. Better when spending time outdoors or with friends. **• Physical Activity: **Attends a spin class twice a week (Monday, Wednesday evenings). Walks for 20 minutes on her lunch break 3-4 times a week. Work is largely sedentary. **• Other Social & Lifestyle Factors: **Active social life on weekends. Enjoys cooking but finds she lacks energy for it during the week. Lives with a partner. Does not smoke. --- **PERSONAL HISTORY – ** **• Family Medical History: **Maternal grandmother had Type 2 Diabetes. Father has high blood pressure. No known autoimmune or significant chronic diseases in immediate family. **• Personal Medical History: ** 0-4 years (early childhood) – Frequent ear infections, tonsillectomy at age 3. 5-12 years (primary school) – No significant medical events. Active and healthy. 13-18 (high school) – Mild acne. No chronic illnesses. 19-25 (young adult) – Recurrent thrush infections in early twenties, treated with antifungals. Mononucleosis at age 22. 26+ (adult years) – Diagnosed with IBS-like symptoms at age 28, managed with diet changes (reduced dairy). Chronic fatigue and weight gain started at age 32. **• Last Medical Check-up: **April 2024 for general health check-up. Blood tests showed slightly elevated cholesterol but otherwise normal. GP advised lifestyle modifications. --- **DIETARY ANALYSIS OF A NORMAL DAY ** • <u>Breakfast</u> – 7:30 AM: Toast with avocado (1 slice white bread, 1/2 avocado). Sometimes a small bowl of sugary cereal (e.g., Kellogg's Corn Flakes) with semi-skimmed milk. **• <u>Snack</u> **– 10:30 AM: Grab-and-go muffin from a coffee shop or a packet of crisps. • <u>Lunch</u> – 1:00 PM: Shop-bought sandwich (e.g., chicken salad on white bread) or a pre-packaged salad with creamy dressing. Often includes a fizzy drink (Coca-Cola). - <u>Snack</u> – 4:00 PM: Chocolate bar (e.g., Cadbury Dairy Milk) or biscuits (e.g., two digestives) with a cup of tea (with milk and 2 sugars). • <u>Dinner</u> – 7:30 PM: Often a ready meal (e.g., supermarket lasagna) or a quick stir-fry with noodles and minimal vegetables. Partner usually cooks once or twice a week (more balanced meals). **• <u>Dessert</u> **– 8:30 PM: Small bowl of ice cream or a couple of biscuits. • <u>Water</u> – Approximately 1-1.5 litres per day, mainly with meals. Struggles to drink consistently throughout the day, often forgets until she feels thirsty. **• <u>Alcohol</u> **– 2-3 standard drinks per week, usually red wine on Friday/Saturday evenings. • <u>Other Beverages</u> – 2-3 cups of black coffee in the morning, 2-3 cups of tea (with milk and sugar) in the afternoon. • <u>Takeaway</u> – 1-2 times per week (e.g., pizza, Indian curry) on evenings when too tired to cook. **DIETARY ANALYSIS OF A BUSY DAY ** • <u>Breakfast</u> – On busy days, often skips breakfast or grabs a coffee on the go. **• <u>Snack</u> **– Mid-morning snack is usually skipped or consists of a quick sugary item if energy crashes. • <u>Lunch</u> – Quick desk lunch, often a larger portion of a shop-bought sandwich or a pastry. - <u>Snack</u> – More frequent sugary snacks to combat energy dips. • <u>Dinner</u> – Reliant on takeaway or ultra-processed ready meals due to lack of time and energy. **• <u>Dessert</u> **– Similar to normal day, seeking comfort from sweet foods. • <u>Water</u> – Significantly less, often less than 1 litre. **• <u>Alcohol</u> **– May have an extra drink to de-stress in the evening. • <u>Other Beverages</u> – Increased coffee intake to stay alert. • <u>Takeaway</u> – Up to 3-4 times per week. --- ADDITIONAL DIETARY INFORMATION **• Cravings: **Strong cravings for sugary foods (chocolate, biscuits) and salty snacks (crisps) particularly in the afternoon and evening when energy is low. **• Food Aversions: **No specific strong aversions, but dislikes overly spicy food. • Allergies / Intolerances: Reports mild intolerance to dairy, which can exacerbate bloating. - **Veggie Intake: **Estimated 1-2 cups of vegetables per day, mainly from stir-fries or pre-packaged salads. Not consistently meeting recommendations. - **Fruit Intake: **Estimated 1 serve of fruit per day, usually an apple or banana. --- PHYSICAL ASSESSMENT **• Tongue: **Slightly pale with a thin white coating. **• Nails: **Brittle, prone to breaking, with faint vertical ridges. **• Capillary Return: **Normal, less than 2 seconds. **• Skin Turgor: **Good, no tenting. **• Eyes/undereyes: **Mild dark circles under eyes, slight puffiness. --- CURRENT MEDICATIONS & SUPPLEMENTS **• Medications: **None currently. **• Supplements: **Multivitamin (generic brand) daily, approximately 6 months (no perceived change). Omega-3 fish oil (1000mg) daily, 3 months (reports slight improvement in dry skin but no impact on fatigue).