Initial Dietetic Assessment
Date: October 15, 2023
Demographics:
- Name: John Doe
- DOB: January 5, 1975
- Age: 48
- Gender: Male
Referral Details:
- Referred by: Dr. Emily Smith, Endocrinologist
- Reason for referral: Management of Type 2 Diabetes
Medical History:
- Relevant medical conditions: Type 2 Diabetes, Hypertension
- Medications: Metformin 500mg twice daily, Lisinopril 10mg daily
- Allergies/intolerances: No known allergies
Anthropometrics:
- Height: 180 cm
- Weight: 85 kg
- BMI: 26.2
- Waist circumference: 95 cm
Biochemistry:
- Recent pathology results: HbA1c 7.5%, LDL cholesterol 130 mg/dL
Nutrition-focused Physical Examination:
- General appearance: Overweight, moderate abdominal adiposity
- Oral health: Good, no dental issues
- Skin integrity: Intact, no rashes or wounds
Diet History:
- Usual eating pattern: Three meals a day with occasional snacks
- Food preferences/aversions: Prefers savory foods, dislikes sweets
- Appetite: Good
- Fluid intake: Approximately 2 liters of water daily
Nutrition-related Symptoms:
- Gastrointestinal issues: Occasional constipation
- Other relevant symptoms: Fatigue
Physical Activity:
- Type and frequency: Walks 30 minutes daily, light gardening on weekends
Psychosocial Factors:
- Living situation: Lives with spouse
- Support network: Strong family support
- Barriers to dietary changes: Limited cooking skills
Nutrition Assessment:
- Estimated energy requirements: 2200 kcal/day
- Estimated protein requirements: 70g/day
- Identified nutrition issues: High carbohydrate intake, inadequate fiber
Nutrition Diagnosis: Excessive carbohydrate intake related to lack of knowledge as evidenced by high HbA1c levels
Nutrition Intervention:
- Goals: Reduce HbA1c to below 7% within 6 months, increase dietary fiber intake
- Nutrition education provided: Carbohydrate counting, reading food labels
- Strategies discussed: Incorporate more whole grains and vegetables, reduce portion sizes
Nutrition Monitoring and Evaluation:
- Parameters to monitor: Weight, HbA1c, dietary intake
- Follow-up plan: Monthly dietitian visits, coordination with endocrinologist
Jane Doe, RD, CDE
