Reason for visit: Patient is seeking guidance on weight management and improving overall nutrition.
Assessment:
- Female, 35 years old, born on 15 March 1989
- Personal history: No significant medical history, family history of diabetes, non-smoker, occasional alcohol use
- Anthropometrics: Height 165 cm, weight 70 kg, BMI 25.7, weight history includes a gain of 5 kg over the past year, ideal body weight 61 kg based on Hamwi equation
- Weight history: Current goal is to lose 5 kg over the next 6 months
- GI: Regular bowel movements, no GI symptoms reported
- Nutrition-focused physical findings: Normal muscle and fat assessment, good skin turgor
Medications:
- None
Supplements:
- Multivitamin daily
Biochemical data: Normal blood glucose levels, slightly elevated cholesterol
Diet pattern: 3 meals and 2 snacks per day
Diet recall: Breakfast includes oatmeal and fruit, lunch is a salad with chicken, dinner is grilled fish with vegetables, snacks include nuts and yogurt, drinks 2 litres of water daily
- Diet history: Prefers vegetarian meals, no food allergies, food secure
- Previous diet attempts: Tried low-carb diet in the past
- Disordered eating: Occasional emotional eating during stress
Physical activity:
- Physical activity history: Jogging for 30 minutes, 3 times a week
- Physical limitations: None
- Interested in starting yoga
Lifestyle/social factors:
- Occupation: Marketing manager, hybrid work schedule
- Sleep quality: Fair, 6 hours per night, occasional disruptions
- Stress levels: Moderate, manages stress through meditation
Summary: The patient is a 35-year-old female seeking nutritional guidance for weight management. She has a family history of diabetes and has gained 5 kg over the past year. Her current goal is to lose 5 kg in 6 months. She maintains a balanced diet and regular physical activity but experiences occasional emotional eating. She is interested in incorporating yoga into her routine.
Diagnosis:
- Nutrition diagnosis: Overweight (ICD-10: E66.3)
- PES statement: Overweight related to excessive caloric intake as evidenced by BMI of 25.7 and recent weight gain
Intervention:
- Nutrition prescription: Reduce daily caloric intake by 500 kcal
- Food and/or nutrient delivery: Increase intake of fruits and vegetables, reduce processed foods
- Education discussed on specific nutrition guidelines, physical activity, health behaviors
- Counseling: Strategies to manage emotional eating and stress
- Coordination of nutrition care with other healthcare professionals if needed
- SMART goals: Lose 5 kg in 6 months by reducing caloric intake and increasing physical activity
Monitoring and Evaluation:
- Progress evaluation: Track weight, dietary intake, and physical activity
- Follow-up care: Schedule follow-up appointment in 3 months
Reason for visit: [patient's reason for visit and/or chief concern]
Assessment:
- [Patient's gender, age, birthday]
- [Patient's personal history: medical, family, and social history]
- [Anthropometrics: height, weight, BMI, weight history, including changes and ideal body weight based on Hamwi equation]
- [Weight history: current weight goals, describe weight trajectory including amount of weight lost/gain over time (only include if applicable)]
- [GI: bowel movement quality and frequency, any GI symptoms (only include if applicable)]
- [Nutrition-focused physical findings: muscle and fat assessment, fluid assessment, skin turgor (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)]
Medications:
- [list medications and dosage (only include if applicable)]
Supplements:
- [list supplements and frequency consumed (only include if applicable)]
[Biochemical data: lab results, medical test outcomes (only include if applicable)]
Diet pattern: [List number of meals and snacks eaten a day]
[Diet recall that includes breakfast, lunch, dinner, snacks, beverages, and water intake]
- [Diet history: dietary intake, food preferences, food allergies, food security (only include if applicable)]
- [Previous diet attempts (only include if applicable)]
- [Describe any disordered eating thoughts or behaviors, such as emotional eating, disorganized eating schedule, mindless eating, past or ongoing eating disorders, yo-yo dieting, etc. (only include if applicable)]
Physical activity:
- [Physical activity history. Include type of activity, exercise duration, and how many times a week (only include if applicable)]
- [Physical limitations and past/existing injuries (only include if applicable)]
- [Mention any exercises the patient expresses interest in (only include if applicable)]
Lifestyle/social factors:
- [Occupation: job title, work schedule, WFH/hybrid schedule/work onsite (only include if applicable)]
- [Sleep quality: rate sleep quality as good, bad, or fair. Hours of sleep a night. Mention any sleep disruptions, loud snoring (only include if applicable)]
- [Stress levels: describe stress levels and stress management techniques (only include if applicable)]
Summary:
[Provide a summary in paragraph form]
Diagnosis:
- [Nutrition diagnosis based on assessment data (only include if explicitly mentioned and insert relevant ICD-10 code)]
- [PES statement: Problem, Etiology, Signs and Symptoms (only include if explicitly mentioned)]
Intervention:
- [Nutrition prescription tailored to the patient's needs and goals (only include if applicable)]
- [Food and/or nutrient delivery: any dietary changes, supplementation (only include if applicable)]
- [Education discussed on specific nutrition guidelines, physical activity, health behaviors]
- [Counseling: strategies to guide the patient towards health priorities (only include if applicable)]
- [Coordination of nutrition care with other healthcare professionals if needed (only include if applicable)]
- [SMART goals]
Monitoring and Evaluation:
- [Progress evaluation: tracking physical activity, food intake, symptoms, lab values (only include if applicable)]
- [Follow-up care: deciding if and when a follow-up appointment is needed (only include if applicable)]
