Patient
AJ

Height: 5 ft 0 in

Weight: 149 lbs

BMI: 29.1

Registered Dietitian

Xyomara Beltran, RD

Insurances: Aetna,Anthem,Blue Cross Blue Shield,Cigna,Humana,United Healthcare

Diagnosis and Treatment Plan

Notes: She went to the lung doctor and dx asthma. They gave her an inhaler. Doctors told he she can start exercising 2 x week. She danced last week twice. Medication for lung, montelukast. They did a breath test. She started eating more veggies. Paying attention to hunger feelings. Daily 1 small soda. Her body feels better when eating fruits and veggies. They started doing Hello Fresh some she likes some she doesn't like.  She is going to a concert on her birthday. She is going to a convention in October, collection of Pokémon card, etc in Charlotte. Upcoming funeral for her uncle. She had 2 people passed away w/n 2 yrs.

Trelegy

Montelukast

Her current barriers/goals?

  • does not want to order door dash past a certain time. (She is purchasing prepackaged meals at the grocery store)
  • parents don't decide until the moment of dinner what is for dinner that night, so she is not able to anticipate/prepare in any way (improving)
  • does not feel that there are options for her to eat in the house in the event that she did not like dinner and could not door dash (whether financial or time reasons) - Improving not door dash

Nutrition Intervention:

Discussed current behaviors/eating habits and helped set goals and recommendations for change.

Recommended MVI an omega 3 fatty acids.

Patient uploaded food pictures in the food journal and provided feedback. This time pt was open to it. Noticed for pt is still challenging to make changes to eat healthier. Pt is open to make some modification. Worked w/ pt to help her determine the changes she is comfortable with.

Pt is incorporating veggies and fruit at lunch and dinner

Continue to encourage to reflect on how she feels before the Dr. Pepper and after, encouraged other ways to get caffeine. Client is open to try cold green tea to try to replace Dr. Pepper. Suggested to make own cold green teat using Monk fruit.

Answered pt's questions and/or concerns.

Verbal education/encouragement given. Discussed focusing on opportunities vs limitation. Thinking about caffeine withdrawal vs possibilities and health

Pt expressed understanding of discussion/goals/recommendations expect, medium-low compliance

Monitoring/Evaluation

Action Plan: Dietitian will continue to monitor and remains available to address future nutrition related questions and concerns via chat.

Will monitor journal entries, exercise, food choices. Will assess client progress towards goals and will modify and/or add goals as needed to help client with goal of healthy eating and identify helpful educational materials.  During next session will continue to provide feedback on journal entry if client feels comfortable. Throughout our session will work with client to increase knowledge about food as medicine, intuitive eating, self-love, cravings vs choices (desires), increasing movement, nutrient dense foods.

Goals: (ongoing)

  1. Exercise more - walk on the treadmill 2-3 x at least 5 minutes or dance twice/week for 10-20 minutes as tolerated
  2. Increase variety on meals add a veggie w/ lunch and dinner
  3. Continue to have fruits twice a day
  4. Decrease soda intake to one soda per day at least 2 x week instead of twice per day. Substitute soda w/ Cold green tea
  5. Try fruit infused water
  6. Try air fryer for French fries
  7. Try low fat ranch salad dressing / low fat mayo.
  8. Tuna twice a week low fat mayo

Follow-up:  scheduled

Topics Discussed

Weight Loss,General Nutrition

Appointment History

Number of Sessions: 20

Last Updated: Jun 01, 2024