Patient
NJ

Height: 5 ft 9 in

Weight: 254 lbs

BMI: 37.5

Registered Dietitian

Dilhari Gunathilaka, RD

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

Diagnosis and Treatment Plan

I. Assessment: F/U

30y/o F

Client reported her BG 97-130. Breakfast: waffle, 5 sasuages lunch/dinner: chicken, vegetables, brown rice.  She added vegetables to her meals since last visit.  She is motivated to make changes.

Today’s visit wt: 254 lbs. BMI: 37.5

Reviewed lab results

II. Diagnosis:

Overweight/Obesity (NC- 3.3) related to lifestyle/foods choices as evidenced by BMI of 37 and unhealthy foods normally eating by Pt.

Altered nutrition-related laboratory values (NC- 2.2) related to unhealthy lifestyle choices as evidenced by alternated labs

Exercises education, guidance, and counseling

Counseling

Provided MNT counseling for wt management, elevated lipids and elevated BG

Diet education

educated about weight management

Seen by dietitian


III. Intervention: Outcome Goals: decrease Nutrition related Labs/measurements, improve eating habits, decrease at least 5-10% of total body wt, LDL<100 and A1c<5.7

Patient Instructions

Provided MNT counseling for wt management, elevated lipids and elevated BG

Action Goals:

  • Follow the Create My Plate Method
  • Have 3 small meals and healthy snacks between meals
  • Have 3-5 serving of non-starchy vegetables per day
  • Continue to exercise/walk 7x per week for 20 min
  • avoid skipping meals
  • follow the recipes

Education:

  • egg recipe
  • waffle recipe

IV. Monitoring and Evaluation:

Will f/u with pt in 2  weeks to assess the attempt of dietary changes/knowledge

Topics Discussed

Weight Loss,Diabetes

Appointment History

Number of Sessions: 3

Last Updated: Jun 03, 2024