Patient
GB

Height: 5 ft 1 in

Weight: 135 lbs

BMI: 25.5

Registered Dietitian

Jaclyn Bart, RD

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

Diagnosis and Treatment Plan

Nutrition Diagnosis

PES: Nutrition and food knowledge deficit r/t no previous diet education re: DM/GERD diet AEB patient interested in learning how to eat with DM/GERD

PMH: DM2, GERD, hx of colectomy (unsure of location), Hiatal Hernia, HTN, NHL S/P chemo, osteoporosis.

Medications: Omeprazole 40 mg, Metformin 500 mg BID, Reclast IV, Metoprolol tartrate 25 mg - Take .5 tables BID, Albuterol inhaler, Aspirin 81 mg, Fish Oil 300-1,00 mg (2 daily).

C/O stomach pain (lower), reflux. Pt has found some foods that appear to irritate the GERD such as french fries, cole slaw, salad, corn, pepperoni pizza. She avoids spicy/Mexican foods.

When she is not using her Omeprazole (delayed prescription), she struggles with significant reflux, burping.

Normal BM. Daily. Formed.

Intervention: Notice foods that upset the GERD, Implement some appropriate food choices for GERD, symptom journal.

Nutrition Intervention

Education materials provided:

GERD handout, Gas Handout

Intervention

1. Meals and Snacks (ND -1) and Nutrition Education (E -)

24-hour dietary recall:

B: Oatmeal, Dates, Nuts

L: French Frieds, Orange Pop

D: Kielbasa, 2 Pierogis

Snacks: 8 cherries, Chocolate Malt

Fluid: Water- 32 ounces, no EtOH

2. Nutrition Counseling (C-1): Goal Setting For Physical Activity

To discuss physical activity at f/u appointment

B. Planned Exercise:

To discuss physical activity at f/u appointment

3. Nutrition Counseling (C-1): Goal Setting For Nutrition

Identify foods that set off GERD symptoms

4. Nutrition Counseling (C-1): Self-Monitoring

A. Journal - Keep daily journal of intake and exercise

B. Weight Checks: Weigh and document in journal

Monitoring and Evaluation

Follow up

June 7 at 5:30


Topics Discussed

GERD,Gut Health

Appointment History

Number of Sessions: 1

Last Updated: May 31, 2024