Patient
AC

Height: 5 ft 4 in

Weight: 105 lbs

BMI: 18

Registered Dietitian

Janelle Bigelman, RD

Insurances: Aetna

Diagnosis and Treatment Plan

Diagnoses:

1. Food, nutrition, and nutrition-related knowledge deficit r/t lack of prior diet education AEB pt reports difficulty adhering to diet that is promotive of health, weight maintenance and to optimize her GI health

2. Underweight r/t suspected inadequate PO intake AEB BMI of 18 kg/m2

Interventions:

  1. Increase amount of fluids drunk daily to optimal amounts, meeting >75% of fluid needs daily.
  2. Consume a minimum of 25 grams of fiber daily
  3. Prioritize wholesome foods like fruits and vegetables, and ensure to incorporate lean protein with every meal. Meals should be well-balanced, including a healthy source of fat, complex carbohydrates, fiber and protein.
  4. Eat 3 nutrient-dense meals daily with 1-2 snacks in between each meal.
  5. Incorporate at least 2-3 days of resistance training per week for a minimum of 30 minutes each session.
  6. Optimize sleep and recovery, by ensuring 8 hours of quality sleep per night.

Monitoring/Evaluation

Monitor weight, physical activity, labs, GI, sleep, fluid and oral intake

Goals:

  1. Implement tips/recommendations of diet modifications laid out in nutrition plan created and shared by RD after each follow-up
  2. Drink adequate amount of fluid to meet >75% of intake needs daily
  3. Maintain body weight within 1-2 lbs. indefinitely, with slight weight gai
  4. Improve sleep quality throughout RD sessions
  5. Improve GI health and reduce symptoms of GI distress by next f/u
Topics Discussed

IBS,General Nutrition

Appointment History

Number of Sessions: 1

Last Updated: May 31, 2024