Name _Cassandra Collevecchio

Part 4 Summary Analysis using the Nutrition Care Process (20 points)

OUTPATIENT NUTRITION CLINIC

Date
Name

Collevecchio, Cassandra

3/5/1995

(Last, First)

(Date of Birth )

4/13/15

Assessment
Chief complaint/reason for visit: Weakness, tiredness, muscle cramps
Diet History/Meal Pattern:

Tries to eat somewhat healthy. Patient says she tries to stay away from fast food or fried food.
However, even though she does not claim to be a vegetarian, she consumes limited meat
because it takes too much time out of her day to cook. She has Acid Reflux, so she tries to stay
away from certain trigger foods. She has 0% of the recommended amount of fruit servings
when calculated by SuperTracker. She says she doesnt eat much fruit due to pickiness, but
would like to find fruits that could fit into her diet. From her 24 hour recall, it was found that she
only had 3422mg of potassium and a 73% percent of DRI for potassium.

Nutrition Supplements: N/A

Physical Activity: Moderate walks to class and goes to the gym for and hour 4 times/week
Food allergies / Intolerance: N/A
Medical diagnosis related to this visit: Deficiency of potassium due to inadequate fruit intake
Pertinent past medical or nutrition history: Acid Reflux
Medications: N/A
Vital Signs: Blood Pressure = 104/63 mmHg, Pulse = 61 bpm
Anthropometric Data:
20
Female
Age
(in years)

56

127lbs

130lbs

---

20.5

Ht

Wt

Ideal
body wt

Adjusted
body wt

BMI

Gender

Based on BMI patient is: (Circle one)

Energy and protein needs:

1800 kcal/day
Estimated kcalorie
needs/day

normal weight

overweight

obese

Actual

46 g

Actual

Indicate if based on actual,

adjusted or ideal wt

Estimated protein
needs/day

Indicate if based on actual,

adjusted or ideal wt

Patient understanding (Circle one):

Expected compliance (Circle one):
Page 1 of 1

underweight

Good
Good

Fair
Fair

Poor
Poor

Adapted from Hershey Medical Center Nutrition Services Form