Ellen Miller

Medical Nutritional Therapy I

Case Study #1

9/21/17

Assessment: 21-year-old underweight, female patient with frequent history of the common cold and
sinus infection. Has been admitted to the hospital and diagnosed with Pneumonia. Frequent
consumption of highly processed foods, some containing high amounts of fat and sugar, along with a
very heavy consumption of caffeine throughout the day and night. No consumption of fruits, vegetables,
or much dairy. Only consumes dietary supplements occasionally. Does not consume breakfast regularly.
Is very physically active. Current body weight is 98 pounds with recent weight loss of 17 pounds over the
last three months from her usual body weight of 115 pounds. Height it 5’4” and therefore her BMI is 18,
classified as underweight. Many of her lab values came out very low, Potassium, Hemoglobin,
Hematocrit, percentage of Lymph, albumin, and MCV. She comes from a lifestyle full of pressure, peer
pressure, a wealthy family influence, and puts pressure on herself for school and her weight, didn’t
identify as anorexic. Upon visiting with the client, she showed signs of malnutrition with weak
appearance, dull and thin hair and nails, dry and itchy skin.

Diagnosis:

1) Inadequate oral intake R/t the highly processed foods & infrequent eating AEB the 24-hour
recall and significant weight loss.
2) Inadequate vitamin (K, C, and Riboflavin) intake R/t the frequent illnesses AEB the admission
into the hospital for pneumonia, physical appearance, low percentage of lymph and low vitamin
K value.
3) Excess caffeine intake R/t high intake of coffee (6-7 cups throughout the day) AEB 24-hour recall
and the deprivation of red blood cell volume.

Intervention (prescription): RD refer to mental health professional

1) RD recommends that client increases the frequency of meals to increase to a healthy weight and
increase energy. The recommended calorie amount for her, including healthy weight gain, is
2000-2500 kcal per day.
2) RD recommends that client increase the consumption of fruits, vegetables, and dairy products.
The recommended amount of fruit daily is 2 cups, the recommended amount of vegetables daily
is 2 ½ cups, the recommended amount of dairy daily is 3 cups.
3) RD recommended that client decrease caffeine intake to 3 cups per day.
Intervention (Goals):
1) RD recommends that client consume more frequent smaller meals, in the form of snacks
throughout the day. Have approximately 6 small meals to keep energy up of about 1-2 cups
each.
 2) RD recommends that client consume at least 2 servings of fruit (about 1 cup or one whole food),
consume at least 2 servings of vegetables (about 1-2 cups), consume at least 2 servings of dairy
(about 1 cup) within the small meals each day.
3) RD recommends that client consume high one cup of coffee in the morning and one midday or
less, and to consume high energy protein foods (eggs, lean proteins, nuts, peanut butter, whole
grains) and plenty of water instead the other parts of the day.

Monitoring & Evaluation:

1) RD will monitor within 1-3 days with the use of calorie counts, weight gain, Hemoglobin,
Hematocrit, and MCV values.
2) RD will monitor within 1-3 weeks with the use of a food journal, Potassium, and % lymph values.
3) RD will monitor within 1-3 days with the use of a Hemoglobin, Hematocrit, and MCV values.