Rachel Matlock

UGI ADIME
FSN 430
Assessment:​ 45 YOWM with busy work schedule. Pt. complains of hip and knee pain,
abdominal, and heartburn. Pt. takes Tylenol and Advil everyday to help with pain. Pt. complains
of increased indigestion from mid-afternoon to bedtime. Pt. takes Tums as needed and is
worried about his health. MD has told pt. To consult RD for GERD and prescribed pt.
lansoprazole 30mg, daily.
Client Hx: Pt is currently taking Advil/Tylenol daily with food interactions can increase mild
heartburn effects and indigestion. Pt. also takes Tums when needed
Anthropometrics:
● Ht: 175.26cm (69”)
● Wt. 87.27kg (192#)
● BMI: 28.5 (overweight)
● IBW: 72.7kg
● IBW%: 120%
● UBW: 79.5-81.8kg
● UBW%: 106-109%
Pt. is overweight with a BMI of 28.27 and above his IBW by about 15kg. Pt. is not at his usual bw
of 79-81kg and is mildly over his UBW. Pt. is not obese but needs to watch his weight. Pt. does
not talk about any PA measures due to his body pain.

Biochemical:​ Pt.’s glucose, overall cholesterol, TG, and LDL are high and he has a low HDL value.
MD states pt has dyslipidemia.

Clinical:​ Pt. appears overweight and his hip and knee are hurting him.

Diet Hx​: Per 24-hour recall, pt. Is consuming 2,410kcals (27.6kcal/kg), 97g protein (1.1g/kg,
16%), 295g carbohydrates (3.3g/kg, 49%), and 94g fat (1.1g/kg, 35%). Diet is high in sodium and
very high in fat sources. Diet lacks fruit completely and does not have adequate vegetable
consumption. Diet is also low in fiber with no whole-grain containing products. Pt. is using MCT
oil supplementation in his morning coffee and should consider stopping use, as it contributes
14g of fat to his total. Pt. also should consider cutting out caffeine and alcohol to reduce GERD
symptoms. No other supplementation is recorded, but could consider taking vitamin C
supplementation if pt. cannot improve with diet. Pt. is consuming 106% of his estimated energy
intake. Pt. does not report any allergies or intolerances, besides that fatty food makes his GERD
symptoms worse. Pt. seems to have limited food-related knowledge and lives a very busy
lifestyle and claims he does not have time.
Estimated Daily Needs:
Estimated kcal needs: 2,272kcals (26kcal.kg) using Mifflin St. Jeor and AF of 1.3, for a weight loss
of .5-1lb/week, pt. Should decrease consumption to 2,000kcals-1800kcals/day
Fluid needs: 2000ml/day
Na: start off with 2,000mg and decrease as tolerated
For weight loss using 2,000kcal goal:
Protein: 90g (18%, 1g/kg)
Carb: 262g (53%, 3g/kg)
Fat: 64g (29%, .73g/kg)

Diagnosis:

1. Altered GI function related to incompetence of LES, caffeine intake, alcohol intake, and
high fat diet as evidenced by 24 hr recall, consistent with lab values, and weight gain.
2. Overweight related to high fat intake and frequent food away from home as evidenced
by 24 hour recall and weight gain.

Intervention:

Goal #1:​ Cessation of caffeine and alcohol intake and decrease total fat intake to 30% of total
kcals.
Strategies:

- Decrease caffeine intake to 0-1 cups per day.

- Discuss with pt alternate substitutes for coffee that are not caffeinated such as
herbal teas or lemon water.
- - Recommend pt to keep a food diary in order to assess his symptoms
afterwards,
especially after drinking trigger foods such as coffee, alcohol, high fat food
choices, and chocolate.
- Decrease alcohol intake to one serving per day (5oz) or less.
- Demonstrate to pt what one serving of red wine (5oz) is considered and
strategies on how to limit it to 0-1 servings per day such as substituting it with
water.
- Decrease consumption of a high fat diet from 94g (35%) to 64g per day (29%).
- Discuss with pt strategies on how to decrease consumption of fat by showing pt
a sample menu plan that limits calories from fat to 30%.
- Increase pt education by demonstrating to pt what is considered a serving size of
fat.
- Discuss with pt examples of PUFA and MUFA in order to substitute for butter.

Goal #2:​ ​Reduce calorie intake to 1800-2000kcals /day for a weight loss of .5-1lb/week.

Strategies:

- Limit take-out food to 2x/week

- Decrease total fat intake to 30% of total kcal
- Decrease saturated fat intake to less than 7% of total fat calories
- Increase physical activity to 4x/week for 30-45min to exercise capable due to his
complaint of knee and hip pain
- Educate pt. on meal-prepping and cooking skills with handouts and
demonstration videos
 - If choosing to eat out, pt states he chooses to eat foods such as a bacon
cheeseburger. Encourage pt. to make smart decisions when it comes to eating out by
limiting high saturated fat options

Monitoring and Evaluating:

- Reorder lab values in 3 weeks to see progress made and hopefully a decrease in LDL, TC
TG, BG, and a raise in HDL. Repeat reorder of labs every 3 weeks until steady progress is
made. If not made in 6 months, consider medication alternative.
- Assess pt. food diary weekly for 2 months to ensure that pt. Is understanding the
substitutes and modifications made.
- Assess pt. confidence levels on portion size and nutrition education
- Test pt at next RD visit to see if he understands the difference between saturated and
unsaturated fat
- Develop follow-up plan and go over with pt every month to ensure diet success and
reduction of GERD symptoms

Rachel Matlock, Student of Nutrition, April 26, 2020