Subjective

Wants to eat more fruits and vegetables and describes lifestyle as very active. Describes
appetite as “good”, identifying being a college student as a financial factor.
Objective
22-year-old male, no pertinent medical history, no medications or supplements, height:
6feet 2inches (187.2cm), weight: 206.14lb (93.7kg), ideal bodyweight: 188.2lb, % desirable
body weight: 109.5%, BMI: 26.7kg/m2, knee height: 59.8cm, elbow breadth: 6.5cm, waist
circumference: 19.3cm, medium frame size: r=9.7, mid arm circumference: 34.8cm, chest
skinfold: 13mm, abdomen skinfold: 28mm, thigh skinfold: 26mm, triceps skinfold: 14mm,
suprailium skinfold: 21mm, subscapular skinfold: 21mm, waist circumference: 37 3/8inches
(94.8cm), hip circumference: 43 7/8inches (94.8cm), cMAMA: 63.5cm, % body fat: 19.8%, T-
score:1.3, triglycerides: 72mg/dL, total cholesterol: 189mg/dL, LDLc: 110mg/dL, HDLc:
64mg/dL, blood glucose: 108mg/dL, hemoglobin: 14.4g/dL, hematocrit: 42%, blood pressure:
126/58mmHg
Physical assessment findings: normal
Dietary: Estimated energy expenditure: 3,756-4,292kcals, 3 day food record intake
average kcals: 3,004, carbohydrates: 346.3g (46%kcals), protein: 151.6g (21%kcals), fat: 113g
(34%kcals), fiber: 23.4g (61%RDA), calcium: 2,256.7mg (225%RDA), Iron: 22.1mg
(276%RDA), vitamin C: 14.5mg (16%RDA), vitamin E: 5.7mg (37%RDA), vitamin K: 43.2ug
(35%RDA), vitamin D: 509.3IU (84%RDA), sodium: 7,128.8mg (475%RDA), magnesium:
269.5mg (67%RDA), potassium: 3,082.7 mg (90%RDA), Omega-3: 1.4g(86%RDA), Omega-6:
13.5 (79%RDA), 0 servings of fruits of recommended 2 1/2cups, about 1 cup of vegetables out
of recommended 4 cups a day, >10 ounce equivalents of grains as recommended, >7 ounce
equivalents of protein as recommended, >3 cups of dairy as recommended
Assessment
Inadequate intake of fruit as evidenced by the 0 cups consumed via the 1-day food group
record in comparison to the recommended amount of 2 1/2 cups a day
Excessive intake of sodium as evidenced by the 7,128.8mg/day as shown on the 3-day
food record averages which is 475% of the sodium RDA

Plan
1. Provide patient with less processed meal options that can still be affordable and
relatively easier to prepare still. Provide patient with food intake records.
Goal: Patient will record food intake for one week then reevaluate sodium intake
and meal options to lower if still necessary.
2. Provide patient with different ideas how to include fruit in their diet, such as buying
canned or frozen fruit (even though they might have added sugar) if the price of fruit
 as a college student is one of the causes for this issue. Provide patient with food
intake records.
Goal: Patient will record food intake for a week and re-evaluate the amount of
fruit in their diet (aiming at 2 ½ cups a day) and re-visit ways to incorporate more
fruits into the diet, and what/if any barriers to this issue still exists.
3. Encourage the patient to incorporate fruit into their diet more following tips found on
choosemyplate.gov (https://www.choosemyplate.gov/focus-on-fruits) such as
experience with flavors, keep visible reminders, and try to incorporate them into all
meals. Provide patient with food intake records.
Goal: Patient will record food intake for one week trying to consume 2 ½ cups a
day and reevaluate.