Dietary/Nutrition Case Study Format

Your report should include all that are appropriate. Be concise and focus on
relevant, significant information.

Introduction

1. Patient Details ( Sex, Age, Admission date, /Chief Complaint / Problem (reason
for referral)

Dietary/ Nutrition Assessment

2. History of Present Problem / Illness

3. Past Medical History

4. Family History (Hx /died or having cancer, CHD, DM, BP risks)

5. Social History (working hours/shift/home maker)

6. Medications – explain why the patient is on the medication

7. Potential Drug and Nutrient Interactions – include nutrition related side effects

8. Pertinent Lab Values – explain what the value indicates

9. Nutrition Screening Data/Score – ex. height, weight, BMI etc…

10. Nutritional Requirements (Energy, Protein, Fluids)

11. Nutrition History or Diet Analysis

Dietary Intervention
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11. Impressions of the Problem/Evaluation

12. Plan – include short term and long term goals

13- Follow up

N.B: Please make sure that to give your justification/Rationale for each of your
Dietary in-put for example if recommended High protein High Calorie diet (give
the reason).
14. Discussion

Summarise the major problem/s

Identify alternative solutions to this/these major problem/s (there is likely to be

more than one solution per problem)

Briefly outline each alternative solution and then evaluate it in terms of its
advantages and disadvantages

a. Etiology of the problem

b. Pathophysiology
c. Symptoms
d. Complications
e. Treatment
i. Medical
ii. Nutritional

15. Summary/Conclusion/ Critical analysis

Sum up the main points from the findings and discussion.

16. Recommendations
Choose which of the alternative solutions should be adopted
Briefly justify your choice explaining how it will solve the major problem/s
This should be written in a forceful style as this section is intended to be
persuasive
Here integration of theory and practical practice is appropriate.

17. References

There are many styles which follow the author-date convention, including the
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American Psychological Association (APA) and the Chicago Manual of Style,

Australian style manual (AGPS style), however, you can use of the Harvard Style
(AGPS).

See examples in electronic databases and electronic journals are cited as Harvard
style.