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Nutrition First Office Call

Pt Initials: E.K.

Appointment length: 60 min

ASSESSMENT
Client History
Reason for visit: Pt wants help with implementing SWANK diet to manage MS Sxs and feel
better.
Personal hx: 46 yo married AA F. No tobacco use.
Medical hx: Diagnosed with Relapsing and Remitting MS 4 yrs ago. Pt has had two severe
exacerbations since dx, followed by periods of remission. Exacerbations treated with Solu-Medrol
and Prednisone taper. Last flare up was 2 mos ago. Pt reports frequent headaches, instable
moods, drowsiness, weakness, and occasional clumsiness and coughing/choking with
fluids.
Family Med hx: CVD (Fa) and colon CA (PGF).
Social hx: Recently moved to a one story home to accommodate needs. Lives with emotionally
supportive husband. Both children are out of the house. Works as a librarian and has requested
to be half-time. Pt is financially secure.
Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results: Current diet reflects
preference for processed, convenience foods and eating out, with low fruit and vegetable intake.
Diet contains approximately 2300 kcal (130% needs), 54% of RDA for fiber, 17% of RDA for
vitamin A, and 43% of RDA for iron. Pts diet is high in fat (38% of kcal), and types of fats are
inconsistent with needs (pt consumes 222% of Swank Diet recommendation for Saturated fat and
45% of RDA for Omega 3 FA). No alcohol intake since Rxs. Pt reports occasional dysphagia
(coughing/choking) with liquids.
Food and Nutrition History: Pt reports limited awareness of nutritional impact of food choices
prior to dx.
Knowledge/Beliefs/Attitudes/Behaviors: Pt eats out 3-5 meals/wk and packs lunch for work.
Pt dislikes milk and radishes. Pt enjoys cooking, but finds it more difficult with Sxs.
Food Access and Preparation: Difficulty preparing food r/t MS Sxs. Pt and husband share
cooking tasks. Reports no financial barriers.
Food allergies/Intolerances: NKFA
Physical Activity: Works with personal trainer at gym 1x/wk, 15 minute stretching routine q
am, and swims 30 minutes 3x/wk.
Medications and Dietary Supplements: Prescribed Avonex, Klonopin, Baclofen, and Dulcolax.
Supplements include fish oil (1 Tbs/d) and Thorne Meta- Fem (4 pills/d). Pt also takes Tylenol prn
for occasional mild HA.
Anthropometric Measurements
Height (in/cm):
67 in / 170.2 cm
Weight (lb/kg): 162 lb/73.6 kg
BMI: 25.4 Kg/m2 (overweight)
Weight hx: slow 10 lb wt gain over last 5 yrs. Previously stable at 150 lb.
Other measurements: not assessed.
Ideal/reference weight: 122- 149 lb
Usual weight:
150 lb/68 kg
% Wt change:
+ 8% in past 5 yrs
Desired weight: not assessed.

%ideal/reference weight: 109%


%usual weight: 108%
Weight change classification: will monitor.

Biochemical Data, Medical Tests and Procedures


Pertinent labs/tests/procedures: TChol 202 mg/dL (High), Vitamin D 22 ng/mL (Low for
optimal levels). Alb, HDL, LDL, FPG, HCT, and Hgb WNL.

Nutrition Focused Physical Exam Findings


GI Function: BM qod, hard and small. No previous constipation prior to Rx. No N/V/D. BM now
more frequent with Rx.
Sleep hx: Sleeps 7 hrs per night.
Energy: pt reports energy level of 3 out of 10
Stress: pt reports stress level of 9 out of 10 r/t stress affecting ADLs.
Blood pressure: 116/78 mmHg at previous ND visit.
Overall clinical observation: Pt appears fatigued, but is motivated to learn about and
implement Swank diet.

DIAGNOSIS
Problem: Inadequate bioactive substance intake (NI 4.1)
Etiology: Limited awareness of nutritional impact of food choices
Signs and Symptoms: Diet low in vegetables (50% of Swank rcmd).
Problem: Intake of types of fats inconsistent with needs (Saturated fat, NI 5.6.3)
Etiology: Limited awareness of nutritional impact of food choices
Signs and Symptoms: Saturated fat intake is 222% of Swank recommendation.

INTERVENTION
Nutrition Prescription
REE/ Kcals: 1409 kcal (Mifflin) x 1.2-1.3 = 1690 1832 kcal/d
Protein (g/kg): 0.8-1.0 g/kg/d = 59-74 g/d
Fluids (ml/kg): 35 ml/kg = 2576 mL/d
Other: Swank Diet: Saturated fat <15 g/d, unsaturated fat 20-50 g/d, no red meat for first year
and 3 oz/wk thereafter, 1% or nonfat dairy products (2 cups/d), no processed food with saturated
fat, 1 tsp/d of cod liver oil, daily MVI, grains (4 servings/d), fruits (2 servings/d), vegetables (2
cups/d), and caffeine (3 cups/d).
Intervention 1: Nutrition Education Priority Modifications (E 1.2): Educated pt about following
the Swank diet to help manage MS sxs. Gave an overview of the different aspects of the diet and
compared to pts current dietary preferences. Asked pt to identify aspects of Swank diet that pt
felt comfortable focusing on, and decided to begin with increasing fruit and vegetable intake.
Discussed the benefits of consuming fruits and vegetables for bioactives and to support
antioxidant capacity and reduce inflammation to help manage MS sxs. Went over the Swank
recommendations for fruit and vegetable intake (goal: at least 2 servings each/day), discussed
what counts as one serving, and provided pt with fruit and vegetable serving size handout for
reference.
Intervention 2: Nutrition Counseling Problem Solving (C 2.4): Discussed with pt the
importance of reducing saturated fat in meals to help manage MS sxs. Briefly went over the fat
composition of different type of foods pt commonly consumes and brainstormed with pt which
aspects of current eating patterns could be modified to meet Swank guidelines of < 15 g/d of
saturated fat. Pt identified that eating out (both processed foods and in restaurants) contributed
greatly to saturated fat content, and agreed to start by focusing on saturated fat content of the
meat and dairy products. To fit with Swank guidelines, pt agreed to replace red meat with 4 oz of
fish or poultry, and to choose 2 cups of 1% or non-fat dairy products, including milk, cheese, and
ice cream per day. Created a list of lean meat options and low fat dairy milk, yogurt, cheese, and
ice cream products for pts reference.

MONITORING /EVALUATION
Professional goal#1: To reduce MS sxs, at next visit, dietary recall will show pt consuming 2
servings each of fruits and vegetables 4 days each week.

Professional goal#2: To reduce MS sxs, at next visit, dietary recall will show pt intake of lean
meat options such as poultry or fish (4 oz servings) and 1%/non-fat dairy products (2 cups/day)
3-4 days each week.
Follow up: Monitor dysphagia and potential COC with SLP, address other aspects of Swank diet
when pt is ready, discuss vitamin D supplement, and stress management.
Handouts provided: Fruit and Vegetable Serving Size handout.
Clinician signature: ________Katherine Ratlif____________________________________________