Tanvi Dalal and Rebecca Tonnessen Case Study

Weight in kg: 117.9 kg

Height in cm: 180 cm
BMI: 36.3
IBW: 189.2 lbs, 75 kg
Total Energy Requirements: 3115.28 kcal/day
ADIME Note
Assessment
38 year old male who is pre-diabetic
Ht: 511, Wt: 260 lbs., BMI: 36.3
Medication: none
Vitamin/Herbal supplements: none
Labs: Doctor says that LDL levels are elevated
Estimated Energy Intake: 3,798 kcals/day
Family History: Father and uncle passed away due to heart attacks in their late 50s
Diet related behaviors: Client lives at home, however all his meals are eaten at the office.
Regular meals include lasagna, pizza, garlic bread and salad, while his snacks include a cup
of nuts or frosted flakes with milk. He leads a sedentary lifestyle over the week, but engages
in physical activity over the weekends.
Diagnosis
Excessive intake of high calorie foods for breakfast, lunch and dinner continues to be the
main issue.
Problem: Pre-diabetic, high LDL cholesterol levels, overweight
Etiology: Related to poor appetite, work stress and almost sedentary lifestyle
Signs and Symptoms: 511 male, 260 lbs, consumes approximately 3,798 kcals/day. Works
long hours, does not have time to prepare home cooked meals; therefore he has to resort to
ordering quick and easy meals.
Intervention
Nutrition- Related Behavior Modification Therapy using goal setting to encourage the client
to increase fruits and vegetables, decrease high calorie foods such as lasagna and pizza and
increase physical activity.
Outcome goals:
Decrease LDL cholesterol levels
Promote weight loss
Gradually increase length of physical activity
Monitoring and Evaluation
Will follow-up with the client in 1.5 months to assess attempted dietary changes and physical
activity status.

SOAP Note
Subjective Data
Patient claims father and uncle died of heart attacks in their late 50s. Patient is sedentary
during the week and claims to exercise on weekends. Patient may not get adequate sleep as
he reports working late during the week. Patient is not on any supplements or medications.
Patient claims his doctor said he has elevated LDL levels and is pre-diabetic. Patient takes no
medications, supplements, or vitamins. Dietary recall reveals he consumes 3,798 kcals. If this
dietary recall is accurate, he exceeds his energy intake for the day. He is also over his limit
for added sugar, saturated fat, and sodium. He consumes almost double the amount of
recommended sodium.
Objective Data: measurements/lab data
The patient is 511, 260 pounds, with a of BMI 36.3 (obese). The patient is a 38 year old
male.
Assessment/Plan
The patient is obese and over his IBW and consumes too many calories of processed food.
The patient does not exercise adequately for his calorie consumption. Patient is at risk of
becoming diabetic and gaining more weight. The patient should begin replacing refined
grains with whole grains, increasing fruit and vegetable intake, decreasing processed food
intake, and decrease portion sizes. Follow up with patient in 1 month to assess dietary
changes and see if pre-diabetes has progressed or reversed.