Katie Escobar

Ambulatory Care

Mr. Robertson
DOB: 11/5/1953
Age: 75 Years Old

Nutrition Assessment:
This is a 30-minute face to face follow-up nutrition consultation. Patient is a 75-year-old
male referred for dietary counseling for Malnutrition and Oncology.

Reason for Visit

Patient made an appointment for management of possible malnutrition and recent

metastatic prostate cancer progression. He had previously visited a dietitian for advice
on healthy eating to lose weight after gaining 4 lbs. (2 kg) a month in the six months
after retiring. In his second visit, he was sent to a dietitian for hypertension management
and in his third visit, 9 years ago, he was referred for Type 2 Diabetes management. He
has now come for Malnutrition and Oncology dietary management. Summary of
previous diagnoses and progressions are below.

Medical History/Family Medical History:

Father passed away from myocardial infarction at age 55. Mother and older brother
were both diagnosed with type 2 diabetes in their sixties. Patient has a family history of
hypertension. Patient was diagnosed with Stage 1 hypertension at age of 65 and type 2
diabetes at 66 and was diagnosed with prostate cancer 5 years ago that has recently
been found to be metastatic.
Anthropometrics

Height: 69 in (175 cm)

Current weight: 170 lb. (77.1 kg) Current BMI: 25.1 kg/m2 (Normal for > 65 years old)
Usual Body Weight: 184 lb. (83.4 kg); UBW %: 92% (Mild depletion)
Ideal Body Weight: 160 lbs. (73 kg); IBW %: 106%

Patient has lost 14 pounds. (6.4 kg) in the last 6 months. This is an 8% decrease from
his usual body weight of 184 lbs. Patient’s weight has been stable at 170 lbs. for the last
2 weeks.

Food and Nutrition Related History:

Notes:
 Overall low protein intake
 Low intake of fruits and vegetables
 No food snacks consumed except on Saturday and Sunday (2 scoops of ice cream in the
evening)
 Not very high calorically dense foods or beverages consumed
 Does not finish his evening meals
 Cooks using a non-stick pan
 No longer eats a hot breakfast
 Been eating less in general for last month

Food and Nutrient Administration

 Previous diet modifications have revolved around decreasing overall caloric intake for
weight loss, consuming lower sodium foods, implementing carbohydrate counting for type 2
diabetes management

Patient Knowledge/Beliefs/Attitudes:

 Inadequate knowledge about malnutrition and consequences

 Inadequacy of knowledge relating to high energy dense foods and beverages
 Patients explained he was “keen to gain his energy back” so he can continue to
enjoy his retirement

Nutrition-Focused Physical Findings

 Depression in the temple

 Mild Fat loss from orbital pads
 Acromion Process is protruding
 Modest amount of fat on biceps and triceps (Mild muscle deficit)
 Interosseous muscle is depressed
 Thigh and calf are still rounded but not well developed (Mild muscle deficit)
 Bones in knees are prominent
 No edema or ascites
 No evidence of dehydration
 Appears to have possible depression
 Blood Pressure: 130/85 mmHg (Hypertension Stage 1)
 Clothes fit looser

Other Nutrition Impact Symptoms

  Finds smell of food unappetizing
 Distaste for greasy food now
 Fatigue
 Mourning death of close friends and shows signs of possible depression
 Overall diminished appetite

PG-SGA Score: 16
Rating: B

Physical Activity and Function

Patient previously bowled 60 minutes weekly, cycled twice a day for 20 minutes, and
gardened and did chores daily for 15 minutes. He now reports having no energy for his
regular exercise. He feels weary after just taking a shower or walking more than 2
minutes.

Personal History

 Patient is married and lives with his wife who does all the cooking. She is very
supportive of the changes being made.
 Retired from his job at the age of 64 as a construction overseer
 Gave up smoking 21 years ago

Biochemical Data, Medical Labs, Procedures:

Protein Profile
 Albumin: 2.55 g/dL (Moderate depletion)
 Pre-Albumin: 8 mg/dL (Moderate depletion)

Lipids
 Total Cholesterol: 155 mg/dL (Within Normal Limits)
 Triglycerides: 116 mg/dL (Within Normal Limits)
 LDL: 70 mg/dL (Within Normal Limits)
 HDL 70 mg/dL (Within Normal Limits)

Endocrine
 HbA1c: 6% (Within Normal Limits)

Blood Pressure: 130/85 mmHg (Hypertension Stage 1)

Current Meds:

 Antihypertensive Agent (Metoprolol)

 Lipid-Lowering Tablet (Simvastatin)
 Oral Hypoglycemic agent (Metformin)

Nutrition Diagnosis:

Inadequate energy intake (NI-1.2) related to loss of appetite as evidenced by 8% weight

loss in the last 6 months, severe muscle wasting in temples, interosseous muscles, and
triceps fold, and self-reported decreases in usual food intake.

Nutrition Intervention:
Nutrition Prescription (NP-1.1)

 Patient is recommended to consume a caloric intake of 2,400-2,700 calories per

day to achieve a weight gain 1 pound per week (30-35 kcals/kg of actual BW)
 Patient is recommended to consume 92-115g of protein per day (1.2-1.5 g/kg of
actual BW for special states)
 Patient is recommended a fluid intake of 1927 mL-2699 mL daily (25-35 mL per
kg of actual body weight)
 Patient is recommended to follow DASH diet guidelines of consuming less than
1,500 mg/day.
 Patient is recommended to increase fruit and vegetable intake to meet the 5
servings a day national guideline recommendation.
 Patient is recommended to gradually increase physical activity <150 minutes per
week as recommended by diabetes guidelines

Implementation Plan
1. Patient will be provided nutrition education and counseling on ways to increase
energy intake with calorically dense foods and how to identify them
2. Patient will also receive nutrition education to discuss the health consequences
of malnutrition
3. Cognitive-Behavioral Theory will be utilized to facilitate behavior modification to
identify ways to increase flavor of foods and make it more enjoyable to eat
4. Will explain to patient the importance of self-monitoring when it comes to dietary
intake and meeting his daily energy and protein requirements.
5. Will encourage having social support from his wife and making healthier meals
that includes at least 2 vegetables together twice a week
6. Provide handouts and resources that the patient and his wife can use to identify
substitutions for higher-dense foods, cooking preparation, and including meal
supplements such as ensure protein shakes
 7. Motivational interviewing will be utilized to set realistic goals that the patient
believes he can achieve related to physical activity and low impact exercises.
8. Patient will be encouraged and referred to see a Psychologist to deal with
mourning of his close friends

Dietitian Assessment/Patient Response to Intervention

Patient seems willing to follow recommendations and interventions discussed while
verbalizing his understanding.

Education Materials Provided

1. Higher Density Foods
2. Increase your Protein!
3. Flavor Up your Food

Monitoring and Evaluation

1. Monitor weight 3x a week to ensure goal of gaining 1 lb. per week
2. Patient will keep a food diary to track food intake > 5 days a week and discuss
during sessions to assess if daily caloric, macronutrient (protein), and
micronutrient goals are being met
3. Patient will take pre and posttests to assess changes in nutrition knowledge and
attitudes towards energy-dense and high protein foods.
4. Patient will also keep a log of physical activity to monitor consistency towards
goal of being active for a total of 30 minutes per day 3-4x a week.
5. Self-Efficacy ratings will be measured to assess changes in belief that he can
achieve his desired goals and have a better outcome because of it
6. Patient’s blood pressure will be measured and logged daily to ensure it is
decreasing towards normal range.
7. Continual albumin and pre-albumin lab assessments to ensure it is moving
towards a normal range

Patient will return in 3 weeks for evaluation and discussion of progress towards goals.
Provided patient with contact information and encouraged to call with any additional
questions. Patient was agreeable with this plan.

Medical Nutrition Therapy provided using the 2018 evidence-based practice guidelines
from the American Academy of Nutrition and Dietetics.

Katie Escobar