Chaya

 Wilhelm       FNDH  631  

Case  Study  1-­‐  Weight  Management    
 
Home Office
02/17/ 2017 9:15 am

A: Patient is very unhappy with his current weight and has a desire to lose. He is single, no
children, and used to live with his grandmother until she passed away. He now lives
independently in low income housing. He consumes large amounts of fast food as well as
precooked meals and microwaves. He claims this is due to the fact that he just does not know
how to cook. He claims that vegetables give him heartburn and therefore he stays away from raw
veggies. Reports no smoking or use of ETOH and states that his mom had dm. He has gained
weight steadily over the past 5 years and has tried to work with an RD 3 years prior but was
unsuccessful. He works in housekeeping and only exercises occasionally on the bike.
Records show that he has a limited IQ.
41 year old male, Caucasian
Medical dx: Morbid Obesity, anger management, Metatarsalgia, Severe Peripheral Neuropathy,
Severe Obstructive Sleep Apnea. He also had corrective heel osteotomy on his left foot.
Skin changes consistent with Candida Intertigo in groin folds.
Ht: 69” Wt: 427.1 # BMI: 63 (Morbid Obesity- Class III) %DBW: 35%
BP: 136/90 HR: 117 Temp: 97.6 O2 Stat: 96
Diet Order: Dietary consult ordered for weight management
EER: 4,250 kcal/day (Mifflin (2,833) x 1.5 AF) Protein Needs: 155 g/day (0.8 g/kg bw)
Labs: HDL 31 (Low) Medication: Neurontin, Amitriptylin, Celexa, Bipap mask for sleep apnea
Family hx: both parents deceased, one sister alive and no hx of HTN or heart disease.

D: PES #1 Obese, Class III adult (NC-3.3.5) RT lifestyle choices AEB documentation of gaining
weight steadily over the past 5 years and a BMI of 63.
PES #2 Food and nutrition related knowledge deficit (NB-1.1) RT fast food consumption
AEB documentation of a limited IQ (78) and stating that he does not know how to cook.

I: Intervention #1 Decreased energy diet (ND- 1.2.2.2) by decreasing his caloric intake to 3500
kcal day, a 750 kcal deficit.
Intervention #2 Purpose of the nutrition education (E-1.1) by helping patient create a
structured healthful menu.

M/E:
• Total energy intake (FH-1.1.1.1)
• Weight (AD 1.1.2)
• Types of food/meals (FH-1.2.2.2)
• Area(s) and level of knowledge/skill (FH-4.1.1)
• Participation in community programs (Fh-6.1.4)
• Body mass index (AD-1.1.5)

Chaya Wilhelm
Future RDN, LD