Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consultation - 1
Description: Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.
(Medical Transcription Sample Report)
SUBJECTIVE: This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia. The patient reports that she has resumed food record keeping which she feels like it has given her greater control. Her physical activity level has remained high. Her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.
OBJECTIVE: Vital Signs: Weight is 189-1/2 pounds. Food records were reviewed
ASSESSMENT: The patient has experienced a weight loss of 1-1/2 pounds in the last month. She is commended for these efforts. We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks. We discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping. We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis. We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms. This will likely be around 2:30 or 3 p.m. for her. We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.
PLAN: I recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m. It will be helpful if this snack includes some protein such as nuts or low-fat cheese. She is also encouraged to continue with her record keeping for food choices and calorie points. I also recommended she maintain her high level of physical activity. Will plan to follow the patient in one month for ongoing support. This was a 30-minute consultation.
Keywords: consult - history and phy., dietary consultation, calorie count, calorie points, consultation, food choices, food record, hyperlipidemia, low-fat cheese, many fruits and vegetables, physical activity, polycystic ovarian syndrome, snack, dietary, polycystic, food, afternoon,