ADIME NOTE
Assessment
[Age/gender/diagnosis/past medical history and pertinent history provided by pt]
56 YO male with type 2 diabetes, not well controlled at this time. Admits he does not take
his metformin as prescribed d/t GI upset, and does not monitor BG. He has peripheral
neuropathy, htn, and CVD with MI 2 yr ago. Has gained 12lb in past yr
Anthropometrics:
Ht: 56 in
Weight: 200 lb UBW: 188lb IBW: 143lb %IBW: 140 % UBW: 106
BMI:
Pertinent Labs: FBG: 166mg/dL. A1c: 8.1 Chol: 270 LDL: 190 HDL 35. TGY: 210
BMI: 32.3
Pertinent Meds: metformin, 1000mg BID
Food/med interaction: Possible B-12 depletion with metformin
Estimated Kcal, protein, fluid needs: [indicate formula/multipliers used]
TEE: 2270 kcal/d (25kcal/kg) 500 kcal deficit for weight loss: 1800kal
Protein needs: 73—90 g/d (0.8-1g/kg)
90 g pro; 200g carb and 70g fat for 20% protein, 45% carb, 35% fat and 1800 kcal
Fluid Needs: 1,800/d (1 ml/kcal)
Nutrition Focused Physical Findings: Abdominal obesity
Food Allergies: NKFA
Current diet (description and assessment):
Skips breakfast, eats fast food lunch of chicken tenders or quarter pound burger, large fries,
and medium regular soda for lunch and dinner consisting of meat entrée, starchy side,
vegetable (large portions), with unsweet tea. Reports excessive snacking at night with chips,
ice cream. Usual beverage is diet soda, tea, or water, but does consumes SSB once a day
Knowledge/Beliefs/Food Access:
Pt has not been instructed on diet for BG control and has not attended DSME/T. Desires to
control BG and weight, but stress has increased his appetite. Food access good, although
lunch is consumed in car during workday.
Diagnosis
PES Statements:
Excessive carbohydrate intake related to nutrition knowledge deficit and stress eating AEB
FBG of 166mg/dL , A1c of 8.1 and diet history.
Food and nutrition related nutrition knowledge deficit RT lack of instruction on diet for
diabetes control AEB pt statement of knowledge lack and diet history.
Excess energy intake RT nutrition knowledge deficit and stress AEB weight gain of 12lb in past
yr and BMI >30.
Intervention
Recommended Nutrition Prescription: 1800 kcal ADA carbohydrate controlled diet providing
3-4 carb choices at meals and 2 at snacks providing 45% carb, 35% fat, and 20% protein
Goals: [SMART]
1. Pt will keep food/glucose log and bring to appointment next week with BG measured
fasting at 2 hr after one meal per day minimum on at least 3 days
2. Food record will indicate 3-4 servings carb for at least 1 meal a day at least 5 d of the
week
Intervention Plan:
1. Instruct pt on carb/calorie controlled diet using My Healthy Plate with 3-4 carb
choices at BLD and 2 at HS snack
2. Instruct pt on food/glucose log use
3. Request referral from PCP for DSME
Monitoring and Evaluation
[Indicate what you will monitor and when]
Pt has f/u appointment in 2 week to go over food/glucose logs
 RD will monitor/evaluate carbohydrate choice servings to determine if pt is
consuming 3-4 carb choices for B, L, D and 2 for snack

RD will monitor energy intake of diet to ensure pt is at 1800 kcal/d, a decrease from
current intake of ~ 3,000 per day
 RD will monitor FBG with goal of 80-130mg/dL, a decrease from current 166mg/dL
 RD will monitor weight for loss of 0.5-1lb per week from current weight of 200lb
 Pt will be able to identify what foods are carbohydrate choices and correctly estimate
portion sizes
A1c to be reassessed in 3 mo for goal of <7%, down from current value of 8.1%
Signature:
Date and Time:
Time spent with patient: