Case Study A client was referred to you for a nutrition assessment and diagnosis. Case Study: Mr Lim Ah Poh Referred Client: Name: MrLim Ah Poh
S3470C Nutrition Care Process – Case Study Analysis
Case Study
A client was referred to you for a nutrition assessment and diagnosis.
Case Study: Mr Lim Ah Poh
Referred Client:
Name: MrLim Ah Poh
Age: 54years old
Gender: Male
Ethnicity: Chinese
Height: 168cm
Weight: 90kg
Occupation: Administration Executive
Living siutation: Lives with wife and 1 daughter in a 3 room HDB flat
Highest education qualification: Secondary School
Diagnosed condition:
- Type 2 Diabetes Mellitues – Diagnosed2 years ago, on metformin
- Hypertension–Just diagnosed, have not started on medication
Recent Blood Test Results:
- HbA1c: 8.5%
- Fasting Glucose: 14.9 mmol/L
- Total Cholesterol: 4.8 mmol/L
- LDL: 2.9 mmol/L
- HDL: 1.1 mmol/L
- Triglycerides: 2.2 mmol/L
- Blood Pressure: 149/95 mmHg
Social & Lifestyle Factors:
- Financial struggles – Relies on savings, preparing daughter’s university education. Wife is housewife at home.
- Sedentary lifestyle –Apart from commuting to work and back home, Mr Lim don’t do any other exercise.
- Stress eating –Like to consume sweetened beverages
- Social interaction –Interacts mainly with colleagues and spend time with wife and daughter at home.
24 hours Dietary History:
| Meals | Food items | Remarks |
| Breakfast8am | 1 cup Kopi (Ga Dai – add extra sugar)2 slices Toast with peanut butter | Purchased from office canteen |
| Snack10am | 1 bottle Coke (500ml)4 pieces Plain Cracker (Flavour: Salted) | Eat at work |
| Lunch1pm | 10 pieces Fried Chicken Nuggets (180g)5 packets Chilli Sauce1 bowl White Rice1 Fried Egg with Dark Soya Sauce1 bottle Fanta Grape drink (500ml) | Purchased from the office canteen |
| Snack3pm | 1 can Red Bull (330ml)4 pieces Plain Cracker (Flavour: Salt and Pepper) | Eat at work |
| Dinner7pm | ¼ plate Braised Vegetable1 palm size Fried Fish2 Fried Eggs1 bowl of Mixed Brown and White Rice1 small Pear1 can Sprite (330ml) | Wife’s cooking |
| Supper11pm | 1 bottle Fanta Orange drink (500ml)8 pieces Plain Cracker (Flavour: Salt and Pepper) | Felt hungry before sleeping |
Based on the information above, you are required to use the Nutrition Care Process (S.O.A.P) and the Nutrition Assessment Form to discuss the process of disease-nutrition care that your client should receive to manage his medical conditions.
Write a (S.O.A.P.) entry for the Mr Lim Ah Poh.
| Subjective (10%) | |
| Objective (10%) | |
| Assessment (10%) | |
| Plan (10%) | |
| Monitoring (10%) |