S3470C Assessment Brief
Case Study
A client was referred to you for a nutrition assessment and diagnosis.
Case Study: Mr Lim Ah Poh
Refered 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 |
| Snack
10am |
1 bottle Coke (500ml)
4 pieces Plain Cracker (Flavour: Salted) |
Eat at work |
| Lunch
1pm |
10 pieces Fried Chicken Nuggets (180g)
5 packets Chilli Sauce 1 bowl White Rice 1 Fried Egg with Dark Soya Sauce 1 bottle Fanta Grape drink (500ml) |
Purchased from the office canteen |
| Snack
3pm |
1 can Red Bull (330ml)
4 pieces Plain Cracker (Flavour: Salt and Pepper) |
Eat at work |
| Dinner
7pm |
¼ plate Braised Vegetable
1 palm size Fried Fish 2 Fried Eggs 1 bowl of Mixed Brown and White Rice 1 small Pear 1 can Sprite (330ml) |
Wife’s cooking |
| Supper
11pm |
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%) |
S3470C Assessment Marking Criteria
| Descriptors | ||||
| Grading Criteria | Excellent | Good | Acceptable | Weak |
| Subjective entry: Contains client’s subjective communications, feeling and complaints, nutritionally significant food habits and diet history. | Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were detailed and accurate. | Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were detailed but contained some errors. | Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were brief and contained some errors. | Entry and recording of client’s subjective input with appropriate evaluation of client’s prescribed needs were brief and contained many errors. |
| Objective entry: Significant data from lab report, anthropometric data, medical diagnosis, diet prescription and medications. | Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were detailed and accurate. | Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were detailed but contained some errors. | Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were brief and contained some errors. | Entry and recording of client’s objective input with appropriate evaluation of client’s prescribed needs were brief and contained many errors. |
| Assessment: Analysis and interpretation of S and O, detailed diet recommendations, level of motivation to change/stage of change, possible problems or barriers, appropriateness of current diet. |
Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration all of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet. | Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration most of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet. | Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration some of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet. | Interpretation and analysis of subjective and objective entries to derive at a diet recommendation was detailed and took into consideration a few of the following: levels of motivation to change, stage of change, possible problems or barriers and appropriateness of current diet. |
| Monitoring: Follow-up and evaluation of prescribed nutrition strategy |
Monitoring was documented with a detailed follow-up and accurate evaluation of prescribed nutrition strategy. | Monitoring was documented with a detailed follow-up, but evaluation of prescribed nutrition strategy contained errors. | Monitoring was documented with a brief follow-up and evaluation of prescribed nutrition strategy contained errors. | Monitoring was documented with a brief follow-up and evaluation of prescribed nutrition strategy contained many errors. |
| Plan: Plans coincide with client’s goals, is/are measurable. |
Plans were developed with all of the SMART principles fulfilled and resonated with the client’s goals including forward planning. | Plans were developed with most of the SMART principles fulfilled and resonated with the client’s goals.
|
Plans were developed with some of the SMART principles fulfilled and while in alignment with the client’s goals, may not have taken into consideration the client’s preferences. | Plans were developed with none of the SMART principles fulfilled and not in alignment with the client’s goals.
|
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