First Name: Claudia Last Name: Villatoro

CASE STUDY #2 NUT 116AL

~ Cardiovascular Disease ~
DUE Monday 11/23/15 (DATE CHANGE)
Instructions:
Review the pts medical record below. Answer each question and show your calculations for each, if required, on a
separate sheet. Reference all calculation formulas with the text and page number from PR (i.e., PR p. ___). Only use
the PR for all calculations. You may use lecture notes (NUT 116A or 116AL) and the textbook for all other
questions. You must type your answers! If not, questions will not be graded and you will receive 0 points. CS #2 is
worth 50 points.
To familiarize yourself with medical terminology, utilize an online dictionary such as:
http://www.medilexicon.com/medicaldictionary.php
Hx, Rx, Male, 59 yo
Allergies: NKA
Code: FULL
Isolation: NONE
Pt. Location: RM 1104
Physician: A. Baum
Admit Date: 9/1
_____________________________________________________________________________________________
Pt Summary: RH is a 59-year old male admitted through the ED for an emergency coronary angiography with
angioplasty of the infarct-related artery.
Hx:
Onset of disease: 59 yo male who noted the sudden onset of severe precordial pain on the way home from work. The
pain is described as pressure-like pain, radiating to the jaw and left arm. The pt has noted an episode of emesis and
nausea. He denies palpitations or syncope. He denies prior hx of pain. He admits to smoking cigarettes (1 pack/day
for 40 years). He denies HTN, DM, or high cholesterol. He denies SOB.
Medical hx: not significant before Dx of MI
Surgical hx: cholecystectomy 10 yrs ago, appendectomy 30 yrs ago
Medications at home: none
Allergies: sulfa drugs
Tobacco use: 1 ppd for 40 yrs
Alcohol use: none
Family hx: father with CAD; MI age 58
Demographics:
Marital status: married, 59 yo spouse
Children: grown and away from home
Years education: BS degree
Language: English
Occupation: Project Manager for a refuse company
MD Progress Note:
Review of Systems
Constitutional:
Skin:
Cardiovascular:
Respiratory:
Gastrointestinal:
Neurological:
Psychiatric:
Physical Exam
General appearance:
Heart:
HEENT:
Head:
Eyes:

negative
negative
no carotid bruits
negative
negative
negative
negative
mildly overwt male in acute distress from chest pain
PMI located at 5th ICS, MCL on the left. S1 nl intensity. S2 nl intensity and split. S4
gallop at the apex. No murmurs, clicks, or rubs.
normocephalic
EOMI, fundoscopic exam WNL. No evidence of atherosclerosis, diabetic retinopathy,
or early hypertensive changes.
1

First Name: Claudia Last Name: Villatoro

Ears:
Nose:
Throat:
Genitalia:
Neurologic:
Extremities:
Skin:
Chest/Lungs:
Peripheral vascular:
Abdomen:
Vital Signs:
Temp: 98.4
BP: 118/78

TM nl bilaterally
WNL
tonsils not infected, uvula midline, gag nl
WNL
No focal localizing abnormalities; DTR symmetric bilaterally
No C, C, E
diaphoretic and pale
clear to auscultation and percussion
PPP
RLQ scar and midline suprapubic scar. BS WNL. No hepatomegaly, splenomegaly,
masses, inguinal lymph nodes, or abdominal bruits
Pulse: 92
Ht: 510

Resp Rate: 20
Wt: 185 lbs

BMI: 26.6

Nursing Assessment:
Abdominal appearance (concave, flat, rounded, obese, distended)
Palpation of abdomen (soft, rigid, firm, masses, tense)
Bowel function (continent, incontinent, flatulence, no stool)
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ
LUQ
RLQ
LLQ
Stool color
Stool consistency
Tubes/ostomies
Genitourinary
Urinary continence
Urine source
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue,
tea)
Integumentary
Skin color
Skin temperature (DI=diaphoretic, W=warm, dry, DL=cool,
CLM=clammy, CD+=cold, M=moist, H=hot)
Skin turgor (good, fair, poor, TENT=tenting)
Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae,
R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated,
T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles,
N=necrosis)
Mucous membranes (intact, EC=ecchymosis, A=abrasions,
P=petechiae, R=rash, W=weeping, S=sloughing, D=dryness,
EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters,
V=vesicles, N=necrosis)
Other components of Braden Scale: special bed, sensory pressure,
moisture, activity, friction/shear (>18=no risk, 15-16=low risk, 1314=moderate risk, <12=high risk)

9/1
Flat
soft
continent
P
P
P
P
Light brown
NA
Catheter in place
Catheter
Clear, yellow
Pale
D, M
TENT
Intact

Intact

Activity; 22

Orders:
IV heparin 5000 units bolus followed by 1000 unit/hour continuous infusion with a PTT at 2 x control.
Chewable ASA 160 mg PO and continued every day
Lopressor 50 mg 2x/day
Lidocaine prn
NPO until procedure completed
Type and cross for 6 units of packed cells
2

First Name: Claudia Last Name: Villatoro

Nutrition:
Meal type:
Hx:
Food allergies/
intolerances/ aversions:
Previous nutrition tx:
Food purchase/
preparation:
Vit/min intake:

clear liquids, no caffeine

appetite good. Has been trying to change some things in his diet. Wife indicates that
she has been using corn oil instead of butter and has tried not to fry foods as
often.
None
Yes, last year, community dietitian
Spouse
None

24-hour recall:
Breakfast:
Mid-morning
Snack:
Lunch:

None
1 large cinnamon raisin bagel with 1 tbsp fat-free cream cheese, 9 oz grapefruit juice, 16 oz
coffee
1 c canned vegetable beef soup, sandwich with 4 oz roast beef, lettuce, tomato, dill pickles,
2 tsp mayonnaise, 1 small apple, 8 oz 2% milk
Dinner:
2 lean pork chops (3 oz each), 1 large baked potato, 2 tsp margarine, c green beans, c
coleslaw (cabbage with 1 tbsp salad dressing), 1 slice apple pie
Snack:
8 oz 2% milk, 1 oz pretzels
Patient reports that this pattern is fairly typical of his usual weekday intake.

Laboratory Results:
Chemistry
Sodium (mEq/L)
Potassium (mEq/L)
Chloride (mEq/L)
Carbon dioxide (CO2, mEq/L)
BUN (mg/dL)
Creatinine serum (mg/dL)
Glucose (mg/dL)
Phosphate, inorganic (mg/dL)
Magnesium (mg/dL)
Calcium (mg/dL)
Osmolality (mmol/kg/H2O)
Bilirubin, direct (mg/dL)
Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
Ammonia (NH3, umol/L)
Alkaline phosphatae (U/L)
ALT (U/L)
AST (U/L)
CPK (U/L)
CPK-MB (U/L)
Lactate dehydrogenase (U/L)
Troponin I (ng/dL)
Troponin T (ng/dL)
Cholesterol (mg/dL)
HDL-C (mg/dL)
LDL (mg/dL)
LDL/HDL ratio
Apo A (mg/dL)
Apo B (mg/dL)

Ref. Range

9/1 1957

9/2 0630

9/3 0645

136-145
3.5-5.5
95-105
23-30
8-18
0.6-1.2
70-110
2.3-4.7
1.8-3
9-11
285-295
<0.3
6-8
3.5-5
16-35
9-33
30-120
4-36
0-35
30-135 F
55-170 M
0
208-378
<0.2
<0.03
120-199
>55 F, >45 M
<130
<3.22 F
<3.55 M
101-199 F
94-178 M
60-126 F
63-133 M

141
4.2
103
20 !
14
1.1
136 !
3.1
2.0
9.4
292
0.1
6.0
4.2
30
26
75
30
25
75

142
4.1
102
24
15
1.1
106
3.2
2.3
9.4
290
0.1
5.9 !
4.3
32
22
70
215 !
245 !
500 !

138
3.9
100
26
16
1.1
104
3.0
2.0
9.4
291
0.2
6.1
4.2
31
25
68
185 !
175 !
335 !

0
325
2.4 !
2.1 !
235 !
30 !
160 !
5.3 !

75
685
2.8
2.7
226
32
150
4.7

!
!
!
!
!
!
!
!

55 !
365

214 !
33 !
141 !
4.3 !

72 !

80

98

115

110

105

First Name: Claudia Last Name: Villatoro

Triglycerides (mg/dL)
Coagulation (Coag)
PT (sec)
Hematology
WBC (x 103/mm3)
RBC (x 106/mm3)
Hemoglobin (Hgb, g/dL)
Hematocrit (Hct, %)
MCV (um3)
MCH (pg)
MCHC (g/dL)
RBC distribution (%)
Platelet count (x103/mm3)
Hematology, Manual Diff
Neutrophil (%)
Lymphocyte (%)
Monocyte (%)
Eosinophil (%)
Basophil (%)
Blasts (%)
Segs (%)
Bands (%)
Urinalysis
Color
Appearance
Specific Gravity
pH
Protein (mg/dL)
Glucose (mg/dL)
Ketones
Blood
Urobilinogen (EU/dL)
Leukocyte esterase
Protein check
WBCs (/HPF)
RBCs (/HPF)
Bacteria

35-135 F
40-160 M

150

140

130

12.4-14.4

12.6

12.6

12.4

4.8-11.8
4.2-5.4 F
4.5-6.2 M
12-15 F
14-17 M
37-47 F
40-54 M
80-96
26-32
31.5-36
11.6-16.5
140-440

11.0
4.7

9.32
4.75

8.8
4.68

15

14.8

14.4

45

45

44

91
30
33
13.2
320

92
31
32
12.8
295

90
30
33
13.0
280

50-70
15-45
3-10
0-6
0-2
3-10
0-60
0-10

55
17
4
0
0
3
45

58
23
4
0
0
3
47

62
35
7
0
0
4
52
8

1.003-1.030
5-7
Neg
Neg
Neg
Neg
<1.1
Neg
Neg
0-5
0-5
0

15

Pale yellow
clear
1.020
5.8
Neg
Neg
Trace !
Neg
Neg
Neg
Neg
0
0
0

17

Pale yellow
clear
1.015
5.0
Neg
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0

Pale yellow
clear
1.018
6.0
Neg
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0

First Name: Claudia Last Name: Villatoro

1. RH had a myocardial infarction. Explain what happened to his heart during his MI. (1 pt)
Myocardial infarction is another way of saying heart attack. This is when the heart stops pumping and dies.
This is due to a prolonged decrease supply of oxygen to the heart due to blocked arteries by built up pf plaque
of the blood vessels walls, known as cardiac ischemia.
https://www.nlm.nih.gov/medlineplus/heartattack.html
Medline Plus- NIH
2. RHs chest pain resolved after two sublingual NTG at 3-minute intervals and 2 mgm of IV morphine.
In the cath lab he was found to have a totally occluded distal right coronary artery and a 70%
occlusion in the left circumflex coronary artery. The left anterior descending was patent. Angioplasty of
the distal right coronary artery resulted in a patent infarct-related artery with near normal flow. A
stent was left in place to stabilize the patient and limit infarct size. Left ventricular ejection fraction
was normal at 42%, and a posterobasilar scar was present with hypokinesis.
Explain and describe what is an angioplasty and what is a stent placement. What is the purpose of these
medical procedures? (2 pts)
Angioplasty is the surgical repair of blocked coronary arteries, and its purpose is to repair the blocked arteries
that are limiting the supply of oxygenated blood to the heart. As part of the procedure a stent, a small tube that
is used to treat weak or narrow arteries, is placed in an artery to help keep the coronary artery open to supply
oxygen to the heart.
https://www.nlm.nih.gov/medlineplus/angioplasty.html
Medline Plus- NIH
3. What are the current recommendations for the progression of nutritional intake during a
hospitalization following a myocardial infarction? (2 pts)
Recommendations are decrease oral intake, consume clear liquids, no caffeine. Over time progress to soft,
more frequent meals. To individualize use TLC recommendations.
Lecture Notes- Nut for CVD (Ischemic Heart Disease)
4. Examine the chemistry results for RH. Which labs are consistent with the MI diagnosis and why? Why
were the levels higher on day 2? (4 pts)
Carbon dioxide (CO2, mEq/L)
23-30
20 (low)
24
26
ALT (U/L)
4-36
30
215 (high)
185 (high)
AST (U/L)
0-35
25
245 (high)
175 (high)
CPK (U/L)
30-135 F
75
500 (high)
335 (high)
55-170 M
CO2: Lack of CO2 lead to MI. A lack of CO2 means that the individual is breathing too heavily which lead
to a decrease of CO2 in the lungs and arterial blood. Will lead to hyperventilation.
ALT: alanine- aminotransferase is an enzyme present in liver and heart cells. Low levels are usually found
in serum. But when there is tissue damage concentration of enzyme increase. High levels can also be caused
by medications (aspirin) and heart tissue damage.
AST: aspartate- aminotransferase is an enzyme found in red blood cells, heart, etc. Low levels are normal.
When heart tissue is damage, level increase in the blood stream, [AST] = extent of tissue damage. Levels
remain high for about 4 days.
CPK: creatine phosphokinase is an enzyme released from damaged cells; found specifically in cardiac
muscle cells. Test to show if there is damage to the heart, skeletal muscle, brain, it is often used to diagnose
5

First Name: Claudia Last Name: Villatoro

heart attacks. Levels stay high due to tissue damage.

http://www.uofmhealth.org/health-library/hw20331#hw20334
http://www.uofmhealth.org/health-library/abq5121#abq5122
http://www.uofmhealth.org/health-library/hw20645
5. Interpret the results of RHs lipid panel, identifying which of the lipids are elevated based on the NCEP
ATP III Guidelines. List the desired therapeutic goals (TLC goal parameter) based on the NCEP
guidelines. (3 pts)
Parameter
RHs Value in mg/dL
Interpretation based on
Therapeutic goal
NCEP classification
Total Cholesterol
235
Borderline high
< 200 mg/day
LDL Cholesterol
30
Optimal
<100 mg/day
HDL Cholesterol
160
Protective against heart
<40 low
disease
>60 high
Apo A
72
Low, impaired clearance
94-178
of cholesterol, low HDL
Triglycerides
150
Borderline high
<150
Overall, what does RHs lipid panel suggest?
RH lipid panel suggest a decrease in cholesterol as Apo A shows low levels, which could lead to cholesterol
build up in the arterial blood vessels. These impaired levels do not appropriately clear up cholesterol, even
though there is an optimal level of HDL. High levels of TG increase adipocytes that could lead to risk factors
that lead to heart attack such as obesity and metabolic syndrome.
6. List & number RHs risk factors for CHD, based on the presentation data from his medical record. (2
pts)
1. High cholesterol: leads to high synthesis, serum cholesterol, and built up in arterial blood vessels.
Levels are high at 235 mg/dL.
2. Overweight with BMI at 26.6 leading to obesity if not controlled.
3. Lack of physical activity: there is not report on PA for RH.
4. Smoking: RH smokes one pack a day.
7. Using RHs 24-hour recall and the food exchange lists, calculate the total number of servings of each
exchange group and number of calories he consumed as well as the energy distribution of calories for
protein, carbohydrate, and fat using the exchange system. (5 pts)
Exchange
kcal
PRO g
CHO g
FAT g
11 Starches
1,075
27
199
19
3 Fruits
196
0
49
0
11 Lean meats
488
77
0
20
5 Fats
285
0
15
25
3 Veg
164
16
25
0
2 LF milk
250
16
24
10
Total
2,458
136 g = 544 kcal
312 g = 1,248 kcal
74 g = 666 kcal
% Of total kcals
100%
22%
51%
27%

First Name: Claudia Last Name: Villatoro

8. Compare RHs 24-hour recall with the TLC dietary plan. Briefly discuss the overall adequacy of RHs
diet and what recommendations you can make to align RHs current consumption with the TLC plan.
(3 pts)
TLC Goals:
Your Recommendations:
Total calories:
2,398 kcal
RH is consuming high amount of calories. It is recommended
that he decrease his consumptions of certain foods during the
day to decrease the total calories per day.
Total fat:
25-35 %
RH is consuming an adequate amount of fat and staying at low
fat % consumption.
Skin/low fat dairy
Saturated fat:
<7%
Limit visible fats, specially from animal source
Be aware of & limit hidden fats
Limit solid fats/ animal fats, use oils rich in omega 3 and 6 FA
Soft margarine
Monounsaturated
< 20 %
RH should aim to eat up to 53g Mono FAT
Fat:
Include beans, nuts, soy protein foods
Oils rich in MUFA canola oil and olive oil
Polyunsaturated Fat:
< 10 %
RH should aim to eat up to 26g Poly FAT
Use oils rich in PUFA safflower and corn oil
Carbohydrate:
50-60 %
Increase fresh fruit and vegetables
Fiber:
20-30 g/d
Include whole grain foods, nuts
Protein:
15 %
Lower protein servings, consume only 360 kcal of PRO
Cholesterol:
< 200 mg/day
High fiber foods, omega 3 FA foods,
Sodium:
< 2,400 mg/day
Do not add salt at the table, us fresh foods, avoid process foods,
use herbs and spices to season food
Potassium:
4,700 mg/day
RH should consume foods high in potassium such as leafy
greens, bananas, avocadoes, and yogurt.
Plant stanols/sterols
3-4 g/d
RH should incorporate nuts and seeds, more fruits and
vegetables to increase plant stanols/sterols for the day
9. RH was prescribed the following medications on discharge. Provide the generic name and indication of
each medication (specific to RH) and its effects. Also note any dietary recommendations,
contraindications/precautions, and interactions. What effect will these medications have on his
nutritional care? Refer to the medication information in the Food-Medication Interactions text. (5 pts)
Lopressor 50 mg daily
Generic name:
Metoprolol
Classification:
Antihypertensive, antiangina, MI Treatment
Indication:
Diet:
Possible FoodMedication
Interactions:
Potential
Nutrition/Oral/GI
Side Effects:

Take tab with food to increase bioavailability. May divide XL tab, but do not crush or
chew
Decrease sodium, decrease calories may be recommended
Avoid natural licorice
Food to increase bioavailability
Oral/GI: dry mouth, N/V, dyspepsia, flatulence, diarrhea, constipation
S/Cond: caution with diabetes may mask signs of hypoglycemia, may reduce insulin
release in response to hyperglycemia. Extreme caution with bronchospasm.

First Name: Claudia Last Name: Villatoro

Zestril 10 mg daily
Generic name:
Lisinopril
Classification:
Antihypertensive
ACE Inhibitor
Antihypertensive, CHF post MI
Indication:
Insure adequate hydration/ fluid intake.
Diet:

Decrease sodium. Decrease calories. Avoid salt substitutes. Avoid natural licorice

Possible FoodMedication
Interactions:
Potential
Nutrition/Oral/GI
Side Effects:

Limit alcohol
Dry mouth, N/V, abdominal pain, constipation, and diarrhea.

Zocor 20 mg/day
Generic name:
Simvastatin
Classification:
Antihyperlipidemic
Indication:

Take without regards to food. Take a single dose. Swallow SR form whole.

Diet:

Decrease fat, decrease cholesterol, and decrease calories if needed.

Possible FoodMedication
Interactions:
Potential
Nutrition/Oral/GI
Side Effects:

Cautions with grapefruit, related citrus, separate fiber, pectin, or oat bran from drug by
several hours.
Nausea, dyspepsia, abdominal pain, constipation, diarrhea, flatulence.
S/Cond: avoid substantial alcohol

Nitrostat 0.4 mg sl prn chest pain

Generic name:
Nitroglycerin
Classification:
Antiangina
Indication:
Diet:
Possible FoodMedication
Interactions:
Potential
Nutrition/Oral/GI
Side Effects:

Consult pharmacist for proper administration.

Take SR forms on empty stomach with full glass of stomach
1 hr before or 2 hr after meals. Swallow SR forms whole.
NA
Avoid alcohol
Oral/ GI: Dry mouth, N/V, abdominal pain
S/Cond: not with sever HTN or severe anemia, caution with CHF

ASA 81 mg daily
Generic name:
Aspirin
Classification:
Analgesic, antipyretic, antiarthritic, nsaid, to prevent CVA or MI
Indication:

Take with 8 oz. water or milk after meals or with food to decrease GI irritation
Food decrease rate of absorption. Swallow enteric-coded tab whole.
8

First Name: Claudia Last Name: Villatoro

Diet:
Possible FoodMedication
Interactions:
Potential
Nutrition/Oral/GI
Side Effects:

New recommendation: low dose ~81mg aspirin for men 45-79 yo

Insure adequate fluid intake/hydration. Increase foods high in vitamin C and Folate with
LT high dose.
Avoid or limit natural products, which affect coagulation.
Limit caffeine to decrease GI affects.
May cause sudden, serious gastric bleeding. Black, tarry stools
S/Cond: Avoid alcohol.
Not for pt. prone to Vit. K deficiency
GI risk usually offset by prevention of initial MI or CVA

10. Make an overall statement as to the discharge dietary advice you would give RH regarding his
medications above. (1 pt)
RH should clearly follow the indication for each drug and paying good attention to the dietetic and medical
interactions of the drug as it could lead to more severe side effects that those stated, as continuing to take
medication will lead to further treat his MI and prevent any further strokes.
11. What is metabolic syndrome & does RH meet the criteria? Why or why not? (2 pts)
A metabolic syndrome is the name given to a group of risk factors that raise the risk for heart disease,
diabetes and stroke. The risks are traits that increase the chance of developing the disease. The risk factors
RH chemistry labs show high TG and low HDL cholesterol levels. However from pt. report there is no proof
of fasting blood glucose, large waistline, and his blood pressure is normal. RH does not meet the criteria for
metabolic syndrome.
12. You talk with RH and his wife, an elementary school teacher. They are friendly and seem cooperative.
They are both anxious to learn what they can do to prevent another heart attack. List 4 questions you
might ask them that will assist you in assessing their lifestyle. (2 pts)
1. What are the 3 main focuses to the research you are doing as to prevent another heart attack, is it PA,
diet, medications, etc.?
2. How far are you wiling to change your lifestyle behaviors to promote better health and decrease
further heart attacks?
3. What are your thoughts on cardiac rehab programs? Is it something you would consider for treatment
of MI and prevention of further heart attacks, and overall improvement of health?
4. Are you open to dietary recommendation such as TLC diet, heart- healthy diet, and other health
promoting diets to help reduce future heart attacks?
13. List 4 lifestyle factors you might recommend to support realistic, successful lifestyle changes for RH? (2
pts)
1. Increase physical activity by going on morning, afternoon, or evening walks for 30 minutes every day
of the week.
2. Increase fruit & vegetable intake by 3-4 servings a day.
3. Decrease saturated fats and protein intake by decreasing portion size and increasing PUFA and
MUFA
4. Smoking reduction

First Name: Claudia Last Name: Villatoro

14. RH is Muslim and from the SF Bay Area. Describe and explain Islamic dietary laws and any dietary
restrictions you would need to consider when counseling RH. (2 pts)
Muslims culture prohibits swine flesh based on God and Allahs laws, to consume only what is good and not
what is harmful. Food is categorized as halal, which is permitted to eat, haram, which is prohibited to eat,
makrooh, what which is doubtful and mash-booh, which is a suspect. Alcohol is not permitted as well as
fermented it pickled foods. Meats are halal, but any animal that has been suffocated, fallen into a gutter/
drain, beaten to death, or already found dead are haram.
15. List and number 4 major teaching points (dietary advice) that you will need to discuss with RH in
order for him to understand and follow the NCEP TLC diet. (2 pts)
1. The difference between bad fats and good fats (saturated, mono, and poly unsaturated fats).
2. Portion control to decrease calorie intake.
3. Importance of consuming fruits and vegetables and the health benefits.
4. Caffeine in relation to heart attacks and the importance to eliminate from diet.
16. You have seen RH one day post-MI and one day after his cardiac procedure. He has been advanced to a
regular cardiac diet and will be discharged the next morning. He is approved for 12 weeks of Cardiac
Rehabilitation, including 3 visits to an RD. Summarize your observations, assessment and plan of
action in an ADIME note. Base your note on the pertinent information given in the presentation data,
24 hr. recall, and questions above. Write the ADIME note below and attach a separate sheet with all
calculations. Include two PES statements. (12 points)
A:
59-year old male admitted for an emergency angioplasty of the infarct-related artery following sudden onset
of severe precordial pain.
Anthropometrics
Ht. 1.78m
CBW: 84.1 kg (115% over IBW)
IBW: 73 kg
BMI: 26.6, overweight
Estimated Energy Requirements
MSJ Kcals: 2,163 - 2,330 kcal, IF: 1.0-1.3
Protein: 67 g PRO, based on non-stress populations
TLC Pro Requirement: 360 kcal
Fluids 2,1023 mL = 2.1 L
24 Hr. Recall
Kcals: 2,458
PRO 22% (exceeds ~15% TLC rec.)
CHO 51% (50-60% TLC rec.)
FAT 27% (25-35% TLC rec.)
Diet Assessment
Exceeds protein requirements at 22%
Normal range for CHO 51% and FAT 27%
Excess kcal intake, 2,458 kcal
Labs
Carbon dioxide (CO2, mEq/L) 20, high, due to heavy breathing, clogged arteries, hyperventilating
ALT (U/L) 30, high, enzyme high due to damage of tissue
AST (U/L) 25, high, enzyme high due to damage of tissue
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First Name: Claudia Last Name: Villatoro

CPK (U/L) 75, high, enzyme high due to damage of tissue, used to diagnose heart attacks
Total Cholesterol 235, border line high could lead to cholesterol build up and inflammation
LDL Cholesterol 30, optimal
HDL Cholesterol 160, high, protective against heart disease
Apo A 72, low, impaired clearance of cholesterol, low HDL

Triglycerides 150, borderline high, hypertriglyceremia, could lead to obesity and metabolic syndrome
Medications
None recorded
D:
PES Statement
1. Excessive oral food/ beverage intake (NI -2.2) r/t large starch and fat portion sizes AEB 24 hr. recall,
border line high fat percentage and total caloric intake.
2. Overweight/ obesity (NC-3.3) r/t high protein portions, high starch servings, low fiber foods, low
PUFA and MUFA food consumption AEB 24 hr. recall that shows excess calorie intake, high protein
calories, and BMI of 26.6.
I:
Overall MNT statement: Assist the pt. to incorporate a TLC Diet Plan to reduce saturated fats to decrease
cholesterol and TG, increase healthy fats (MUFA & PUFA), increase fiber to decrease cholesterol build up to
support healthy arterial blood pressure and blood flow to the heart to prevent secondary complications and
metabolic syndrome.
Recommendations:
1. Diet Rx: Pt. may benefit from the TLC diet paired with an increase in exercise and a decrease in
smoking in order to prevent secondary diseases and promote healthy arterial blood flow.
Decrease calories by 500 to promote weight loss to decrease BMI
Decrease starch servings by half to decrease calories and percent fat.
Intake of ~70 g PRO, pt. to reduce PRO by 60 g
Increase lean meat to decrease fats
Intake of seeds, nuts, high fiber to reduce cholesterol
Decrease CHO servings to reduce calories and serum glucose that could lead to hyperglycemia,
obesity, metabolic syndrome, and insulin resistance.
2. Recommendation:
Pt. will benefit from a low fat diet as individual suffered a heart attack, lower LDL levels and
decrease probabilities of atherosclerosis
Pt. will benefit from increase of fiber rich foods to reduce cholesterol from serum, promote SCFA via
fermentation in colon, and inhibit hepatic cholesterol synthesis.
Diet instructions given to pt. and wife to decrease saturated fats and increase high fiber, whole grain
foods to decrease cholesterol, decrease portion size, increase fruits and vegetables, and consume a
nutritious breakfast. Handouts given for snacks, healthy breakfast, ways to decrease saturated fats,
and portion size control. Any questions regarding medications can be forwarded to pt. medical
doctor, but have instructed pt. to ensure proper diet when consuming the medications.
3. Behavioral goals:
RH can encourage decreasing the amount of cigarette packets he smokes a day by one pack to half a
pack, slowly to ensure no withdrawals or drawbacks.
RH can increase PA by walking in the mornings, afternoon, or evening with his wife for 30 minutes
to up to one hour 3-5 days a week.
4. Compliance: As pt. and his wife have been researching ways to prevent future heart attacks or heart
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First Name: Claudia Last Name: Villatoro

problems, it is speculated that pt. will comply with dietary and behavioral recommendations. There is
strong evidence that pt. is concern with heart health, and the recommendations will be easy to follow
and handouts are clear and simple to understand.
M/E:
1. Cholesterol labs on next visit complete a new 24 hr. recall taking into account suggested recommendations
on TLC diet and portion control. Monitor PO intake by keeping a food record and be mindful of the healthy
and bad foods RH is consuming.
2. Follow up in one week. Pt. will bring food records with him, all medications currently taking, list of
behavioral changes he has done since last visit to better his health, and any further questions on MI or stokes.
Claudia Villatoro

Nutrition Students

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