Garcia, Jose Male, 61 y.o.

Allergies: NKA
Code: FULL Isolation: None
Pt. Location: RM 30 Physician: H. Junder
Admit Date: 12/30
Patient Summary: Jose Garcia is a 61-year-old male admitted through the emergency
department with diagnosis of unstable angina
Onset of disease: 61-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 patient has noted an episode of emesis and nausea. He denies palpitations or syncope. He
denies prior history of pain. He admits to smoking cigarettes (1 pack/day for 40 years). He denies
hypertension, diabetes, or high cholesterol. He denies SOB.
Medical history: Not significant before this admission
Surgical history: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago
Medications at home: None
Allergies: Sulfa drugs
Tobacco use: 40-year history, 1 pack /day
Alcohol use: 1 glass of wine per day
Family history: What? CAD. Who? FatherMI age 41
Marital status: Married, Spouse name: Alice Garcia, 59 yo
Number of children: Daughter and two grandchildren live in the home.
Years education: AA degree
Language: English, Spanish
Occupation: IT network specialist Hours of work: 40/wk
Household members: 5
Ethnicity: Mexican American
Religious affiliation: Catholic
MD Progress Note (Admitting History/Physical):
Review of Systems
Constitutional: Negative
Skin: Negative
Cardiovascular: No carotid bruits
Respiratory: Negative
Gastrointestinal: Negative
Neurological: Negative
Psychiatric: Negative

Physical Exam General appearance: Mildly overweight male in acute distress from chest pain
Heart: PMI sustained in 6th intercostal space in AAL in the left lateral decubitus position.
Normal intensity, no murmurs. A 4th heart sound was present.
HEENT: Head: Normocephalic
Eyes: EOMI, fundoscopic exam WNL. No evidence of atherosclerosis, diabetic
retinopathy, or early hypertensive changes.
Ears: TM normal bilaterally
Nose: WNL
Throat: Tonsils not infected, uvula midline, gag normal
Genitalia: Grossly physiologic
Neurologic: No focal localizing abnormalities; DTR symmetric bilaterally

Extremities: No clubbing, cyanosis, or edema

Skin: Diaphoretic and pale
Chest/lungs: Clear to auscultation and percussion
Peripheral vascular: Peripheral pulses palpable
Abdomen: RLQ scar and midline suprapubic scar. BS WNL. No hepatomegaly,
splenomegaly, masses, inguinal lymph nodes, or abdominal bruits.
Vital Signs: Temp: 98.6 Pulse: 94
Height: 5'10" Weight: 215 lbs
DX: MI, hypertensive heart disease

Resp rate: 23 BP: 140/99

Laboratory Results
Chemistry
Sodium (mEq/L)
Potassium (mEq/L)
Chloride (mEq/L)
Carbon dioxide(mEq/L)
BUN (mg/dL)
Creatinine (mg/dL)
Glucose (mg/dL)
Osmolality
Bilirubin, direct (mg/dL)
Protein, total (g/dL)
Albumin (g/dL)
Prealbumin (mg/dL)
Ammonia (NH3, mol/L
Alkaline phosphatase (U/L)
ALT (U/L)
AST (U/L)
CPK (U/L)

Ref. Range 12/30 (Admit) 12/31 0630

136145
141
142
3.55.5
4.2
4.1
95105
103
102
2330
20 !
24
818
14
15
0.61.2
1.1
1.1
70110
136 !
106
285295
292
290
<0.3
0.1
0.1
68
6.0
5.9 !
3.55
3.5
3.8
1635
30
32
933
26
22
30120
75
70
436
30
215 !
035
25
245 !
30135 F
55170 M
75
500 !
CPK-MB (U/L)
0
0
75 !
Lactate dehydrogenase (U/L) 208378
325
685 !
Troponin I (ng/dL)
<0.2
2.4 !
2.8 !
Troponin T (ng/dL)
<0.03
2.1 !
2.7 !
Cholesterol (mg/dL)
120199
235 !
226 !
HDL-C (mg/dL)
>55 F,>45 M 30 !
32 !
LDL (mg/dL)
<130
160 !
150 !
LDL/HDL ratio
<3.22 F
<3.55 M
5.3 !
4.7 !
Apo A (mg/dL)
101199 F
94178 M
72 !
80 !
Apo B (mg/dL)
60126 F
63133 M
115
110
Triglycerides (mg/dL)
35135 F
40160 M
160
150
Coagulation (Coag)
PT (sec)
12.414.4
12.6
12.6

1/1 0645
138
3.9
100
26
16
1.1
104
291
0.2
6.1
4.2
31
25
68
185 !
175 !
335 !
55 !
365
3.1 !
3.2 !
214 !
33 !
141 !
4.3 !
98
105
140
12.4

Hematology
WBC (x103/mm3)
RBC (x106/mm3)
Hemoglobin (Hgb, g/dL)
Hematocrit (Hct, %)
Urinalysis
Color
Appearance
Specific gravity
pH
Protein (mg/dL)
Glucose (mg/dL)
Ketones
Blood
Urobilinogen (EU/dL)
Prot chk
WBCs (/HPF)
RBCs (/HPF)
Bact

4.811.8
11.0
4.25.4 F
4.56.2 M
4.7
1215 F
1417 M
15
3747 F
4054 M
45

9.32

8.8

4.75

4.68

14.8

14.4

45

44

yellow pale
clear
1.015
5.0
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0

yellow pale
clear
1.018
6
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0

yellow pale
clear
1.0031.030 1.020
57
5.8
Neg
Neg
Neg
Neg
Neg
Trace !
Neg
Neg
<1.1
Neg
Neg
Neg
05
0
05
0
0
0

MD Orders on Admission:
IV heparin 5000 units bolus followed by 1000 unit/hour continuous infusion with a PTT
Chewable aspirin 160 mg PO and continued every day
Lopressor 50 mg twice daily
Lidocaine prn
NPO until procedure completed then Clear liquids, no caffeine
Type and cross for 6 units of packed cells
Will have emergency coronary angiography with angioplasty of the infarct-related artery
MD Progress Note s/p procedure:
Procedures: Emergency coronary angiography with angioplasty of the infarct-related artery- 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. 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 pt and limit infarct size.
Hospitalization, coronary care unit, rhythm monitoring, bed rest, sequential cardiograms, and
cardiac enzymes; Urinalysis and blood chemistry; 25 mg hydrochlorothiazide daily; evaluate for
initiation of HMGCoA reductase inhibitor therapy; social work consult; nutrition consult; pt to
be reassessed in 3 weeks.
Nutrition Consult:
Meal Type: Clear Liquid, no caffeine
History: Pt states that he has a good appetite. He eats 3 meals/d and 1 evening snack. 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. Got rid of salt shaker on table. He has been
eating out more often.
Food Allergies/intolerances/aversions: None
Previous nutrition therapy: Yes, last year by community dietitian about healthy heart.
Food purchase/preparation: Wife
Vit/min intake: no supplements
24-hr Recall (typical for pt):
Breakfast (11 pm):
24 oz coffee
2 Tbs half and half creamer
2 Tbs sugar
1 McDonalds apple pie
Lunch (1:00 pm):
6 oz deli ham on 6 hoagie roll (white)
2 Tbs mayonnaise
1/3 cup iceburg lettuce
2 slices tomato slice
16 oz Pepsi

Dinner (7:00 pm):

5 Wendys chicken nuggets
Wendys French fries, Biggie
4 Ketchup packets
16 oz Pepsi
Evening Snack (10:00 pm):
7 oz Bar-B-Q potato chips
1.5 cans beer

Name: _______________________
Instructions: This is not a group case study; it is an individual assignment! Complete the
following questions using the background information above. Use this as a template and
type in your answers.
Remember RDs are experts in researching evidence-based practice for their patients so
you can use other credible sources. ***Be sure to reference your answers in-text and
provide a Work Cited page at the end.***
1.

Mr. Garcia had a myocardial infarction. Explain what happened to his heart.

A myocardial infarction, also known as a heart attack, occurs when there is a blockage to the heart, and oxygen
rich blood cannot get to it. When the heart does not receive oxygenated blood, the muscle will start to die.
2.

Mr. Garcia was treated with an angioplasty and stent placement. Explain this medical procedure and its
purpose.

Angioplasty is a procedure that open blocked coronary arteries in order to increase blood supply to the heart.
Before the blood vessels are opened, the doctor will inject die into the blood steam to indicate where blockages are
forming. Once this is determined, a balloon catheter is inserted where the blockage is and is inflated to restore
proper blood flow to the heart. A stent, which is a small, metal mesh tube, is placed in the coronary artery where the
balloon is after angioplasty to prevent the artery from closing up again.
3.

List all of Mr. Garcias risk factors for heart disease in his medical record. Outline the appropriate
nutrition therapy for those risk factors that can be addressed through nutrition therapy.

Mr. Garcias medical record indicates various risk factors for heart disease. He smokes one pack of cigarettes
per day, he is obese, and has relatives with heart disease. His lab values indicated high glucose levels, high
cholesterol, low HDL, high LDL cholesterol, and low Apo A. These factors, can be improved with a healthier diet
that is low in saturated fat, sodium, and cholesterol with controlled sugar intake. A therapeutic lifestyle change diet
would be the right diet prescription for Mr. Garcia.
4.

What are the current recommendations for nutritional intake during a hospitalization following a
myocardial infarction? Does his current diet order reflect this?

After a myocardial infarction, nutrient intake should include progression from liquids to soft, easily chewed
foods with smaller, more frequent meals in order to reduce risk of vomiting and aspiration following the procedure.
Once the doctor determines that the patient is ready to return to a normal diet, a nutrition therapy plan, consisting of
a therapeutic lifestyle change diet, is implemented that will help restore his health and prevent future heart
complications. Currently, the doctor has prescribed clear liquids for recovery and requested a nutrition consult.
5.

Mr. Garcia works in a sedentary job, but he does get some exercise daily. He walks his dog outside for
about 15 minutes at a leisurely pace each day and plays with his grandchildren. Calculate his energy
and protein requirements. Identify the formula/calculation method you used and explain your rationale
for using it.

I used the Mifflin St. Jeor equation to calculate Mr. Garcias energy needs because it is most accurate.
BMR=10 x Weight(kg) + 6.25 x height(cm) 5 x age(y) + 5
BMR= (10 x 97.5) + (6.25 x 177.8) (5 x 61) + 5
BMR= 1,786.25
Activity Factor=1.3 because he incorporates minimal daily exercise into his day.
Daily Energy Intake=1,786.25 x 1.3 = 2,322.125 = 2,320 kcal/day
Protein Intake =.8g/kg body weight.
97.5kg x .8g= 78g protein/day
Using a computer dietary analysis program or food composition table, compare Mr. Garcias usual dietary
intake to his Goal diet. (HINT: you need to determine what standard to base the goal diet on)
NUTRIENT PATIENT
Goal diet
COMPARISON
DISEASE
Your diet
INTAKE
IMPLICATIONS
recommendations
6.

kcal

3,396.37kcal

2,200 kcal

Pt consumes an
excessive number
of calories each
day.

Average energy intake

leads to obesity and risk
of cardiovascular
disease, hypertension,
and metabolic syndrome.

% kcal Pro

10%

15%

Pt does not
consume enough
protein.

Inadequate protein can

lead to weakness,
decreased immunity, and
impaired bone health.

% kcal CHO

50%

55%

Pt is slightly below
optimal
carbohydrate
intake.

Inadequate carbohydrate
intake can lead to weight
gain and hypoglycemia.

Decrease overall
energy intake with
nutrient dense,
smaller meals
throughout the day
to decrease total
intake and increase
satiety.
Increase lean
sources of protein
with addition of
chicken, turkey,
and fish in the diet,
along with nuts,
seeds, and
legumes.
Substitute simple
sugars with
complex
carbohydrate
sources from whole
grains throughout
the day.

% kcal Fat

40%

30%

Pt consumes
excessive fat each
day.

High total fat intake can

lead to weight gain, and
increased risk of heart
disease and metabolic
syndrome.

%SFA

20%

<7%

Pts saturated fat

intake is excessive

High saturated fat intake

can lead to high LDL
cholesterol, weight gain,
and increased risk of
cardiovascular disease
and metabolic syndrome.

%MUFA

22%

Up to 20%

Pts
monounsaturated
fat intake is
excessive.

High monounsaturated
fat intake leads to weight
gain.

%PUFA

29%

Up to 10%

Pts
polyunsaturated fat
intake is excessive.

Cholesterol

153.57mg

<200 mg

Pts cholesterol
intake is managed.

High polyunsaturated fat

intake leads to weight
gain and can lower HDL
cholesterol.
No disease implications
with Pts cholesterol
intake. If it were higher,
heart disease would be
worrisome as well as
metabolic syndrome.

Fiber

12.29g

20-30 g

Pt consumes
inadequate daily
fiber.

Na

5108.73mg

<2400 mg

Pt consumes
excessive amount
of sodium.

Low fiber intake can

cause increased LDL
cholesterol levels,
gastrointestinal issues,
and increased risk for
heart disease.
High sodium intake
leads to hypertension
and increases LDL
cholesterol and increases
risk for cardiovascular
disease.

Decrease total fat

intake by replacing
high fat meals with
a balanced meal
with adequate
protein,
carbohydrate and
healthy fats.
Decrease saturated
fat to less than 7%
intake by limiting
fast food and
snacking
throughout the day
and replacing with
baked or broiled
home cooked
meals that
incorporate all food
groups.
Replace undesired
saturated fat
sources from fast
food and chips with
canola oil, olive
oil, avocado, and
peanuts.
Replace undesired
food choices with
vegetable oils and
fatty fish sources.
Maintain
cholesterol intake
of less than 200mg
per day Increasing
lean protein,
unsaturated fats,
and whole grains
will lower patients
cholesterol levels
and keep
cholesterol intake
under control.
Increase fruits,
vegetables, whole
grains, and beans/
legumes
throughout the day.
Decrease fast foods
and processed food
intake for they are
known to contain
an excessive
amount of sodium.
Increase potassium
and fluid intake to
help balance
sodium levels and

Ca

226.45mg

100-1,000 mg

Pts Calcium intake

is managed.

3159.96mg

4,700 mg

Pt consumes
inadequate
Potassium.

Mg

176.91mg

400 mg

Pt consumes
inadequate
Magnesium.

7.

Calcium intake is on the

lower side and can cause
impaired bone health due
to coupled protein
inadequacy.
Low potassium can
cause an abnormal heart
beat, kidney stones, and
bone loss.
Low magnesium intake
can cause calcium and
potassium deficiency as
well as hyperglycemia.
It can also lead to an
irregular heartbeat

regulate blood
pressure.
Increase intake of
dairy products,
leafy greens, and
seafood to reach
goal diet.
Increase intake of
spinach, sweet
potatoes, and
bananas to reach
goal diet.
Increase intake of
leafy greens, beans,
nuts, and whole
grains to reach goal
diet.

From the information gathered within the intake domain, list important nutrition problems using the
diagnostic term (just the P of PES). Which is highest priority?

Excessive energy intake

Excessive Oral Intake
Excessive Fat Intake
Inadequate Fiber Intake
Undesirable Food Choices

Excessive Oral Intake is of highest priority because it is contributing to his overweight figure which is most highly
linked to his undesirable lab results and myocardial infarction. This problem can have the most impact on his health
status can be addressed and improved with the help of an RD.
8.

Complete the chart using admission labs.

Parameter
Glucose

CO2

Total cholesterol

Patients Value and

interpretation
136 mg/dL which is
above the
normal range of
70-110mg/dL.

20 mEq/L which is
below the
normal range of
20-23 mEq/L.
235 mg/dL which is
above the
normal range of
120-199
mg/dL.

Reason for
Abnormality
The diet is high in
carbohydrates and
insulin in the body
may not be able to
keep up with
glucose entering
the body.
Patients heart
attack lead to
decreased CO2
levels.
Patient is
overweight and
consumes a diet
high in saturated
fat and sodium
cause high total
cholesterol.

Your diet recommendations based on

results
Complex carbohydrate sources spread
out throughout the day to account for
55% of total carbohydrate intake.

Liquids, and soft, easily chewed foods to

recover from heart attack, followed by
TLC diet to restore health and prevent
recurrence of heart complications.
TLC diet with fat primarily from
monounsaturated and polyunsaturated
sources to limit cholesterol intake to less
than 200mg.

Parameter
Glucose

CO2

HDL-cholesterol

9.

Patients Value and

interpretation
136 mg/dL which is
above the
normal range of
70-110mg/dL.

20 mEq/L which is
below the
normal range of
20-23 mEq/L.
30 mg/dL which is
lower than the
reference range
of at least 50
mg/dL.

LDL-cholesterol

160 mg/dL, which

is high. LDL
cholesterol
should be
below 130
mg/dL.

Apo A

72 mg/dL which is
lower than the
reference range of
94-178 mg/dL.

Apo B

Apo B is within the

63-133 mg/dL
reference range at
115 mg/dL.

Triglycerides

Triclyceride levels
are 160 mg/dL
which is high but
within the normal
range of 40-160
mg/dL

Reason for
Abnormality
The diet is high in
carbohydrates and
insulin in the body
may not be able to
keep up with
glucose entering
the body.
Patients heart
attack lead to
decreased CO2
levels.
Patient is
overweight and
consumes a diet
low in fiber, omega
3 fatty acids, and
whole grains.
Patient is
overweight and
consumes a diet
high in saturated
fat and sodium
which increases
LDL cholesterol.
Associated with
low HDL levels
and high risk of
cardiovascular
disease due to poor
diet and minimal
exercise.
Although still
within the normal
range, Apo B
levels are on the
higher side most
likely linked to
high LDL
cholesterol due to
suboptimal diet.
Diet high in fat can
cause high
triglyceride levels
in the body.

Your diet recommendations based on

results
Complex carbohydrate sources spread
out throughout the day to account for
55% of total carbohydrate intake.

Liquids, and soft, easily chewed foods to

recover from heart attack, followed by
TLC diet to restore health and prevent
recurrence of heart complications.
TLC diet that incorporates fruits and
vegetables, complex carbohydrates, and
unsaturated fat sources to increase HDL
cholesterol levels.

TLC diet that does not exceed 200mg of

cholesterol, is high in unsaturated fat,
whole grains, and fiber to decrease LDL
cholesterol levels.

TLC diet to increase HDL levels and

prevent further instances of
cardiovascular disease by adding
unsaturated fats, fiber, and whole grains
to the diet.

TLC diet to bring LDL cholesterol down,

restore lipid panel, and lower risk of
heart disease by adding more sources of
unsaturated fat and fiber through fruits,
vegetables, and whole grains.

A TLC diet consisting of 25-35% of

energy from healthy fat sources will
bring triglyceride levels down to a more
desired amount and prevent future
cardiovascular complications. Food
eaten out should be limited and variety
should be added to the diet through fruits
vegetables and legumes to increase fiber
and protein while decreasing fat and
cholesterol.

Examine the chemistry results for Mr. Garcia on Admission. Which labs are diagnostic of the MI diagnosis?
Explain.

Mr. Garcias diagnosis of myocardial infarction relates to various lab indicators including troponin T and I,
lactate dehydrogenase, and CPK-MB. Troponin T is associated with scar tissue replacing necrotic cardiac cells and
is seen after a myocardial infarction. Mr. Garcias results for troponin T was higher than normal at 2.1 ng/dL

signifying his MI. Troponin I prevents myosin from binding actin in relaxed muscle due to its binding function to
actin. Because of a myocardial infarction, Troponin I would increase as seen in Mr. Garcias lab results. Upon
admittance his Troponin I levels were 2.4 ng/dL when they should be below .2 ng/dL. Lactate dehydrogenase is
another lab result that indicates myocardial infarction. This enzyme catalyzes the conversion of lactate to pyruvic
acid and is highly elevated after 24 hours of an MI. Lactate dehydrogenase should be 208-378 U/L. On day two of
admittance Mr. Garcias lactate dehydrogenase reached 685 U/L. CPK-MB chemistry results should be 0 U/L but
will be elevated if the heart was damaged. On day 2 and 3, Mr. Garcias CPK-MB levels read 75 U/L and 55 U/L,
respectively and are diagnostic of myocardial infarction.
10. Mr. Garcia was prescribed the following medication. What are the food-medication interactions for this list
of medications?
Medication
Lopressor 50 mg daily

Mechanism of action
Lopressor lowers blood pressure to
help prevent stroke, heart attacks,
and kidney issues. It is used to treat
angina and recover after having a
heart attack.

Lisinopril 10 mg daily

Lisinopril inhibits ACE, and is

therefore used in patients with
hypertension and heart failure. ACE
catalyzes the conversion of
angiotensin I to angiotensin II to
enable vasoconstriction. Lisinopril
decreases blood pressure by
preventing this conversion from
happening.
NTG relaxes vascular smooth muscle
promotes dilation of arterial and
venous beds and lower blood
pressure.
ASA, also known as aspirin, prevents
the recurrence of a heart attack by
defecting platelet function. This
prevents blood clotting and maintains
blood flow to the heart.

NTG 0.4 mg sl prn

chest pain

ASA 81 mg daily

Possible Food-Medication Interactions

Calcium can interfere with the absorption
of Lopressor and lead to nausea, diarrhea,
stomach pain, dry mouth, gas, and
heartburn. It is best to take Lopressor on
an empty stomach because food in the
stomach can increase Lopressor levels in
the blood to dangerous levels.
Consuming high amounts of potassium
while taking Lisinopril can cause
hyperkalemia. These foods include sweet
potatoes, orange juice, bananas, and salt
substitutes that are often high in potassium.

NTG should not be coupled with alcohol

because it can cause severe reactions in the
body and lead to fainting, increased body
temperature, and low platelet count.
ASA should not be taken with cranberry
juice or alcohol, along with foods high in
omega 3 fatty acids for they have
anticoagulant effects and can lead to
bleeding problems.

11. How does a hydrochlorothiazide lower blood pressure. What are the pertinent drug-nutrient interactions?
Hydrochlorothiazide decreases blood pressure because it is a diuretic that increases urine output to rid the body
of extra salt and water. This drug can decrease potassium levels so it is important to have an adequate intake of
spinach, sweet potatoes, and bananas, etc.
12. How does an HMG-CoA reductase inhibitor lower serum lipid? What are the pertinent drug-nutrient
interactions?
HMG-CoA reductase inhibitor blocks the HMG-CoA enzyme that helps manufacture cholesterol. This will
then lower LDL cholesterol, total cholesterol, and triglycerides, as well as increase HDL cholesterol. HMG-CoA
increases vitamin A in the blood so it is important to control vitamin A sources such as leafy green vegetables, milk
and eggs, and liver.
13. What other classes of medication can be used to treat hypercholesterolemia?
Other medications can lower cholesterol aside from hydrochlorothiazide and HMG-CoA reductase inhibitor such as
bile acids, niacin, and fibrates. Bile acids can lower HDL cholesterol as well, so they are used less commonly.
Niacin lowers LDL cholesterol, however, it also brings about various side effects such as stomach pain, headaches,
and loss of appetite. Fibrates are especially helpful in lowering triglycerides.

14. What is the rationale for the use of plant stanols/sterols? List some specific products that you may
recommend?
Plant stanols and sterols have a similar structure to cholesterol. They work to reduce the absorption of cholesterol in
the digestive tract which causes more of it to be lost in the feces. This will lower total cholesterol and LDL
cholesterol in the blood. 1.5-2.4g of plant stanols and sterols per day can lower cholesterol by 7-10% in two weeks.
Many foods have fortified plant stanols and sterols which are beneficial to people with high blood cholesterol and
high risk of heart disease. These foods include fortified milk, spreads, and yogurts. There are also plant stanol and
sterol supplements available. Fruit, vegetables, whole grains, lean meat, low fat dairy, fish, nuts, and soy naturally
contain stanols and sterols and would benefit cholesterol levels and are more financially accessible.

15. Using the EAL, review the Disorders of Lipid Metabolism Project. Would you recommend antioxidant
supplements? Would you recommend nuts? Would you recommend folate? Make sure to provide your
rationale.

Antioxidant supplements should not be recommended. It has been found that high doses do not actually
provide any cardiovascular benefits, but could actually be detrimental to a persons health and shorten their
lifespan. Instead, Mr. Garcia should be consuming foods that are naturally high in antioxidants, such as nuts,
fruits, and vegetables. The EAL found that when one ounce of nuts was consumed five times a week, total
LDL decreased by 10-15%. The researchers also saw a 30-50% decline in CHD risk in the subjects. Food
sources of folate should be recommended. Supplements should not be taken due to the fact that although they
may decrease homocysteine levels, they have not been found to reduce CHD and could actually be harmful.
16. When you ask Mr. Garcia how much weight he would like to lose, he tells you he would like to weigh 170,
which is what he weighed when he was in college. Is this reasonable? What would you suggest as a goal for
weight loss for Mr. Garcia?
Although it is great to see Mr. Garcias ambition, his goal is not very attainable for his situation. He is obese
and much older than he was in college. His hormones and lifestyle will most likely not support a body weight of
170lbs. I would start with a smaller, more attainable goal within a shorter time span. I would hope to see Mr.
Garcia start by losing 1/2 pound per week as this will support healthy weight loss, it is manageable for Mr. Garcia,
and it will improve his health status. In regards to long term goals, I would suggest that Mr. Garcia should strive for
185 pounds and the maintenance of this weight through adoption of a TLC diet and healthful lifestyle that
incorporates daily exercise.

17. How quickly should Mr. Garcia lose this weight?

It is recommended that when losing weight, adults should strive for 1-2 pounds per week. Because Mr. Garcia
will only just be starting on a weight loss plan and is used to consuming excess calories, he should strive for .5
pounds per week. He will have to follow a diet plan with a 250 calorie deficit which will be manageable for Mr.
Garcia. As time progresses and he is comfortable with this plan, he can increase his weight loss to one pound per
week if he would like. If Mr. Garcia chooses to quicken his weight loss, he would increase his calorie deficit to 500
calories. This will quicken his weight loss progress and he will sooner reach his goal.
18. Select two KEY nutrition problems and complete the PES statement for each.
1.

Excessive fat intake related to food and nutrition knowledge deficit as evidenced by 24-hour recall
containing processed foods high in saturated fat, BMI of 30.9 (obesity class 1), myocardial infarction, and
abnormal lab levels reading 160 mg/dL LDL cholesterol, 30mg/dL HDL cholesterol, 72 mg/dL Apo A, and
160 mg/dL triglycerides upon admittance.

2.

Excessive oral intake related to food and nutrition knowledge deficit as evidenced by 24-hour recall
containing large portion sizes of high calorie, low nutrient foods and BMI of 30.9 (obesity class 1).

19. Write Nutrition Prescription for patient. Include Diet type, kcal level, % kcal from CHO, PRO, FAT,
Saturated fat, cholesterol, Na.

Therapeutic Lifestyle Change diet with three meals and 2 small snacks per day to reach 2,320 kcal. 55%
carbohydrates, 15%protein, and 30% fat, <7% saturated fat, with no more than 200mg of cholesterol and 2,300mg of
sodium. 30 minutes of daily exercise.
20. For each of the PES statements that you have written, establish an ideal goal (based on the signs and
symptoms) and an appropriate intervention (based on the etiology). Use Standardized Language to label
Intervention domains and subclasses; and give details of exactly what you are going to do.
PES #1
o Goal: Lower fat intake to from 40% to 30% of total calories made up mostly of unsaturated fat sources.
o Intervention: Educate patient about healthier food and lifestyle choices to increase amount of meals
consumed at home, increase physical exercise, and limit undesirable lifestyle choices like smoking and
alcohol consumption.
PES #2
o Goal: Consume up to 2,320 calories per day with 30 minutes of daily exercise.
o Intervention: Educate patient about portion sizes and healthful food choices and components to
increase satiety.

21. Write a concise ADIME note. Hand-in a double spaced typed version only.
A:
61-year-old male, patient, admitted to hospital with unstable angina and diagnosed with myocardial infarction
and hypertensive heart disease. Patient smokes one pack of cigarettes/day for forty years with a family history of
coronary artery disease. Pt works a sedentary job as an IT network. Pt. is obese: 215 pounds, 510 with,
BMI=30.9. Lab values indicate low carbon dioxide at 20 mEq/L, high glucose at 136 mg/dL, high CPK at 400
U/L, high LDL cholesterol at 160 mg/dL, low HDL cholesterol at 30mg/dL, high Apo A at 72 mg/dL and
borderline high triglycerides at 160 mg/dL. Patient states that he has a good appetite and eats three meals each
day with one evening snack. Recently, pt is trying to change his diet but his wife purchases and prepares food,
diet recall includes large portions of fast foods. Pt consumes excessive calories-approx. 3,000/day, with 10%
protein, 40% fat, 20% saturated fat. Diet is low in fruits, vegetables, whole grains, and fiber. Diet needs to be
altered to 2,300 kcal TLC diet with 30-35% fat, 15% protein, and 50-55% carbohydrate.
D:
Excessive fat intake related to food and nutrition knowledge deficit as evidenced by 24-hour recall containing
processed foods high in saturated fat (20% of daily diet), BMI of 30.9 (obesity class 1), myocardial infarction,
and abnormal lab levels reading 160 mg/dL LDL cholesterol, 30mg/dL HDL cholesterol, 72 mg/dL Apo A, and
160 mg/dL triglycerides upon admittance.
I:
Nutrition Prescription: Therapeutic Lifestyle Change diet with three meals and 2 small snacks per day to reach 2,320
kcal. 55% carbohydrates, 15%protein, and 30% fat, <7% saturated fat, with no more than 200mg of cholesterol and
2,300mg of sodium. 30 minutes of daily exercise.

Goal: Lower fat intake to from 40% to 30% of total calories made up mostly of unsaturated fat sources in
order to normalize LDL, HDL, and triglycerides.
Intervention: Educate patient about healthier food and lifestyle choices to increase amount of meals
consumed at home, increase physical exercise, and limit undesirable lifestyle choices like smoking and alcohol
consumption. Patient should have be able to follow a TLC diet with < 7% saturated fat, <200mg cholesterol, whole
grain, high fiber carbohydrate sources, lean meats, and 30% of the diet from unsaturated fat foods.
M & E:
Monitor Food and Nutrient Intake: Total Energy Intake
Outcome: Patient will complete a food record that illustrates a balanced diet of 2,320 total kcal with
smaller portion sizes throughout the day and healthy food selections including fruits and vegetables, complex
carbohydrates, lean meat, and low fat dairy.
Monitor Food and Nutrient Intake: Percent Calories from Fat
Outcome: Patients fat intake will be 30-35% of calories with a focus on unsaturated fat sources and
<7% saturated fat sources to normalize LDL and HDL cholesterol as well as triglyceride levels and manage a
healthier weight.
Monitor Biochemical Data: Cholesterol and Triglycerides
Outcome: LDL cholesterol will be lowered and HDL cholesterol will be increased to reach
recommendations of less than 130 mg/dL and at least 55 mg/dL, respectively. Triglycerides will be improved
toward the lower range of the spectrum at 40 mg/dL.
Will follow up with patient in one month in an outpatient setting.
Jane Loprieno RD Pager #1129

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