Theodore Mitchell

Cardio Vascular Disease CS II

Hxxxxx, Rxxxxx, Male, 59 yo
Allergies: NKA
Pt. Location: RM 1104

Code: FULL
Physician: A. Baum

Isolation: NONE
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:

negative
negative
no carotid bruits
negative
negative
negative
negative

Physical Exam
General
appearance:
Heart:
HEENT:
Head:
Eyes:
Ears:
Nose:

mildly over wt. 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.
TM nl bilaterally
WNL

Theodore Mitchell
Throat:
Genitalia:
Neurologic:
Extremities:
Skin:
Chest/Lungs:
Peripheral vascular:
Abdomen:

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

Vital Signs:
Temp: 98.4
BP: 118/78

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, 13-
14=moderate risk, <12=high risk)

Orders:

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

Theodore Mitchell
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
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:
Dinner:
Snack:

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
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
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)

Ref. Range

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

9/1 1957

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

9/2 0630

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 !

9/3 0645

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 !

Theodore Mitchell

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)
Triglycerides (mg/dL)
Coagulation (Coag)
PT (sec)
Hematology
3
3
WBC (x 10 /mm )
6
3
RBC (x 10 /mm )
Hemoglobin (Hgb, g/dL)
Hematocrit (Hct, %)
3

MCV (um )
MCH (pg)
MCHC (g/dL)
RBC distribution (%)
3
3
Platelet count (x10 /mm )
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

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
35-135 F
40-160 M

12.4-14.4

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

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

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

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

150

140

130

12.6

11.0
4.7

12.6

9.32
4.75

12.4

8.8
4.68

15

14.8

14.4

45

45

44

91
30
33
13.2
320

55
17
4
0
0
3
45
15 !

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

92
31
32
12.8
295

58
23
4
0
0
3
47
17 !

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

90
30
33
13.0
280

62
35
7
0
0
4
52
8

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

Theodore Mitchell

1.

RH had a myocardial infarction. Explain what happened to his heart during his MI.

Atherosclerotic occlusion led to necrosis in left portion of coronary artery. Point of maximal
impulse happened in the fifth intercostal space, midclavicular line on the left hand side. ???
for the rest. cant find in medical terminology



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? (
An angioplasty is a procedure that uses a laser catheter to remove plaque and permit a
balloon to be inflated within the clogged artery. A stent placement is in which a tiny piece of
plastic or metal that looks like a straw is placed in a narrowed coronary artery to keep open.
The goal of these procedures is to restore blood flow through the obstructed coronary
artery. Its purpose is to reduce pain, stabilize cardiac function and begin rehabilitation post
MI.

3.
What are the current recommendations for the progression of nutritional intake during a
hospitalization following a myocardial infarction?
Decreasing oral intake of food, clear liquids no caffeine, progress to soft diet, increase
frequency of meals gradually. Individualize the TLC diet for the patient.
Source- NTP CVD Lecture

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?
CO2= 20; levels were low on 9/1 and after receiving medical treatment,
troponin levels are high because there is increased physical stress on the heart .
ALT= 30, 215, 185 normal levels, however skyrocketed day 2 and day 3 possibly due to
medication or overwork of heart or liver
AST=25, 245, 175 normal levels, however skyrocketed day 2 and day 3, possibly due to
medication or overwork of heart or liver as a result of the MI
CPK= 75, 500, 335 normal levels, however skyrocketed day 2 and day 3 due to cell death

Theodore Mitchell

ALT, AST, and CPK abnormal values possibly due to the lack of the gallbladder and damage
done to heart after heart attack causing leakage from damaged muscle and overwork of the
liver. CPK, enzyme found in heart, elevations further confirm heart muscle damage.
increased levels of %band is also associated with athersclerotic plaques
increased ketones levels were high day one due to TCA cycle metabolism, may have
contributed to MI.
Troponin and LDH lactose dehydrogenase was also high which is associated with MI and
cellular distress.

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.
Parameter

RHs
Value in
mg/dL

Interpretation
based on NCEP
classification

Therapeutic
goal

Total
Cholesterol

235

Borderline High

<200 mg/dL

LDL
Cholesterol

160

High

<100 mg/dL

HDL
Cholesterol

30

Major CVD risk

factor

>40 mg/dl

Apo A

72

Low

>178

Triglycerides

150

Borderline high

<150

Overall, what does RHs lipid panel suggest?

RHs lipid panel suggests that he was and is at very high risk for future cardiovascular
diseases and heart attacks. He has incredibly low HDL and very high LDL cholesterol, two
classification of dyslipidemia, a risk factor in atherosclerosis. This is not surprising as this
is a precursor of a myocardial infarction, which RH just experienced.
Important to note that his very low HDL cholesterol constitutes him at major risk for
CVD.

6. List & number RHs risk factors for CHD, based on the presentation data from his medical record.
#1) Cigarette Smoking leading to systemic inflammation possibly contributing to higher

Theodore Mitchell

total cholesterol and LDL and lower HDL; oxidative modification of LDL and other lipid
metabolites
#2) Dyslipidemia: high cholesterol; high LDL and low HDL
#3) Hypertension increases risk
#4) Physical Inactivity
#5) Sex: men develop atherosclerosis at faster rate than females
#6) family history: his father had CHD at age 58 had a heart attack
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.
Exchange
13 starches

kcal

PRO g

CHO g

FAT g

1077

40

200

13

208

52

11 lean meats

506

77

22

2 fats

135

15

1 veg

32

250

16

24

10

2,208

135

282

60

6 fruits

___ LF milk
Total
% of total kcals

100%

24.4%

51.2%

24.4%

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
RH is consuming more than the desired amount of daily protein and too many of the calories come
from carbohydrates and saturated fats.
Breakfast:
Mid-morning
Snack:
Lunch:
Dinner:
Snack:

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
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
8 oz 2% milk, 1 oz pretzels

TLC Goals: Your Recommendations:

Theodore Mitchell

Total calories:

Total fat:

Saturated fat:

25-35%

<7% of kcal

2573 kcal
weight conversion: 185 lbs/2.2 kg=84.09 kg
height conversion: 70inx0.0254=1.778 m
662-9.53x59+1.11x(15.91x84.09+539.6x1.778)
662-562.27+1.11x(1268.92+959.41)
99.73+1.11x(2228.33)
99.73+2473.45=2573.18=2573
72-100 gm
2573x.25=643.25/9 kcal/gm=71.47=72
2573x.35=900.55/9 kcal/gm=100.06=100
<20 gm
2573x.07=180.11 kcals/ 9 kcal/gm= 20.01=20
gm

Monounsaturat
ed Fat:

~20% of
kcal

<57gm
2573x.20=514.6 kcals/ 9kcal/gm=57.18=57 gm

Polyunsaturate
d Fat:

~10% of
kcals

<29gm
2573x.10=257.3 kcals/9 kcal/gm=28.58= 29gm

50-60% of
kcals

322-386 gm
2573x.50=1286.5/4 kcals/gm=321.63=322 gm
2573x60=1543.8/4 kcals/gm=385.95=386 gm

Carbohydrate:

Fiber:

b/t 2030g/day

20-30 gm/day

Protein:

~15% kcal

97gm
2573x.15=385.95/4 kcal/gm=96.49= 97gm

Cholesterol:

>160 mg d

<200 mg/day

<2400 /day

<2400 mg/day

Sodium:
Potassium:
Plant
stanols/sterols

RDA
3-4g/day

RDA
3-4 mg/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,

Theodore Mitchell
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.

Lopressor 50 mg daily
Generic name:

metoprolol

Classification:

Beta Blocker

Indication:

MI; antihypertensive

Diet:

decrease Na, decrease Ca, reduction of calories may be

necessary, avoid licorice root

Possible FoodMedication
Interactions:

licorice root and products with natural licorice flavorings

Potential
Nutrition/Oral
/GI Side
Effects:

dry mouth, N/V, dyspepsia, flatulence, diarrhea, constipation

Zestril 10 mg daily
Generic name:

Lisinopril

Classification:

ACE Inhibitor

Indication:

Acute MI, HTN, CHF treatment for left ventricular dysfunction

and as adjunct treatment for CHF post MI. Diabetic nephropathy

Diet:

insure adequate fluid intake, decrease Na, decrease caloric

intake if necessary. Avoid salt substitutes, caution against K
supplementation

Possible FoodMedication
Interactions:

Fe, Mg and Al decreased on drug and avoid licorice root

Theodore Mitchell

Potential
Nutrition/Oral
/GI Side
Effects:

anorexia reported, weight loss, , dysgeusia, dry mouth, N/V,

abdominal pain, constipation, diarrhea, decrease alcohol
consumption, Side effects increased in Black patients.

Zocor 20 mg/day
Generic name:

simvistatin

Classification:

HMG CoA Reductase inhibitor

Indication:

antihyperlipidemic, prevent or reduce risk of CVD, slows progression of

atherosclerosis

Diet:

decrease fat, decrease cholesterol, decrease caloric intake if necessary,

avoid grapefruit,

Possible FoodMedication
Interactions:

Grapefruit and related citrus fruits, no St. Johns Wort

Potential
Nutrition/Oral/GI
Side Effects:

Nausea, dyspepsia, abdominal pain, constipation, diarrhea, constipation,

flatulence

Nitrostat 0.4 mg sl prn chest pain
Generic name:

Nitroglycerin

Classification:

Antiangina

Indication:

relief of acute MI

Diet:

take on empty stomach with water

Possible FoodMedication
Interactions:

Avoid alcohol

Potential

dry mouth, N/V, abdominal pain

Theodore Mitchell

Nutrition/Oral/GI
Side Effects:

ASA 81 mg daily
Generic name:

aspirin

Classification:

platelet aggregation inhibitor

Indication:

analgesic, antipyretic, anti-arthritic, NSAID, prevent progression of CVA or

incidence MI

Diet:

insure adequate food intake/hydration, increase foods rich in vitamin c & folate,
avoid natural products that affect coagulation, garlic, ginger, ginseng, gingko,
horse chestnut

Possible FoodMedication
Interactions:

garlic, ginger, ginseng, gingko, horse chestnut and other foods with blood
coagulation altering properties coumarin/Coumadin; ethanol

Potential
Nutrition/Oral/GI
Side Effects:

anorexia, sudden serious gastric bleeding, N/V, dyspepsia, black tarry stool

10. Make an overall statement as to the discharge dietary advice you would give RH regarding his
medications above.
Advise patient to avoid grapefruit. decrease intake of foods with high saturated fat
content. decrease foods high in sodium.
Increase foods high in vitamin c and other antioxidant vitamin and phytonutrients.
Increase consumption of high fiber foods (e.g. whole grains, beans, unrefined
products) Avoid foods containing natural licorice.

11. What is metabolic syndrome & does RH meet the criteria? Why or why not?
A number of symptoms including increased high blood pressure, high fasting blood
sugar level, increased waist circumference, low HDL, High TG, metabolites that occur
together, increasing your risk of heart disease, stroke and diabetes. BMI is 26.6 slightly
overweight.
RH does meet the criteria for MetS. He has abnormal cholesterol levels, above normal
blood sugar levels but non-fasting, waist circ. r/t slightly overweight. He has three of the
symptoms meeting the diagnosis of MetS

Theodore Mitchell

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.
1. What type of things they do to relax/stress management techniques?
2. How often do they vacation? When is the last time they had a vacation?
3. How much leisure or non-work related physical activity do they participate in,
regular sexual activity?
4. What the general composition of their diet over the course of week? How that
changes throughout the month and varies with the season?

13. List 4 lifestyle factors you might recommend to support realistic, successful lifestyle changes for
RH?
1.
2.
3.
4.

Increase leisure physical activity. Walking with wife

Increase time spent in relaxing settings
Smoking cessation strategies, education, detoxification etc
Nutrition education about total diet changes, to help increase HDL levels and
decrease LDL, increase fiber and vegetable consumption.

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.
islamic dietary laws restrict eating foods considered Haram or unclean. These foods
include
Pork-based products and by-products
Animals improperly slaughtered, or already dead before slaughtering is due to take
place
Animals killed or sacrificed in the name of others than Allah (swt)
Intoxicants/alcohol
Most carnivorous animals, birds of prey and land animals without external ears (i.e.,
snakes, reptiles, worms, insects etc.)
Blood and blood by-products
Foods contaminated with any of the above products
These foods are believed to bring about harm to the person and negate their physical
and spiritual health.

http://www.islamforlife.co.uk/haram%20list.htm

Theodore Mitchell
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.
1. The classification and roles of dietary lipids. Importance of ensuring a healthy ratio
of omega 3 and omega 6 containing foods. In addition to sources of those foods, and
ways of incorporating them into the diet.
2. The importance of the role fiber plays in promoting health, e.g. decreasing
cholesterol levels and feeding gut biota.
3. The role of plants in promoting healthy metabolism and general physiologic
functions.
4. The importance of variety and being a good self monitor without interfering with his
general satisfaction and enjoyment with eating.
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.

A:
59 year-old male admitted through the ED for an emergency coronary angiography with
angioplasty of the infarct-related artery. Personal history of chronic smoking. Family medical
history of father with CAD and MI at age 58.
Anthropometrics
Wt: 185 lbs/2.2 kg= 84.09 kg Ht: 510=70 in x 0.254=177.8cm BMI= 26.6 (overweight)
IBW= 105 lb. first 5ft + 6 lb. for each additional inch 105.6*10= 165 kg
Labs
Lipid profile: CHOL value 214 (high), 141 LDL value (high), HDL value 33 (low, major CVD risk
factor); Abnormally high chemical value: ALT (185 U/L), AST (175 U/L), and CPK (335 U/L) all
at high ends of the normal values; Hematological values: Bands (%) (15% and 17% day 1 and
day 2 respectively)
Medications
Lopressor 50 mg/d, Zestril 10 mg/d, Zocor 20 mg/d, Nitrostat, 0.4 mg/d, ASA 81 mg/d
Surgical History: cholecystectomy 10 yrs ago, appendectomy 30 yrs ago
Estimated Nutrient Needs
Energy: (10x80.09kg) +(6.25x 177.8)-(5x59)+5= (800.9 kg)+(1111.25)-(295)+5= 1912.15-

Theodore Mitchell

300=1612.15= 1612 kcal/day (AF of 1.2-1.3and an injury factor of 1.1-1.2 for combined
factor of 1.3-1.5. 1612 * 1.3= 2095.6; 1612 * 1.5= 2418. 2095-2418 kcal/d
Protein= 1612x.15=241.8/4 kcal/gm= 60.45g
We will use 0.8g/kg/d with the same factor so 67.27g * 1.3 = 87.45; 67.27 * 1.5= 100.9 so
range 88-101 g/d
Fluid: 1 mL/estimated kcal using 2256.5 as estimated kcal from range above 2.25L/d
Food and Nutrition History
RH reports a typical eating pattern of a usual weekday is similar to that of his 24-HR recall:
he does not report having breakfast regularly. A mid-morning snack consists of 1 large
cinnamon raisin bagel with 1 tbsp fat-free cream cheese, 9 oz grapefruit juice, 16 oz coffee.
For lunch, he ate 1 c. canned vegetable beef soup, sandwich with 4 oz roast beef, lettuce,
tomato, dill pickles, 2 tsp mayonnaise, 1 small apple, 8 oz of 2% milk. For dinner he reports
having 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), and 1 slice of apple pie. He had 8
oz of 2% milk and 1 oz of pretzels for a late night snack. His wife usually purchases and
prepares the food and indicates that she uses corn oil instead of butter, although she tries
not to fry foods often. RH reports having a good appetite and that he has been trying to
change some things in his diet.
Family and Social History
RH married with a 59 y/o spouse. He has two children who are grown and live away from
home. He has a BS degree, speaks english and is a Project Manager for a refuse company.
His father had CAD and had a mI at the age of 58 y/o. Seen R.D. in past

D:
1. Excessive fat intake (NI 5.6.3) r/t dietary intake and poor hdl/ldl ratio as indicated by
lab results of high cholesterol levels
2. Undesirable food choices (NB 1.7) r/t patients preferences and availability

I:
Overall MNT goal is to reduce progression of CVD and occurrence of MI
Motivational interviewing and emotional and socio-cognitive support to enhance
compliance.
Referral to smoking cessation class or counselor; stress management techniques,
detoxification specialist if available
Increase amount of MUFA/PUFA sources in the diet to shift lipid levels to desired states.
Increase leisure physical activity/light exercise
Provide handouts related to desirable food choices and sample diet log

Theodore Mitchell
M/E:
Monitor patients oral intake PO via food journal and dietary records and analysis
Return for follow up in two weeks for lipid panel and CBC followed by two more visits at
week 6 and week 10.
Theodore R. Mitchell
Theodore R. Mitchell B. Sci. Clinical Nutrition 11/30/15