CASE STUDY #2 Cardiovascular Disease

NUT 116AL Due 11/18/2016

Instructions:
Read all questions before starting on the case study as many are related to eachother.
Review the pts medical record below. Answer each question and show your
calculations (if necessary) for each. You may include your calculations in the answer
box and, if needed, attach as a separate, hand-written sheet. Use the following
conversion factors: 1=2.54 cm and 1#=2.2kg.
Reference all calculation formulas with the text and page number from the Pocket
Resource (i.e., PR p. ___). Only use the PR for all calculations. You may use lecture notes
and the textbook for all other questions. Cite lecture notes as 116AL CVD Lecture,
slide#.
After you have EXHAUSTED your search for answers to your CS questions and you are
still unable to find the answer, you may use outside resources as long as they are
credible resources. e.g.: Mayo Clinic, medline plus, research articles, etc., NOT
wikipedia. Remember to conduct a thorough search of the resources available to you
prior to using outside references to avoid losing points.
In your citation, please include the resource name (i.e.: Mayo Clinic), title of
page/article, & exact URL link
You must type your answers! If not, questions will not be graded and you will receive 0
points.
To familiarize yourself with medical terminology, utilize an online dictionary such as:
http://www.medilexicon.com/medicaldictionary.php
CS #2 is worth 50 pts.

MD NOTES:
___________________________________________________________________________________________
Bxxxxx, Bxxxxx Female 59 yo
Allergies: NKA Pt ID: XXXXX1234 DOB: 02/01/1957
Pt. Location: Room 1576 Physician: D. Rostari Date: 11/10/2016
___________________________________________________________________________________________

Pt Summary: BB is a 59 yo black female admitted through the ED for an emergency

coronary angiography with angioplasty of the infarct-related artery.

Dx: AMI, CAD, HTN

Onset of disease: 59 yo female who noted the sudden onset of severe precordial pain
while out walking. The pain is described as pressure-like pain, radiating to the jaw, back,
and left arm. Pt took sublingual nitroglycerin after onset of chest pain. Pt has noted an
episode of emesis and nausea. Pt denies palpitations or syncope. Pt denies prior hx of pain
or SOB.
Medical hx: s/p MI and stint placement 1 year ago. HTN dx one y ago. No hx of rheumatic
fever, DM, kidney disease. Gravida 2. c/o intermittent constipation over past y.
Surgical hx: cholecystectomy 10 yrs ago, appendectomy 30 yrs ago
Rx: Lisinopril 2.5mg/D; Bystolic 2.5mg/D; Crestor 20mg/D; Effient 10mg/D, Nitrostat
0.4mg prn chest pain (all x 1 y)
OTC: ASA 85mg/D, Ca 1000 mg/D, Senokot prn
Allergies: sulfa
Tobacco use: 1 ppd for 40 yrs; quit 1 year ago cold turkey
Alcohol use: none
Family hx: father with CAD; MI age 45

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Social Hx:
Marital status: married, 60 yo spouse
Children: grown and away from home
Years education: 4 years college
Language: English
Occupation: Project Manager for an insurance company
Exercise: Walks 30 min 4-5x/wk

MD Progress Note:
ROS
Constitutional: negative
Skin: negative
Cardiovascular no carotid bruits
:
Respiratory: negative
Gastrointestina negative
l:
Neurological: negative
Psychiatric: negative

PE
General mildly overwt female in acute distress from chest pain
appearance:
Heart: 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.
HEENT: WNL
Head: normocephalic
Eyes: EOMI, fundoscopic exam WNL. No evidence of
atherosclerosis, diabetic retinopathy, or early hypertensive
changes.
Ears: TM nl bilaterally
Nose: WNL
Throat: tonsils not infected, uvula midline, gag nl
Genitalia: WNL
Neurologic: No focal localizing abnormalities; DTR symmetric bilaterally
Extremities: No C/C/E
Skin: diaphoretic
Chest/Lungs: clear to A&P
Peripheral PPP
vascular:
Abdomen: RLQ scar and midline suprapubic scar. BS WNL. No
hepatomegaly, splenomegaly, masses, inguinal lymph nodes,
or abd bruits
VS:
Temp: 98.4 Pulse: 92 Resp Rate: 20
BP: 118/75 Ht: 56 Wt: 160 lbs BMI: 25.8
Nursing Assessment:
9/1
Abdominal appearance (concave, flat, rounded, obese, rounded
distended)
Palpation of abdomen (soft, rigid, firm, masses, tense) soft
Bowel function (continent, incontinent, flatulence, no stool) continent

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 Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color NA
Stool consistency NA
Tubes/ostomies NA
Genitourinary
Urinary continence Catheter in
place
Urine source Catheter
Appearance (clear, cloudy, yellow, amber, fluorescent, Clear, yellow
hematuria, orange, blue, tea)
Integumentary
Skin color WNL
Skin temperature (DI=diaphoretic, W=warm, dry, DL=cool, DI, M
CLM=clammy, CD+=cold, M=moist, H=hot)
Skin turgor (good, fair, poor, TENT=tenting) TENT
Skin condition (intact, EC=ecchymosis, A=abrasions, Intact
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, Intact
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 Activity; 22
pressure,
moisture, activity, friction/shear (>18=no risk, 15-
16=low risk,
13-14=moderate risk, <12=high risk)

Pre-procedural Orders:
d/c all meds
IV heparin 5000 units bolus followed by 1000 unit/hour continuous infusion with a PTT at
2 x control.
Chewable ASA 160 mg po
Lopressor 50 mg 2x/D
Lidocaine prn
NPO until procedure completed
Type and cross for 6 units of packed cells

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Post-procedural Nutrition:
Diet Rx: Clear liquids, no caffeine
Hx: Appetite good. Following vegetarian diet x 12 mo.
Food allergies/ None
intolerances/
aversions:
Previous nutrition Yes, last year, cardiac rehab RD
tx:
Food purchase/ Self & spouse
preparation:
Vit/min intake: 1000mg Ca daily

BB describes her appetite as very good. Pt and spouse share responsibility for shopping
and cooking dinners. Pt usually eats 3 meals/D, but on bingo nights, she usually skips
dinner and just snacks. When she does this, she is really hungry when she gets home in
the late evening, so she often eats leftovers from the night before. They usually go out on
Friday and Saturday evenings at chain restaurants. After her HTN was diagnosed and
following her MI and stint placement last year, she met with the cardiac rehab RD. She
was instructed on the TLC diet and foods to avoid for a lower-salt diet. Pt and spouse tried
to comply with the diet guidelines, but they found foods bland and tasteless, and they
soon abandoned the effort. Pt states that her medication is managing her HTN now. Pt
read that a vegetarian diet is beneficial, so she gave up meat one year ago.

Pt began a walking program resulting in a 10-lb wt loss, which she has maintained over
the past year. She walks 30 min 4-5x/wk, though she sometimes misses on bingo nights.
Pt was a 2 pack/D smoker but quit 1 yr ago after HTN dx and MI.
24-hour recall:
Breakfast: Starbucks Grande Coconut milk latte
Lowfat blueberry scone
Mid-morning 1 large orange
Snack: 12 oz black coffee
Lunch: 2 c Annies brand Golden Lentil Indian Dal soup
1 lowfat cheese stick
1 medium apple
12 oz water to drink
Afternoon: 12 oz diet cola or sparkling water
Dinner: 4x4x3 slice vegetarian lasagna (spinach and cheese)
1 cup green salad (romaine, 4 cherry tomatoes, 4 cucumber
slices)
1 TB FF Italian salad dressing
baguette (24 long)
1 TB olive oil for dipping
12 oz water to drink
Snack: 1 small package corn nuts (4 oz)
Patient reports that this pattern is fairly typical of her usual weekday intake. She starts
with breakfast on the road, followed by morning coffee at work. She brings her lunch,
typically canned soup or a store-bought salad and fruit. She makes dinner ahead on the
weekends. She and her husband typically snack while watching TV at night.

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Laboratory Results:
Ref. 11/10 1957 11/11 0630 11/12 0645
Range (non-fasting) (fasting) (fasting)
Chemistry
Sodium (mEq/L) 136-145 141 142 138
Potassium (mEq/L) 3.5-5.5 4.2 4.1 3.9
Chloride (mEq/L) 95-105 103 102 100
Carbon dioxide (CO2, 23-30 21 ! 24 26
mEq/L)
BUN (mg/dL) 8-18 14 15 16
Creatinine serum 0.6-1.2 1.1 1.1 1.1
(mg/dL)
Glucose (mg/dL) 70-110 135 ! 105 103
Phosphate, inorganic 2.3-4.7 3.1 3.2 3.0
(mg/dL)
Magnesium (mg/dL) 1.8-3 2.0 2.3 2.0
Calcium (mg/dL) 9-11 9.4 9.4 9.4
Osmolality 285-295 292 290 291
(mmol/kg/H2O)
Bilirubin, direct <0.3 0.1 0.1 0.2
(mg/dL)
Protein, total (g/dL) 6-8 6.0 5.9 ! 6.1
Albumin (g/dL) 3.5-5 4.2 4.3 4.2
Prealbumin (mg/dL) 16-35 30 32 31
Ammonia (NH3, 9-33 26 22 25
umol/L)
Alkaline phosphatae 30-120 75 70 68
(U/L)
ALT (U/L) 4-36 30 215 ! 185 !
AST (U/L) 0-35 25 245 ! 175 !
CPK (U/L) 30-135 F 75 500 ! 335 !
55-170 M
CPK-MB (U/L) 0 0 75 ! 55 !
LDH 1 (U/L) 208-378 325 685 ! 365
Troponin I (ng/dL) <0.2 2.4 ! 2.8 !
Troponin T (ng/dL) <0.03 2.1 ! 2.7 !
Cholesterol (mg/dL) 120-199 235 ! 226 ! 214 !
HDL-C (mg/dL) >55 F, 30 ! 32 ! 33 !
>45 M
LDL (mg/dL) <130 160 ! 150 ! 141 !
LDL/HDL ratio <3.22 F 5.3 ! 4.7 ! 4.3 !
<3.55 M
Apo A (mg/dL) 101-199 F 110 111 115
94-178 M
Apo B (mg/dL) 60-126 F 115 110 105
63-133 M
Triglycerides (mg/dL) 35-135 F 150 140 130
40-160 M
Coagulation
(Coag)
PT (sec) 12.4-14.4 12.6 12.6 12.4
Hematology

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WBC (x 103/mm3) 4.8-11.8 11.0 9.32 8.8
RBC (x 106/mm3) 4.2-5.4 F 4.7 4.75 4.68
4.5-6.2 M
Hemoglobin (Hgb, 12-15 F 15 14.8 14.4
g/dL) 14-17 M
Hematocrit (Hct, %) 37-47 F 45 45 44
40-54 M
MCV (um3) 80-96 91 92 90
MCH (pg) 26-32 30 31 30
MCHC (g/dL) 31.5-36 33 32 33
RBC distribution (%) 11.6-16.5 13.2 12.8 13.0
Platelet count 140-440 320 295 280
(x103/mm3)
Hematology,
Manual Dif
Neutrophil (%) 50-70 55 58 62
Lymphocyte (%) 15-45 17 23 35
Monocyte (%) 3-10 4 4 7
Eosinophil (%) 0-6 0 0 0
Basophil (%) 0-2 0 0 0
Blasts (%) 3-10 3 3 4
Segs (%) 0-60 45 47 52
Bands (%) 0-10 15 ! 17 ! 8
Urinalysis
Color - Pale yellow Pale yellow Pale yellow
Appearance - clear clear clear
Specific Gravity 1.003- 1.020 1.015 1.018
1.030
pH 5-7 5.8 5.0 6.0
Protein (mg/dL) Neg Neg Neg Neg
Glucose (mg/dL) Neg Neg Neg Neg
Ketones Neg Trace ! Neg Neg
Blood Neg Neg Neg Neg
Urobilinogen (EU/dL) <1.1 Neg Neg Neg
Leukocyte esterase Neg Neg Neg Neg
Protein check Neg Neg Neg Neg
WBCs (/HPF) 0-5 0 0 0
RBCs (/HPF) 0-5 0 0 0
Bacteria 0 0 0 0

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 First Name: _Britt______________ Last Name: _Robinson___________

1. Based on the NCEP guidelines, interpret the results of BBs lipid panel on
11/10, identifying which of the lipids are elevated. (2 pts)
Parameter BBs Value in Interpretation Therapeutic goal
mg/dL based on NCEP
classification
Total Chol 235 mg/dL Borderline High
LDL Chol 160 mg/dL High <100 mg/dL
HDL Chol 30 mg/dL Low
Triglycerides 150 mg/dL Borderline High

2. Based on the NCEP ATP III Guidelines, determine BBs risk category and
explain your conclusion below (see NTP p. 313-314). List the appropriate LDL
therapeutic goal above. (2 pts)
BBs current LDL level is 160 mg/dL. She is post AMI 1 year ago. Other major risk factors
include a history of cigarette smoking, HTN diagnosis and use of antihypertensive
medication, low HDL cholesterol (30 mg/dL), an family history of CAD (father, MI age 45),
and her age (59 years). Based on the presence of these additional risk factors (smoking,
HTN, HDL, family hx, and age), she is in the >20% - CHD risk equivalent short term
category. Her therapeutic LDL goal is therefore should be below 100 mg/dL. (NTP, 313)

3. Examine the chemistry results for BB. Which labs are consistent with the
AMI diagnosis and why? Why were the levels higher on day 2? (2 pts)
Laboratory results that are consistent with her MI are elevated glucose, ALT, AST, total
cholesterol, troponin, and LDL. Additionally, her low HDL levels are consistent with the
AMI diagnosis (NTP, 325).
Specifically, on day 2, her CPK was highly elevated, which is also consistent AMI.
The values were higher on the second day because the second day was when her
surgery (ie, cellular injury) occurred.

4. List & number BBs risk factors for CHD, based on the presentation data
from her medical record. (2 pts)
1. Family hx of CAD (father, MI age 45)
2. Dyslipidemia (LDL 160 mg/dL; HDL 30 mg/dL)
3. HTN diagnosis (managed with meds, 118.75)
4. Fasting blood glucose (135 mg/dL)
5. Smoking (quit 1 yr ago)
6. African American (NTP, 309-313)

5. What is metabolic syndrome & does BB meet the criteria? Why or why not?
(2 pts)
Metabolic Syndrome is a combination of many different symptoms, and to be diagnosed
with MetS, a patient must exhibit 3 of the 5 following symptoms: Triglycerides >/=150
mg/dL, Fasting Glucose >/= 100 mg/dL, Blood Pressure >/= 130/85, HDL <40 mg/dL
(men) <50 mg/dL (women), waist circumference >102 cm (men) >88 cm (women).
(Obesity, slide 40)
On 11/10, BB exhibited low HDL (30 mg/dL) and elevated blood glucose (135 mg/dL).
Her waist circumference is unknown, and she does not meet the other criteria for MetS.
By meeting 2/5 criteria, BB will not be diagnosed with metabolic syndrome. However, as
she is on antihypertensive drugs, her values for blood pressure could be dramatically
different. If the medications were removed, she would likely be hypertensive, and
7
 therefore would meet 3/5 criteria to be diagnosed with Metabolic Syndrome. (Obesity,
slide 40)
6. What are the current recommendations for the progression of nutritional
intake during a hospitalization following a myocardial infarction? (2 pts)
During hospitalization following MI, treatment protocol includes a clear liquid diet with no
caffeine, which will progress to soft, easily chewed foods. After stabilization, the patient
will receive personalized nutrition therapy, which follow Therapeutic Lifestyle Change
recommendations. (NTP, 325)
7. Conduct a nutrient analysis of the 24 hr. recall above, using the Food
Processor program on the UC Davis website:
http://nutrition.ucdavis.edu/admin/remote/. Connect to the Food Processor
Remote Desktop Server to access the database. For a review of how to use
Food Processor, click on the Nutrition 112 Lab link. After youve input BBs 24
Hour Recall, select Spreadsheet from the Reports menu. Remember, to
print all food items, select the + for the day and meals for them to show up
on your spreadsheet report (all foods entered must be included in the print-
out). The spreadsheet is what you will save on your desktop and print out and
turn in (you may print 4 per page to save paper). Please hand-write at the top
BBs 24-Hour Recall. Complete the table below and attach the data print-
out at the end of the Case Study. Briefly discuss the overall adequacy of BBs
diet in the space below (partial credit will be given for providing only the
daily totals without the print-out). (8 pts)
Total calories: 2867
Total fat: 72 gm % of kcals: 22.6%
Saturated fat: 22 gm % of kcals: 6.9%
Monounsaturated Fat: 21 gm % of kcals: 6.6%
Polyunsaturated Fat: 6 gm % of kcals: 1.9%
Carbohydrate: 452 gm % of kcals: 63.1%
Protein: 121 gm % of kcals: 16.9%
Fiber: 59 gm
Sodium: 5629 mg
Potassium: 1382 mg

Adequacy of BBs diet: BB is taking in too many calories (2867 when her needs are
1917-2212 kcals/d. She is taking in appropriate amounts of fats (<7% SFA, <20% MUFA,
<10% PUFA), although those values could be comfortably higher in proportion to total
energy. Her carbohydrate consumption is higher, potentially crowding out her fat
calories. The main concern for her diet is the very high amount of sodium. As a person
diagnosed with HTN, this amount of Na is inappropriate and should be addressed. (NTP,
318)

8. Make changes in the diet in order to make it consistent with a 2000 kcal
TLC dietary plan and summarize your changes below. Highlight the changes
that you have made on the Spreadsheet print-out for BBs modified diet.
Please hand-write at the top BBs 2000 kcal TLC Diet. Complete the table
below and attach the data print-out at the end of the Case Study. Briefly
summarize the changes youve made in BBs diet in the space below (partial
credit will be given for providing only daily totals without the print-out). (8
pts)

TLC Goals:
Total calories: 2000 kcal 2048
8
Total fat: 25-35% (56-78 67 gm % of kcals: 29.4%
gm)
Saturated fat: <7% (16 gm) 14 gm % of kcals: 6.1%
Monounsaturated </=20% (44 gm) 30 gm % of kcals: 13.2%
Fat:
Polyunsaturated </= 10% (22 gm) 11 gm % of kcals: 4.8%
Fat:
Carbohydrate: 50-60% (250-300 298 gm % of kcals: 58.2%
gm)
Protein: ~15% (75 gm) 83 gm % of kcals: 16.2%
Fiber: 20-30 gm 43 gm
Sodium: < 2400 mg 1847 mg
Potassium: 4700 mg (slide 3880 mg
22,CVD/HTN)

Summary of changes made:

Exchange scone at breakfast for large banana to decrease carbohydrate and increase
potassium. Add nonfat yogurt at breakfast to increase protein. Exchanged lunchtime
soup from regular canned lentil soup to a no sodium added soup. Added sweet potato
with margarine (and decreased soup portion to compensate for volume) at lunch to
increase potassium.
Increased salad portion at dinner to increase potassium. Decrease baguette portion size
to reduce carbohydrate. Replaced Italian dressing with a tablespoon each of olive oil
and balsamic vinegar to reduce sodium and increase potassium and PUFAs. Decrease
serving size of lasagna, add cup cooked spinach to decrease carbohydrate and
increase potassium. Decrease portion size of corn nuts at evening snack.

9. Compare the fat and cholesterol in your modified diet to the target goals
based on a caloric intake of 2000 kcals/D. (4 pts)
TLC Diet Goal BBs TLC Target BBs
(% of kcals in Modified Diet grams/mg Modified Diet
diet) (% of kcals in in 2000 (gm)
diet) kcals/D
Total fat: 25-35% 31.3% 56-78 gm 67 gm
Saturated fat: <7% 6.5% 16 gm 14 gm
Monounsatd. fat: </= 20% 14.0% 44 gm 30 gm
Polyunsatd. fat: </= 10% 5.1% 22 gm 11 gm

10. BB was prescribed the following medications on discharge. Provide the

generic name and indication of each medication (specific to BB) and its
efects. Also note any dietary recommendations,
contraindications/precautions, and interactions. What efect will these
medications have on her nutritional care? Refer to the FMI text. (5 pts)
Lisinopril 2.5mg/D
Generic name: Lisinopril
Classification: Angiotensin Converting Enzyme (Ace) Inhibitor

Indication: Antihypertensive

Diet: Insure adequate fluid intake/hydration. Decrease sodium, decrease

calories may be recommended. Avoid salt substitutes. Caution
with potassium supplements. Avoid natural licorice.
Possible Food- Take without regard to food. Avoid natural licorice. Limit alcohol.
9
Medication
Interactions:
Potential Anorexia, decreased weight reported. Dry mouth, abdominal pain,
Nutrition/Oral/GInausea and vomiting, constipation, diarrhea. Decrease blood
Side Effects: pressure with possible hypotension, cough, dyspnea, syncope,
rash, dizziness, headache, fatigue, muscle pain, insomnia, <1%
but can be fatal angioedema (increased incidence in black
patients), pancreatitis, hepatotoxicity/jaundice, acute renal failure,
SJS. Drug efficacy may decrease and side effects may increase
with black patients.
Bystolic 2.5mg/D
Generic name: Nebivolol
Classification: Beta 1 blocker

Indication: Antihypertensive

Diet: Decrease sodium, decrease calories may be recommended. Avoid

natural licorice.
Possible Food- Avoid natural licorice.
Medication
Interactions:
Potential Nausea, diarrhea. Decrease in blood pressure with possible
Nutrition/Oral/GI hypotension, headache, fatigue, dizziness, insomnia, chest pain,
Side Effects: bradycardia, rash, dyspnea, peripheral edema.

Crestor 20 mg/day
Generic name: Resuvastatin
Classification: HMG-CoA reductase inhibitor

Indication: Antihyperlipidemic (to decrease total & LDL cholesterol or TG), To

prevent or decrease risk of cardiovascular events
Diet: Decrease fat, decrease cholesterol (decrease calories if needed).

Possible Food- No or minor interaction with grapefruit/related citrus. Not with high
Medication dose niacin possible myopathy. Separate fiber, pectin, or oat bran
Interactions: from drug by several hours. Avoid substantial alcohol.
Potential Nausea, dyspepsia, abdominal pain, constipation, diarrhea, flatulence.
Nutrition/Oral/GI Myopathy, back pain, weakness, headache, rash, dizziness, chest
Side Effects: pain, insomnia, bronchitis, decrease risk of fracture due to decrease
bone resorption. Rare rhabdomyolysis, neuropathy with long term
use.
Effient 10mg/D
Generic name: Prasugrel
Classification: Platelet aggregation inhibitor

Indication: Acute Coronary Syndrome Treatment

Diet:

Possible Food- Must be taken with aspirin. Take without regard to food.
Medication
Interactions:
Potential Do dental care cautiously, increased risk of bleeding. May cause:
Nutrition/Oral/GI headache, back pain, bradycardia, atrial fibrillation, dizziness, cough,
10
Side Effects: dyspnea, bleeding (can be fatal), bruising, fever, rash, edema.
ASA 81 mg/D
Generic name: Aspirin
Classification: Platelet aggregation inhibitor

Indication: Prevent CVA or MI

Diet: Insure adequate fluid intake/hydration. Increase foods high in Vit C

and folate with long term high dose. Avoid or limit natural products
which affect coagulation (garlic, ginger, gingko, ginseng, horse
chestnut). Limit caffeine to decrease GI effects.
Possible Food- Avoid or limit natural products which affect coagulation (garlic,
Medication ginger, gingko, ginseng, horse chestnut). Limit caffeine to decrease GI
Interactions: effects. Avoid alcohol.
Potential May cause sudden, serious gastric bleeding. Do dental care
Nutrition/Oral/GI cautiously, increases risk of bleeding. May contribute to iron
Side Effects: deficiency anemia. Long term use may cause occult fecal blood loss

11. Make an overall statement as to the discharge dietary advice you would
give BB regarding her medications above. (1 pt)
Regarding the above medications, BB should keep in mind her fluid intake. Based on her
24 hr recall, she stays well hydrated, and so her antihypertensives and the asa should not
cause her problems with water balance. A key nutrient of concern for BB is Na, which,
according to her 24 hr recall, is very high (5629 mg/d). Due to her MI Dx, she should follow
TLC guidelines and limit Na intake to <2400 mgd, which is also advised when taking
antihypertensives. She should also be advised to limit caffeine currently she has three
potential sources of caffeine in her diet, and these could increase potential GI distress with
the asa. Her current diet has adequate fat levels, but this is also a nutrient of concern and
one that she should be aware of while taking statin drugs. Overall, her vegetarian diet
provides almost the right proportions of macronutrients, and so her primary concern
should be reducing sodium. If she follows TLC guidelines, she should have less trouble
avoiding coronary problems in the future.

11
12. You have seen BB one day post-MI and one day after her cardiac
procedure. She has been advanced to a regular cardiac diet (TLC) and will be
discharged the next morning. She 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 and references next to each calculation. Include two PES
statements. (12 points)
A:
Onset of disease: Pt is 59 yo woman admitted for emergency coronary angiography after
sudden onset of severe precordial pain in jaw, back, and left arm.
Pt took sublingual nitroglycerin after onset of pain. Noted episode
of emesis and nausea, denies palpitations or syncope, denies prior
hx of pain or SOB.
Medical hx: s/p MI and stent placement 1 yr ago. HTN dx 1 yr ago. No hx of rheumatic
fever, DM, kidney disease. c/o intermittent constipation over past
yr.
Rx: Lisinopril 2.5 mg/d; Bystolic 2.5 mg/d; Crestor 20 mg/d; Effient 10 mg/d; Nitrostat 0.4
prn chest pain (all x 1 yr); OTC: ASA 85 mg/d; Ca 1000 mg/d;
Senokot prn.
Tobacco use: 1 ppd for 40 yr, quite 1 yr ago cold turkey
Exercise: Walks 30 min 4-5x/wk
VS assessment: P 92, RR 20, BP 18/75, Ht 56 (167.6 cm), Wt 160 # (72.7 kg), BMI 25.8
Biomedical data: Glu 135 mg/dL (High); Chol 235 mg/dL (High); HDL 30 mg/dL (Low); LDL
160 mg/dL (High)

Estimated Nutrient needs (based on 72.7 kg wt):

Energy: 1917 2212 kcal/d
Protein: 58 g pro/d
Fluid: 2181 mL/d

Food & Nutrition Hx: Pt describes appetite as very good. Was instructed about TLC diet
s/p HTN dx, MI, and stent placement 1 yr ago, pt and spouse
noncompliant with guidelines soon after beginning diet, claims that
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 meds are managing HTN. Pt currently eating vegetarian food
pattern.
24 hr recall:

Current intake 2867 kcal/day; 121 g pro; 452 g CHO; 72 g Fat; 5629 mg Na consumed per
pt 24 hr recall.

D:
1: Overweight (NC-3.3.10767) R/T excessive energy intake (NI-1.3) AEB consumption of
2867 kcal/day from 24 hr recall, over needs of estimated 1917 2212 kcal/day, and
160# body wt (ideal wt 130#).
2: Limited adherence to nutrition-related recommendations (NB 1.6) R/T dislike of TLC
diet foods AEB consumption of 5629 mg Na/d from 24 hr recall, dyslipidemia (LDL 160
mg/dL; HDL 30 mg/dL), and pt report of not adhering to TLC guidelines in the past due
to taste.
I:
TLC dietary guidelines to address macronutrient balance and decrease intake of Na.
Recommend Nutrition education to teach nutrition relationship to health/disease (E-
1.4), referral to RD with cardiac expertise (RC-1.2), and collaboration with other
providers (Cardiac Rehabilitation)(RC-1.4). Provided pt with modified diet plan based on
24 hr recall following TLC guidelines.
Goals: pt to begin TLC diet to decrease energy and Na intake, keep a food log for self-
monitoring of new diet, begin Rx therapy to control HTN and lipid profile.
M/E:
At follow up in 2 wks, obtain 24 hr recall to evaluate adherence to TLC diet. Go over
food log with pt to evaluate adherence or make changes to diet. Obtain PE and fasting
blood work to assess efficacy of diet therapy and Rx therapy on HTN and lipid profile.

Calculations:

Energy: 10(72.7 kg) + 6.25(167.6cm) -5(59yrs) -5 = 1474.5 (1.3 1.5) = 1917 2212
kcal/d (PG 3)
Protein: .8g x (72.7kg) = 58 g pro/d (PG 5)
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Fluid: 72.7 kg(30 mL) = 2181 mL/d (PG 6)
Ideal body wt = 100# (first 5 ft.) + 5#/additional inch = 130#. (PG 2)
Ht: 56 = 66 in x 2.54 cm/in = 167.6 cm
Wt: 160lb/2.2 kg/lb = 72.7 kg

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