NUT 116AL CASE STUDY #2 - CVD Due 12/5/14

Transcription

1 First Name:_Madeline Last Name:_Pitman NUT 116AL CASE STUDY #2 - CVD Due 12/5/14 Instructions: Review the pt s medical record below. Answer each question and show your calculations for each, if required. Reference all calculation formulas with the text and page number from PR (i.e., PR p. ). You must type your answers! If not, questions will not be graded and you will receive 0 points. CS #2 is worth 50 points. Medical Record Information: Present Illness: MW is a 42 yo engineering technician referred to his family physician for evaluation of arterial hypertension detected during a routine evaluation at an employment site wellness fair & health screening. The BP reading was confirmed by repeat measurements over the course of one month. Pt relates no prior history of elevated BP but had been warned to watch his weight. Pt denies current symptoms of chest pain, SOB, edema, or visual symptoms. Pt smokes one pack of cigarettes a day; holds a desk job and plays tennis one or twice a week. Pt s body weight has been increasing by 2-3 pounds per year for the last ten years. Past Medical History: Pt had measles, mumps, and chicken pox in childhood and an appendectomy approximately 20 years ago. No hx of rheumatic fever, DM, or kidney disease. Family History: Father died at age 48 from an acute MI; mother is being treated for essential hypertension. Social History: Married with two children; wife works as a legal secretary. Review of Systems: Patient has no complaints except for C/O occasional mild tension headaches. Physical Exam: Somewhat overweight white male; 5 ft. 10 in., 190 #, small frame, waist circumference 96 cm. UBW 170 (10 years ago). BP 155/103 right arm, sitting, without postural changes. P 76 and regular. R 15. Neck without thyromegaly, venous distention, or bruits. Lungs clear to P&A. Heart: regular rhythm without murmur or gallop. Abdomen slightly obese, soft and without bruit. Extremities revealed no edema. Screening neurologic exam, including mental status exam, is completely WNL. Laboratory: Hct: 48%, Hgb 16 g/dl, FBG 96 mg/dl, BUN 15 mg/dl Lipid panel (fasting): T-chol 210 mg/dl, LDL 147 mg/dl, HDL 38 mg/dl, TG 150 mg/dl. U/A negative for glucose, protein and blood. EKG: normal sinus rhythm with rate of 80, normal intervals and no evidence of ischemia, strain, or hypertrophy. CXR unremarkable. Rx: Lasix 20 mg daily, Lipitor 20 mg daily Impression: Essential hypertension with elevated T-chol, LDL, and low HDL in a 42 yo overweight, otherwise healthy male with a positive family history of CHD. Plan: Nutrition outpatient clinic referral for instruction in 1,500 kcal, 2 g Na, NCEP TLC diet. Encourage cessation of smoking and increase in exercise. RTC for BP and lipid panel check in 6 weeks.

2 24 Hr. Diet Recall Client reports that this pattern is fairly typical of his usual weekday intake: Breakfast McDonald s Lunch Dinner Milk, 2%, 8 oz. Diet Coke Milk, 2%, 8 oz. Eggs, 2 poached Quarter Pounder, with cheese Potato, baked, 1 med. Toast, wheat, 2 slices French fries, small Sour cream, 2 Tbsp. Butter, 1 Tbsp. Table salt, 1/8 tsp. Questions: Chicken breast w/ skin, baked 6oz Broccoli, ½ cup Tossed salad, 1 cup Lettuce, ½ tomato Ranch Dressing, 2 Tbsp. Roll, 1 small Butter, 1 Tbsp. Ice Cream, 10%, 1 cup Table salt, 1/8 tsp. 1. Conduct a nutrient analysis of the 24 hr. recall above, using the Food Processor program on the UC Davis website: 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 you ve input MW s 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 MW s 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 MW s diet in the space below (partial credit will be given for providing only the daily totals without the print-out). (5 pts) Total calories: Total fat: grams % of kcals: 46.9 Saturated fat: 56.3 grams % of kcals: 19.6 Monounsaturated Fat: 35.0 grams % of kcals: 12.2 Polyunsaturated Fat: 17.6 grams % of kcals: 6.2 Carbohydrate: grams % of kcals: 32.8 Protein: grams % of kcals: 20.7 Fiber: 16.5 grams Cholesterol: mg Sodium: mg Potassium: mg Adequacy of MW s diet: MW consumed enough calories, as it is suggested he consume 2500 kcal/day and he consumed 2578kcal/day. It is recommended that MW consume 69 g of protein each day, MW consumed 133g on one day. According to recommendations, MW should consume 787 kcal from fat/day, the dietary recall recorded that MW consumed 1207 kcal from fat in one day. 28 g of saturated fats/day are suggested for MW, but MW consumed 56g/day. MW should consume 31 g of monounsaturated fats/day and he consumed over 35 g in one day. The TLC diet suggest that less than 200 mg of cholesterol/day should be consumed, MW consumed 795 mg in one day. It is suggested that Americans consume less than 2400 mg of sodium each day, but MW consumed over 2

3 3660 mg/day. MW consumed enough calcium because he consumed 1366 mg when the suggested about is 1000 mg/day. MW s diet is not providing enough fiber, his dietary recall suggested he consumed 16 grams of fiber while the TLC diet recommends that he consume grams. MW should be consuming 4700 mg of Potassium, but his dietary recall only accounted for 3505 mg. MW should consume up to 28 g of polyunsaturated fats, however he only consumed 17g according to his dietary recall assessment. 2. Make changes in the diet in order to make it consistent with a 2500 kcal TLC dietary plan and summarize your changes below. Highlight the changes that you have made on the Spreadsheet print-out for MW s modified diet. Please hand-write at the top MW s 2500 kcal TLC Diet. Complete the table below and attach the data print-out at the end of the Case Study. Briefly summarize the changes you ve made in MW s diet in the space below (partial credit will be given for providing only daily totals without the print-out). (5 pts) Total calories: Total fat: 86.9 grams % of kcals: 33.8 Saturated fat: 13.9 grams % of kcals: 5.4 Monounsaturated Fat: 42.6 grams % of kcals: 16.5 Polyunsaturated Fat: 12.8 grams % of kcals: 4.9 Carbohydrate: grams % of kcals: 48.8 Protein: grams % of kcals: 19.9 Fiber: 41.5 grams Cholesterol: mg Sodium: mg Potassium: mg Summary of changes made: 2% milk was replaced with fat free milk in order to reduce fat intake, but maintain dairy intake. MW consumed milk twice a day, so in order to help changes of compliance; milk was kept in the diet. Eggs were replaced with egg whites in order to reduce cholesterol intake. Whole grain toast, whole grain bread, and brown rice were added to increase fiber intake. Fruit and oatmeal were added to breakfast to keep MW full while providing fiber and calories with out adding fat. Butter was replaced with olive oil in order to provide a wider range of fat types, including monounsaturated and polyunsaturated fats. Avocado was also added to add healthier fats. Turkey was used to replace hamburger meat, and salmon was served in order to reduce saturated fat intake. Table salt was eliminated in order to keep sodium intake low. Vegetables were used to add fiber, minerals and flavor. 3. Compare the fat and cholesterol in your modified diet to the target goals based on a caloric intake of 2,500 kcals/day. (4 pts) TLC Goal (% of kcals in diet or grams chol.) MW s Modified Diet (% of kcals in diet or grams chol.) TLC Target grams in 2,500 kcals/d MW s Modified Diet (grams) Total fat: 25-35% 33.8% g 86.9 g Saturated fat: < 7% 5.4% < 19 g 13.9 g Monounsatd. fat: Up to 20% 16.5% < 55 g 42.6 g Polyunsatd. fat: Up to 10% 4.9% 27 g 12.8 g Cholesterol: < 0.2g (200 mg) mg <0.2g (200 mg) mg 3

4 4. Interpret the results of MW s lipid panel, identifying which of the lipids are elevated based on the NCEP ATP III Guidelines. List the desired therapeutic goal (TLC goal parameter) for LDL cholesterol for MW, based on the NCEP guidelines. (3 pts) Parameter MW s Value in mg/dl Interpretation based on Therapeutic goal NCEP classification Total Cholesterol 210mg/dl Borderline High LDL Cholesterol 147mg/dl Borderline High < 130mg/dl HDL Cholesterol 38mg/dl Low Triglycerides 150mg/dl Borderline High 5. List 3 food choices that together will provide 1600 mg of potassium and provide no more than a total of 300 kcals. The food choices should be reasonable foods and serving sizes that could be used to recommend to a client that needs to increase potassium intake due to use of a potassium wasting diuretic. (3 pts) Food Portion size mg K provided kcals provided Kale 6 oz Banana 5 oz Broccoli 1.25 cup Total =1690 Total = List & number MW s risk factors for CHD, based on the presentation data from his medical record. (2 pts) 1. Pt has hypertension, BP 155/ Pt has increased LDL cholesterol at 147 mg/dl, qualifying the pt for hyperlipidemia. 3. MW smokes one pack of cigarettes each day. 4. Pt s father died of an acute MI at age Pt s HDL cholesterol was measured at 38mg/dl, which is below the suggested level of 40mg/dl. 6. Pt s BMI of 27.3 means the pt is overweight because the pt s BMI is between Pt s triglycerides are increased. Normal triglyceride levels are below 150mg/dl, the pts levels are 150mg/dl. PR pg What is metabolic syndrome & does MW meet the criteria? Why or why not? (2 pts) Metabolic syndrome occurs when a pt has three or more of the following risk factors; abdominal obesity (men waist circumference > 102cm, women waist circumference >88cm), hypertriglyceridemia (>150mg/dl), low HDL (men < 40 mg/dl, women <50 mg/dl), hypertension (BP >130/>85) and/or insulin resistance (fasting glucose >100mg/dl). Metabolic syndrome increases the risk of CHD. MW meets the criteria for metabolic syndrome (MS) because MW has three of the MS risk factors; pt s BP is 155/103 which is greater than 130/85 and therefore indicated hypertension, pt s triglycerides are 150mg/dl which is borderline high, pt s HDl levels are 38mg/dl which is lower than the suggested 40mg/dl. 4

5 8. How do each of MW s prescribed medications work? What effect will these medications have on his nutritional care? Refer to the medication information in the NTP or PR texts or (online Physician s Desk Reference). Cite the resource used for each drug. (4 pts) Lasix Lasix is a diuretic used to treat edema that is associated with congestive heart failure, cirrhosis of the liver, renal disease or HTN ( Lasix may cause dehydration, electrolyte imbalance, and dysfunction of renal system ( Pt s GI health, and appetite may decrease (PR pg 73). Pt s should avoid alcohol (PR pg 73). Pt should be monitored to make sure Lasix does not cause the pt to loose too much water or electrolytes. and PR pg 73 Lipitor Lipitor decreases total cholesterol, LDL and TG levels by inhibiting HMG-CoA reductase ( Lipitor may cause GI distress, and should be consumed with a low cholesterol & low fat diet (PR pg 71). Pts taking lipitor should not consume large amounts of grapefruit, and should avoid alcohol (PR pg 71). and PR pg 71 You assess MW s knowledge of a low-sodium, NCEP TLC diet as being limited to just don t add any salt to food and avoid fried foods. He also tells you that he dislikes nonfat milk. He knows that he needs to make some changes, but did not feel like he knew what to do on his own. After discussion with you (the RD) using motivational interviewing techniques, the client is now verbalizing confidence to try to make some changes. Some mutually agreeable goals are set: he usually eats fast food for lunch but is willing to eat in the work cafeteria 2-3 times/wk, he agrees to substitute fruit for 1or 2 high calorie foods each day, and he would like to make time to exercise >30 min 3 days/wk. 9. List and number 3 major teaching points (dietary advice) that you will need to discuss with MW in order for him to understand and follow a 2400 mg Na diet. (3 pts) 1. Meat and mixed dishes contain the highest amounts of sodium. These items should be eaten in moderation. 2. Nutrition labels list the amount of sodium contained in each portion size. When shopping, comparing labels to determine which options contain lower amounts of sodium per portion can help reduce sodium intake. Items with lower sodium, like fruits and vegetables, are suggested to be consumed in higher quantities. 3. The taste buds will take a while to be retrained. This means it may be tempting to add salt into the diet. However, adding salt to foods should be avoided in order to maintain a sodium consumption of <2400mg/day. 10. List and number 3 major teaching points (dietary advice) that you will need to discuss with MW in order for him to understand and follow the NCEP TLC diet. (3 pts) 1. Make sure MW understands what a saturated fat is, why they should be avoided in the diet, and how they can be avoided in the diet. 2. Fruits and vegetables provide fiber, vitamins and minerals, which are beneficial to the body. 3. Explain the differences between the different types of fats (omega 3s, omega 6s ). Explain why it is important to get a variety of fat types in the diet. Discuss how adding fish, nuts, dairy products, and lean meats can add different types of fats to the diet. 5

6 11. MW is Jewish and resides in the SF Bay Area. Describe and explain Kosher dietary laws and any dietary restrictions you would need to consider when counseling MW. (4 pts) Kosher is the Jewish set of biblical dietary restrictions. Kosher laws include; meats that may not be eaten, how animals that will be eaten should be killed, draining blood from meat and poultry, forbidding certain organs/animal parts, fruits and vegetables must be free of bugs, dairy can not be eaten with meat, meat or dairy can not be eaten with fish, eggs, fruits, vegetables or grains, special treatment of certain utensils, and other details depending on the individuals. When counseling MW, I would make a point to understand which meats MW eats, as this can vary between different Jewish denominations. Understanding how MW keeps Kosher will help be best meet his needs. I would consider how MW could avoid certain un-kosher meats while avoiding high amount of saturated fats. It is important to make sure MW can find a store that supplies appropriate Kosher foods. MW would need to understand how to clean fruits and vegetables so that he could consume enough fruits and vegetables while avoiding insects. MW should understand the kinds of fats that are provided by the meats he does eat, so that he can better understand what he is eating and what portion sizes are appropriate for his diet. I would make sure MW had options, so he did not feel restricted in his diet MW has been referred to your Nutrition Clinic by his primary care physician for instruction on a 1,500 kcal, 2.4-g Na, TLC diet. Summarize your observations, assessment and plan of action in a SOAP note. Base your note on the pertinent information given in the presentation data, 24 hr recall, and questions above. It is important that you assess whether you feel that the current referral diet Rx (1,500 kcal, 2-g Na, NCEP TLC diet) is realistic and appropriate for your client s needs. Remember that this is an outpatient setting and the client is referred to you for counseling, which you will begin on this visit. Attach the SOAP note below and a separate sheet with all calculations as an attachment (the calculations may be hand-written). (12 points) S: Pt married with two children, works as an engineering technician and works at a desk. Plays tennis 1-2 times a week. Pt reports weight gain of 2-3 lbs/year for 10 years. Pt smokes one pack of cigarettes/day. Pt is Jewish and keeps Kosher diet. O: 42yo male, 70 inches, 190 lbs, waist circumference 96cm, BMI 27.3, UBW (10 yrs ago) 170. BP 155/103, P 76 and regular, R 15. Hct: 48%, Hgb: 16g/dl, FBG: 96 mg/dl, BUN: 15mg/dl. Lipid Panel (fasting): T-chol 210mg/dL, LDL 147 mg/dl, HDL 38mg/dL, TG 150mg/dL. 24-hour dietary recall reports consumption of 2578 kcal, 134g of fat, 211g of carbohydrates, and 133g of protein. A: Excess energy intake (P) (NI 1.3) r/t excessive oral intake (E) (NI 2.2) AEB 24-hour dietary recall with consumption of 2,578 kcal/day and 134g of fat/day (S). Excessive sodium intake (P) (NI ) r/t excessive oral intake of sodium (10716) AEB 24-hour dietary recall, 3665mg/day sodium consumption (S). 6

7 P: Pt will receive nutrition education and educational material on fat types and the importance of consuming enough monounsaturated & polyunsaturated fats while reducing saturated fats. Nutrition education to reduce sodium intake to < 2400mg/day. Pt will keep daily food record to ensure that <2400 mg is consumed daily. Follow up appointment in 2 weeks. Pt s BP will be recorded at next appointment. Pt will record daily food records. Pt s lipid panel should be measured in 3 months to ensure compliance with recommended fat consumption. Madeline Pitman 5 December 2014, 11:00am Clinical Nutrition Student 7