Last Name __Hirata_________________ First Name Miles_____________ CASE STUDY ~ Cardiovascular Disease ~ Medical Record Information: HPI: RB is a 55 yo African

American male marketing director referred to his family physician for evaluation of hypertension detected during a worksite BP screening. His BP reading was confirmed by repeat measurements over the course of one month. He relates no prior hx of elevated BP but had been warned to watch his salt intake. He denies symptoms of chest pain, SOB, edema, or visual symptoms. He smoked one pack of cigarettes per day up until one month ago. Currently he is smoking e-cigarettes. RB has a desk job and goes to the gym at work during his lunch hour once or twice a week. His weight has been increasing by 2-4 pounds per year for the past ten years. PMH: He had measles and chicken pox in childhood and an appendectomy at age 22. There is no hx of rheumatic fever, diabetes, or kidney disease. FH: Father died at age 48 from an acute MI, and mother is being treated for essential hypertension and pre-diabetes. Social Hx: Has two children, his husband works as an elementary school teacher. ROS(review of systems): Pt has no complaints except for occasional mild tension headaches. PE: General: Somewhat overweight, black male; CW=192# ht=511, medium frame, UBW=165# (10 years ago), Waist circumference = 37.5 Vitals: T 98.5F; P(pulse) 76 & regular; R(respiratory rate) 15; BP=145/89 Lungs: Lungs clear to P&A Heart: nl rhythm without murmurs HEENT(head Neck without thyromegaly(no enlarged thyroid), venous distention, eyes ears or bruits(turbulent bloodflow) nose throat): Abdomen: Abdomen soft, no tenderness, no liver enlargement Genitalia: nl Extremities: No edema CNS: Screening neurologic exam, including mental status exam, all WNL Currently being treated for mild depression. Skin: Smooth, warm, dry, no edema Peripheral Pulse +4 bilaterally(+4 is the strength of the pulse, bilaterally is Vascular: measured on both sides of the body) Labs: Hct Hgb FBG fasting blood glucose: BUN blood urea nitrogen: Lipid panel: (fasting) U/A urine analysis:

45% 15.8 g/dL 94 mg/dL 14 mg/dL Total cholesterol 246 mg/dL, LDL 158 mg/dL, HDL 34 mg/dL, TG 214 mg/dL Negative for glucose, ketones, protein & blood(normal)
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Last Name __Hirata_________________ First Name Miles_____________ EKG:electrocardiogram nl sinus rhythm with rate of 80 Chest x-ray: Unremarkable Impression: Essential hypertension and elevated LDL cholesterol and TG, low HDL in a 55 yo overweight, otherwise healthy male with a positive family hx 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(return to clinic) for BP and lipid panel check in 6 weeks. Rx: Lasix 20 mg daily, Pravachol 10 mg daily, Marplan 40 mg daily 24 hr. Diet Recall: Client reports that this pattern is fairly typical of his usual weekday intake. Breakfast @ home Lunch @ work Dinner @ home Milk, whole, 8 oz. Veggie burger, 4 oz patty Bun Lettuce, tomato 1 slice each mayonnaise, ketchup, mustard (1 Tbs each) French fries, small 1 Tbs ketchup Diet Coke, 12 oz Snack Cupcake, red velvet Chicken fried steak, 8 oz

Instant oatmeal, 2 Mashed potatoes(3/4 cup) packets maple brown with cup gravy sugar flavor Toast, wheat, 2 slices, Sauted collard greens, 1 Tbs butter cup 4 oz grapefruit juice Cornbread, 3x3x3 piece 10 oz coffee 1 Tbs butter 1 oz whole milk Green salad, 1 cup Snack Ranch Dressing, 2 Tbs 10 oz coffee Sweet tea, 12 oz 1 oz whole milk QUESTIONS: 1. Conduct a nutrient analysis for 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 link. After youve input RBs 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 printout). 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 RBs 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 RBs 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: Saturated fat: Monounsaturated Fat: Polyunsaturated Fat: Carbohydrate: 3,410 kcals 172.7 grams 66.8 grams 14.3 grams 18.6 grams 378.7 grams

% of kcals: 45.6% % of kcals: 17.6% % of kcals: 3.8% % of kcals: 4.9% % of kcals: 44.4%
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Last Name __Hirata_________________ First Name Miles_____________ Fiber: Protein: Cholesterol: Sodium: Potassium: 32.2 grams 90.1 grams 326.4 mg 6,691.9 mg 812.4 mg

Adequacy of RBs diet: Comment on what is low/high and why Saturated fat is high due to high amount of processed foods and fried foods. Sodium levels are also high from pre-processed foods. Total calories are elevated as well due to the calorically dense processed foods. Monounsaturated and polyunsaturated fat is low as most of the fat found in the 24 hour diet recall is from saturated fat.

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 RBs modified diet. Please hand-write at the top RBs 2500 kcal TLC Diet. Complete the table below and attach the data print-out at the end of the Case Study. (**Attach the data print-out; partial credit will be given for providing only daily totals without the print-out.) (5 pts) Total calories: Total fat: Saturated fat: Monounsaturated Fat: Polyunsaturated Fat: Carbohydrate: Fiber: Protein: Cholesterol: Sodium: Potassium: 2,509.7 71.8 grams 11.9 grams 32.8 grams 15.0 grams 374.7 grams 46.2 grams 116.5 grams 167.3 mg 2,323.8 mg 2,432.2 mg

% of kcals: 25.7% % of kcals: 4.3% % of kcals: 11.8% % of kcals: 5.4% % of kcals: 59.7%

Summary of changes made: Fried and processed foods were replaced with fruits, vegetables, and sources high in protein with low fat content. Foods high in saturated fat were replaced with foods high in monounsaturated and polyunsaturated fat such as fish, nuts, chicken, and olive oil. Sodium intake was extremely reduced to assist with hypertension. Dietary fiber was increased from the abundance of fruits and vegetables and should help RB lower his BMI to within normal range.

Last Name __Hirata_________________ First Name Miles_____________

3. Compare the fat and cholesterol in your modified diet to the target goals based on
a caloric intake of 2,500 kcals/day. (2 pts) 9kcal/gram Show work on written piece of paper Total fat: TLC Goal (% of kcals in diet or grams chol.) RBs Modified Diet (% of kcals in diet or grams chol.) 25.6% 25-35% Saturated fat: Monounsatd. fat: Polyunsatd. fat: Cholesterol: <7% <or 20% <10% <200mg 4.3% 11.8% 5.4% .1673 g <19.4g <55.6g <27.8g <0.2 g 11.9 g 32.8 g 15.0 g 0.167 g TLC Target grams in 2,500 kcals/d 69.4-97.3g RBs Modified Diet (grams)

71.8 g

4. Interpret the results of RBs 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 RB, based on the NCEP guidelines. (4 pts) Parameter RBs Value in mg/dL 246 mg/dl 158 mg/dl 34 mg/dl 214 mg/dl Interpretation based on NCEP classification High Borderline High Low High

Therapeutic goal

Total Cholesterol LDL Cholesterol HDL Cholesterol Triglycerides

<200 mg/dl <100 mg/dl >60 mg/dl <150 mg/dl

NCEP ATP III Guidelines (NTP pg. 303)

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Last Name __Hirata_________________ First Name Miles_____________

5. List & number RBs risk factors for CHD, based on the presentation da ta from his
medical record. (3 pts) dont forget to number. At least 5.

1. 2. 3. 4. 5.

Family history. Hypertension. Smoking. (e-cigarettes) African American descent related to cholesterol. Hyperlipidemia.

6. What is metabolic syndrome & does RB meet the criteria? Why or why not? (3 pts)
Metabolic syndrome is a combination of medical disorders that can increase the risk of diabetes and cardiovascular disease. According to NCEP guidelines, to be diagnosed with metabolic syndrome, the individual must meet at least 3 of the following: waist circumference of 102cm or higher for males, 88cm or higher for women, Triglyceride level of 150mg/dl or higher, HDL levels of less than 40 mg/dl for males, less than 50 mg/dl for females, a blood pressure of 130/85mmHg or higher, and a fasting plasma glucose of 110 mg/dl or higher. RB meets the requirements for triglycerides, HDL, and blood pressure, indicating he does meet the criteria for metabolic syndrome. Metabolic Syndrome (NTP p.303)

Last Name __Hirata_________________ First Name Miles_____________

Last Name __Hirata_________________ First Name Miles_____________

7. How do each of the prescribed medications work? What effect will these

medications have on his nutritional care? Refer to the medication information in the NTP or PG texts or http://www.pdr.net (online physicians Desk Reference). Cite the resource used for each drug. (6 pts) Lasix Lasix is a common drug used for hypertension. It primarily functions by inhibiting absorption and reabsorption of sodium and chloride in the proximal and distal tubules, as well as in the loop of Henle. Since Lasix is a loop diuretic drug, urine output is expected to increase. RB should be monitored for any signs of dehydration and electrolyte imbalances. Side effects include diarrhea, dizziness, rash, fever and restlessness. While taking this drug RB should discontinue eating grapefruits as they could possibly interact negatively and increase serum levels of cardiac drugs to dangerous levels. Lasix Information (www.pdr.net)

Pravachol Pravachol is an HMG-CoA reductase inhibitor drug used to reduce the risk of a myocardial infarction. Pravachol reduces cholesterol levels by inhibiting the conversion of HMG-CoA to mevalonate, a metabolite produced in the cholesterol synthesis pathway. Pravachol reduces VLDL and triglyceride levels and increases HDL levels. Side effects include diarrhea, rash, fatigue, upper respiratory tract infection, chest pains, headaches and muscle cramps. RB should avoid eating grapefruits to prevent interaction with Pravachol. Pravachol Information (www.pdr.net)

Last Name __Hirata_________________ First Name Miles_____________ Marplan Marplan is a monoamine oxidase inhibitor drug used to treat depression. Its main component is hydrazine which involves the elevation of brain levels of biogenic amines. It also inhibits monoamine oxidase in the brain, heart, and liver. Side effects include dizziness, headaches, dry mouth, constipation, and orthostatic hypotension. Because hypotension is a possible side effect, Marplan should not be taken with other drugs that are known to cause hypotension. I would advise not to take Marplan while also taking Lasix, as Lasix can cause hypotension. Foods high in tyramine, such as avocados, aged cheeses and meats should not be consumed while taking Marplan. Marplan information (www.pdr.net)

You assess RBs knowledge of a low -sodium, NCEP TLC diet as being limited to just dont 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 in the work cafeteria for lunch but is willing to bring his lunch to work 2 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. 8. List and number 3 major teaching points (dietary advice) that you will need to discuss with RB in order for him to understand and follow a 2400 mg Na diet. (3 pts)

1. Meal Portion Sizing. By reducing the portion size of each meal, sodium is also reduced. 2. Attempt to fill half of his plate with fruits and vegetables. 3. Avoid processed foods by cooking more meals. Since RB is beginning to make his lunch twice a week, he can try to slowly increase the number of lunches he makes each week.

Last Name __Hirata_________________ First Name Miles_____________

9. List and number 3 major teaching points (dietary advice) that you will need to
discuss with RB in order for him to understand and follow the NCEP TLC diet. (3 pts) 1. Replace saturated fat with sources high in monounsaturated and polyunsaturated fats. Sources can be identified by reading the products nutrient label. 2. Consume 5 servings of fruits and vegetables each day. 3. Informing RB to avoid simple, processed grains and to replace them with sources of whole grains. Examples of both will be provided if necessary.

10. RB 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 RB. (4 pts) Since RB is Muslim, there are many dietary laws that must be considered when counseling him. Dietary restrictions include the prohibition of consuming pork, alcoholic beverages and blood. Food hygiene is an important concept of Islamic dietary laws, which is why pork, generalized as a filthy animal, is prohibited to be eaten. Dhabihah outlines the chosen method of animal slaughter. According to Dhabihah, the animal must be slaughtered by a Muslim who mentions the name of God while doing so. The animal must also be killed quickly and not see or smell blood from previous slaughters. Animals must also not be killed by being boiled or electrocuted. Foods of unknown origins, including gelatin enzymes, emulsifiers and flavorings, are also prohibited. Foods acceptable to eat are known as halal meaning lawful, as foods that are prohibited from eating are termed haram or unlawful. Although some of the foods restricted from these laws, such as pork, can provide health benefits from decreasing intake of saturated/animal fats, there are also other consequences. Since only halal food is acceptable to eat, RB is significantly limited to what he can eat. Islamic dietary laws (www.islam.about.com/od/dietarylaw/)

Last Name __Hirata_________________ First Name Miles_____________

11. RB 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 an ADIME 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 clients 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 ADIME note and a separate sheet with all calculations as attachment. (12 points)

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Last Name __Hirata_________________ First Name Miles_____________ A: Pt is 55 yo African American male admitted for elevated BP. Pt reports hx of smoking, no hx of rheumatic fever, diabetes, or kidney disease. Pt father died from acute MI, mother being treated for HTN. Pt reports mild tension headaches and weight increase of 2-4#/year for last 10 years. Pt is currently taking Lasix (20mg), Pravaachol (10mg), Marplan (40mg) daily. Current BW 87.09kg (192#), Ht 511 (1.8 m), BMI 26.88 kg/m^2 (Overweight). Current labs Hct 45%, Hgb 15.8 g/dl, FBG 94 mg/dl, total cholesterol 246 mg/dl, LDL 158 mg/dl, HDL 34 mg/dl, TG 214 mg/dl, waist circumference 37.5 (95.25cm), BP 145/89 (Hypertension I). IBW 78.02kg + 10%, %IBW 112%, EER 2,246.43 kcal, Protein requirement 69.67g (RDA), fluid requirement 2,246.43 ml fluid/day(1ml/kcal). 1,500kcal 2.4g sodium TLC diet is not realistic at this time considering the drastic changes compared to 24hr diet recall. D: P (NI-5.6.2) Excessive fat intake, E: r/t high fat foods in 24 hour diet recall, S: AEB BMI (overweight), lipid panel labs. P: (NI-5.10.2.7) Excessive sodium intake, E: r/t high amounts of processed foods in 24 hour diet recall, S: AEB BP (hypertension I) I: Encourage slight weight loss, consuming more meals at home (home cooked). Increase nutrition education of reading nutrition labels and TLC diet. Encourage eating foods high in potassium and omega-3 fatty acids. Encourage low fat meals and snacks. Increase fruits and vegetable intake. ME: 1. Follow up every 2 weeks. 2. Monitor weight, BMI, BP. 3. Monitor lipid lab levels.

Miles Hirata 11/25/13

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