First Name:____Ziying______________

Last Name:___Tan_______________

CASE STUDY #2 - CVD

Instructions:
Review the pts 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. Pts 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.

24 Hr. Diet Recall

Client reports that this pattern is fairly typical of his usual weekday intake:
Breakfast
McDonalds Lunch
Dinner
Milk, 2%, 8 oz.
Eggs, 2 poached
Toast, wheat, 2 slices
Butter, 1 Tbsp.
Table salt, 1/8 tsp.

Diet Coke
Quarter Pounder, with cheese
French fries, small

Milk, 2%, 8 oz.

Potato, baked, 1 med.
Sour cream, 2 Tbsp.
Chicken breast w/ skin, baked 6oz
Broccoli, cup
Tossed salad, 1 cup
Lettuce, tomato
Ranch Dressing, 2 Tbsp.
Roll, 1 small
Butter, 1 Tbsp.
Ice Cream, 10%, 1 cup
Table salt, 1/8 tsp.

Questions:

1. 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 MWs 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 MWs 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 MWs 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:
Protein:
Fiber:
Cholesterol:
Sodium:
Potassium:

2579.2 kcals
134.7grams
56.2grams
35.0grams
17.6grams
211.6grams
133.0grams
15.9grams
795.8mg
3512.9mg
3290.0mg

% of kcals:47%
% of kcals:20%
% of kcals:12%
% of kcals:6%
% of kcals:33%
% of kcals:21%

Adequacy of MWs diet:

According to MWs % of recommendations from food processor program, MWs diet is high in total fat
(153.92%), saturated fat (199.95%), monounsaturated fat (112.01%), protein (192.88%), cholesterol
(265.27%), and sodium (234.20%). Also, MWs diet is low in total calories (91.70%), polyunsaturated fat
(62.41%), carbohydrate (54.71%), fiber (40.33%), and potassium (70%). From his 24-hour recall, MW
had two poached eggs in his breakfast and he had large amount of chicken breast in dinner, which leads to
have high protein and cholesterol levels in his diet. MW ate lunch at McDonalds, which increases the
total fat, saturated fat, monounsaturated fat, sodium levels in his diet. Also, in his diet, he did not eat fruit
or many vegetables, which leads to have low levels of carbohydrate, fiber, and potassium in his diet.
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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 MWs
modified diet. Please hand-write at the top MWs 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 youve made in MWs 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:
Saturated fat:
Monounsaturated Fat:
Polyunsaturated Fat:
Carbohydrate:
Protein:
Fiber:
Cholesterol:
Sodium:
Potassium:

2497.7 kcals
91.2grams
17.8grams
28.8grams
20.7grams
340.0grams
94.4grams
33.8grams
119.1mg
1454.4mg
3937.9mg

% of kcals: 33%
% of kcals: 6%
% of kcals: 10%
% of kcals: 7%
% of kcals: 54%
% of kcals: 15%

Summary of changes made:

In MWs 2500kcals TLC diet, certain changes have been made in order to meet the requirement of NCEP
TLC guidelines:
Switched 2% milk to 1% milk in order to reduce fat, protein, and cholesterol level
Switched poached eggs to egg white in order to reduce cholesterol level
Eat lunch at subway because there are more options opened such as wheat bread
Increased vegetable and fruit intake to increase the potassium intake
Added snacks in between meals avoiding eating too much at night (increase total calories)
Reduced portion sizes of most of the food items to have a lower calories and sodium diet
Switched ice cream to nonfat yogurt to reduce fat content
Added fish because fish contains low-saturated fat, but high in monounsaturated fat and
polyunsaturated fat, which provides omega-3.
After changing MWs diet, TLC diet requirements have been met. The total calories changed to
2497.7kcals, a lower level of total fat: 33%, a lower level of saturated fat: 6%, a lower level of protein:
15%, a lower level of cholesterol: 119.1mg, a lower level of sodium: 1454.4mg, a higher level of
carbohydrate: 54%, a higher level of potassium (3937.9mg), and a higher level of fiber (33.8g). All of the
nutrient contents meet the TLC guidelines, and fat, cholesterol, and sodium level have significantly
reduced to a level below the TLC target.

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.)

MWs Modified
Diet (% of kcals in
diet or grams chol.)

TLC Target
grams
in 2,500 kcals/d

MWs Modified
Diet
(grams)

33%

69.4~97.2 g

91.2g

Saturated fat:

25~35% of total
kcals
<7% of total kcals

6%

<19.4 g

17.8g

Monounsatd. fat:

<20% of total kcals

10%

<55.5 g

28.8g

Total fat:

Polyunsatd. fat:
Cholesterol:

<10% of total kcals

<200 mg

7%

<27.8g

20.7g

119.1mg

<200 mg

1.19g

4. Interpret the results of MWs 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
MWs Value in mg/dL Interpretation based on
Therapeutic goal
NCEP classification
Total Cholesterol
210 mg/dL
Borderline High (200 to
239 mg/dL)
LDL Cholesterol
147 mg/dL
Borderline High (130<130 mg/dL
159 mg/dL)
HDL Cholesterol
Low, A major risk factor
38 mg/dL
for heart disease (< 40
mg/dL)
Triglycerides
150 mg/dL
Borderline High (150199 mg/dL)

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
Baked sweet potato
1 cup
950
180
Squash with skin
cup
237.6
13.5
Banana, medium
1 each
422.4
105.0
Total =1610 mg
Total = 298.5 kcals

6. List & number MWs risk factors for CHD, based on the presentation data from his medical record. (2 pts)
1) Family history of premature CHD: MWs father was died from an acute MI (heart attack) and his
mother is being treated for essential hypertension.
2) Hypertension: his blood pressure (155/103) is higher than 140/90.
3) Hyperlipidemia: his LDL cholesterol level is at borderline high level.
4) Low HDL cholesterol level: his HDL cholesterol is 38 mg/dL, which is less than the normal value (40
mg/dL).
5) MW is overweight (physical exam) and from %IBW, which is 114.4%. (See calculation sheet)
6) MW smokes cigarette.
7) Increasing triglycerides (emerging risk factor): his triglycerides level is at borderline high level
(150gm/dL)

7. What is metabolic syndrome & does MW meet the criteria? Why or why not? (2 pts)
Metabolic syndrome is a health condition, and it is a group of risk factors, such as abdominal obesity, high
triglycerides, low HDL cholesterol, high blood pressure, and high fasting plasma glucose (WedMD.com).
A person who has three of these five risk factors is considered as metabolic syndrome. MW has high
triglycerides, because his triglycerides level is 150mg/dL, which is borderline high, and it should be <150
mg/dL(NCEP ATP III criteria). He has high blood pressure (155/103mmHg), which is higher than criteria
(130/85mmHg). He has low HDL cholesterol level (38mmHg), which is lower than criteria (men:
<40mg/dL). His fasting plasma glucose (96mg/dL) is normal compared to the criteria (>100mg/dL).
Finally, his waist circumference is normal (96cm) compared to the criteria (men: >102cm). Therefore,
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MW has a metabolic syndrome because he has three of these five risk factors.
(NTP p.303, table 12.9)

8. How do each of MWs 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 http://www.pdr.net (online
Physicians Desk Reference). Cite the resource used for each drug. (4 pts)
Lasix
Lasix (Furosemide) is a type of diuretic medications and it is an anti-hypertensive medication
administered by oral IV or IM route. It decreases blood volume by increasing urinary output, and it
primarily inhibits renal sodium and water reabsorption. There are possible food-drug interactions and side
effects, such as, hypokalemia, hyperlipidemia, hypercholesterolemia, and dry mouth. Therefore, MW
should take with Low salt/high potassium diet, because MW should watch his intake of potassium in order
to avoid hypokalemia. He should also take with low cholesterol and low saturated fat die in order to avoid
hypercholesterolemia and hyperlipidemia. And, MW should also drink more water when he takes this
medication in order to avoid excessive fluid loss and dry mouth (NTP p.291).
http://www.pdr.net/drug-summary/lasix?druglabelid=2594
Lipitor
Lipitor (Atorvastain) is in a drug class of HMG CoA reeducates inhibitors, and it is an anti-hyperlipidemia
medication administered by oral route. It inhibits the rate-limiting enzyme in hepatic cholesterol synthesis.
There are possible food-drug interactions and side effects, such as GI distress, amount of grapefruit juice,
and hepatic dysfunction. Therefore, MW should take this medication with food to avoid GI distress. MW
should take with low cholesterol and low fat diet because of the side effect of this medication (hepatic
dysfunction). Also, for better outcomes, MW should avoid drinking grapefruit juice when he takes this
medication (NTP p.307).
http://www.pdr.net/drug-summary/atorvastatin-calcium?druglabelid=3523&id=1088

You assess MWs 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 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) Be aware of the sodium intake in sauces, condiments, and dressing. Those contain high sodium
contents. It is better to have unsalted/ light dressing, sauces, and condiments.
2) Avoid eating processed foods such as sausage, meat patty or fried foods because those foods contain
large amount of sodium. It is a better idea to eat fresh foods rather than processed foods.
3) Fill of your plate with fruit and vegetables, vegetables and fruits contain rich potassium and low
sodium.

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) Limit visible fats in diet because it is critical to control saturated fat intake in TLC diet. For
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example, remove skin when eating chicken.

2) Try to decrease portion size for each plate because of 2500kcal TLC dietary plan: smaller portion
lesser total calories.
3) Consume skim/ low fat dairy products because these are lower calories than whole fat dairy
products. Skim/low fat dairy products can also provide some essential vitamins and minerals such
as calcium and vitamin A,D.

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 foods are the foods that are prepared in accordance with Jewish law. There are seven basic rules of
kosher dietary laws:
1) Restrict the consumption of certain animals such as flesh, organs, eggs and milk of forbidden
animals.
2) Birds and mammals must be killed in accordance with Jewish law.
3) All blood must be out before eating.
4) Meat (the flesh of birds and mammals) cannot be eaten with dairy. Fish, eggs, fruits, vegetables
and grains can be eaten with either meat or dairy.
5) Certain parts of permitted animals may not be eaten.
6) Utensils that have come into contact with meat may not be used with dairy, etc.
7) Grape products made by non-Jews may not be eaten.
Therefore, when counseling MW, make sure he understands and follows the kosher dietary laws. He did
not strictly follow the Kosher dietary laws, for example, he had milk and meat products in one meal (24hour recall). I would not suggest including grape juice or wine in his diet because it is costly and hard to
find grape products made by Jews.
http://www.jewishvirtuallibrary.org/jsource/Judaism/kashrut.html

12. 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 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 SOAP note below and a
separate sheet with all calculations as an attachment (the calculations may be hand-written). (12 points)
S: Patient reports occasional mild tension headaches, and body weight has been increasing by 2-3 pounds
per year for the last ten years. Patient reports his father died from an acute MI, and his mother is being
treated for essential hypertension. Patient smokes cigarette and he is lightly active due to job position.
Patients revealed that he is willing to make changes to his diet now and wants to increase his knowledge
of NCE TLC diet.
O: 42 yo male, doctor prescribes 1500 kcal, 2.4-g Na, TLD diet, Ht. 510, Wt.190#, BMI: 27.3. %IBW:
114.4%
Labs: LDL 147 mg/dL(borderline high), T-chol 210 mg/dL(borderline high), HDL 38mg/dL(low), TG
150mg/dL(borderline high), Blood pressure readings: 155/103mmHg (high).
Medications: Lasix 20mg daily and Lipitor 20mg daily
EER: 2852.5kcals, total fat requirement: 79.2g-110.9g, saturated fat requirement: 22.2g, carbohydrate
requirement: 356.6g-427.9g, protein requirement: 107g, daily estimated sodium: <2400mg/day,
cholesterol: <200mg/day, fiber requirement: 20-30g/day.
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24-hour diet recall reveals intake of 2579.2kcals, 134.7g fat (high), 56.2g saturated fat (high), 211.6g
carbohydrate (low), 3512.9mg sodium (high), and 132.99 g protein (high).
A: 1) Excessive fat intake (NI-5.6.2) related to poor food choices from dietary patterns as evidenced by
borderline high level of LDL (147 mg/dL), low HDL (38mg/dL), borderline high level of triglyceride
(150mg/dL), and total fat intake from 24-hour recall analysis above recommended target goals.
2) Excessive sodium intake (NI-5.10.2, 10736) related to food-and nutrition-related knowledge deficit
as evidenced by high blood pressure (155/103mmHg), and sodium level from 24-hour recall analysis
above recommended target goals.
According to the 24-hour recall analysis data, the current diet exceeds the prescribed diet. Current diet
contains high levels of fat and sodium, which increases the total calories of his diet. Therefore, patient
may benefit from a low-fat diet, and low-sodium diet because this diet would lower the total calories of
this diet. Moreover, based on patients lab values and medications, a low fat, low sodium, low cholesterol
and high potassium diet should be encouraged. His lipid panel results (borderline high level of LDL, TG,
and T-chol, low level of HDL) reports that he needs to lower intake of fat, and his blood pressure reading
(1155/103) reports that he needs to lower his intake of sodium and quit smoking. Moreover, the two
medications he needs to take have nutrition-drug interactions, which should take with a low fat, low
sodium, low cholesterol, adequate water consumption, and high potassium diet. Patient now is willing to
take some changes to modify his dietary pattern, however, based on his EER (2852.5 kcals) and his
protein requirement (107g), the prescribed diet from doctor may not be beneficial and realistic to patient
because he needs more calories than 1500kcals per day in order to stay healthy. But, patient should be
motivated to understand the importance to have a low-fat and low- sodium TLC diet based on his 24-hour
recall analysis, labs, and meds.

P: The overall MNT goal is for the patient to follow the TLC guidelines for a healthy diet, and to
encourage cessation of smoking. This healthy diet consists of: 2500 kcals total calories, 2400mg Na, and
2496mL fluid requirement, therefore, consuming more foods consisting of fat-free and low-fat dairy
products, fish, whole grains, vegetables, and fruits. As well as consuming fewer foods with saturated fat,
sodium, cholesterol, and refined grains. By following these guidelines the patient will begin to lose
weight. Motivational interviewing to assist patient in making changes in food-related behaviors and
educating on how to eat foods properly. The patient should also focus on specific strategies such as,
removing salt on the table, decrease portion sizes, and replace 2% milk to skim/low fat milk. The patient
should try to bring his own lunch three days a week, remove salt from the table, fill a plate of vegetables
and fruits, and join a cessation of smoking program. Next visit, patient will be assessed body weight,
height, vitals, lab results, food records of everyday, and progress of cessation of smoking. The patient
needs have follow-up return appointment: twice phone check-in per month and one in-person appointment
per month.
Name: Ziying Tan (Clinical Nutrition student)
12/05/2014
Signature: ziying tan
Time: 8:00AM