CASE STUDY #1 Patient Presentation: Mr. G. is a 45 yo, WDWN(well developed well nourished) Latino male.

He was well at his last PE(physical Exam), as he reports that he has been for his entire adult life. One week ago he was admitted to the TLC Hospital following a MVA in which he suffered multiple fx including both of his legs and his right clavicle. Anthropometrics: 510"=177.8cm tall and weighed 228#=103.63kg at the time of his last PE, one month PTA. Biochemical: Lab Value Last PE Albumin Prealbumin HCT Hgb 3.8 gm/dL NA 43% 16 gm/dL When admitted 3.1 gm/dL 10 mg/dL 38% 12 gm/dL 4 days p admission 2.8 gm/dL 12 mg/dL 39% 14 gm/dL Today 3.0 gm/dL 15 mg/dL 41% 15 gm/dL

Clinical: Though this patient has multiple bruising over large portions of his body, he appears to be otherwise WDWN. Dietary: His diet hx reveals that he is on no special diet but he states that he tries to eat healthy foods and avoid too much junk food. On weekends he often eats traditional foods with extended family members. No food dislikes, though he prefers to drink diet soda at every meal instead of other beverages. Food allergies: NKA Alcohol intake: occasional beer Vitamin/mineral intake: CAM: none none

Sociocultural Mr. G is Mexican-American and has been living in the US for most of his life. He has a wife and 2 children. He is employed as a manager in the computer industry, and has good health insurance. No religious or ethnic constraints on his dietary intake. Please show your calculations below for each question, if required. Reference all calculation formulas with the text and page number (i.e., NTP p. ___). You must type your answers! If not, questions will not be graded and you will receive zero points. Case Study #1 is worth 50 points.

Last Name _______________________ First Name ________________________ Section # ____ 1. Mr. Gs BMI is __32.78kg/m^2_, which indicates that he is ___Obese_____ Grade __1__. (2 pts) BMI=(kg)/(ht in m^2)=103.63kg/1.778^2=32.7809 2. Mr. Gs IBW is __75.29kg___ and his percent IBW is __137%__. (2 pts) IDW= 106lb for 5feet plus 6 lbs per inch=166lbs=75.29kg %IBW= current weight/IBW= 103.63kg/75.29kg=137% >130%IBW=obese (Reference from Pocket Guide pg. 32) 3. Using the Mifflin-St Jeor equation (from NTP), calculate Mr. Gs kcal needs for weight maintenance. (2 pts) 2544-3007kcal 10 x wt(kg) + 6.25 x ht(cm) 5 x age(yr) +5 10 x 103.63kg + 6.25x 177.8cm 5 x 45 + 5 1036.3 + 1111.25 225 + 5=1927.55 Reference from Pocket Guide (pg 17) text as well as AF and IF (Pg. 20 of Pocket Guide) AF=confined to bed=1.2 IF= 1.1-1.3 1927.55kcal x 1.2AF x 1.1-1.3IF= 2544-3007kcal 4. Given his weight, should Mr. G be on a kcal-restricted diet at this time? Why or why not? (1 pts) yes no No, he should not begin cutting calories until he is healed and no longer confined to bed. He needs the calories right now to heal and recover. 5. How much protein does Mr. G need? (1 pt) _113-150g Protein when obese you use the IDW for protein requirements then decide how many grams of protein per kg IBW x Protein Req= grams of protein 75.29kg x 1.5-2.0= 113-150 grams of Protein (Reference from pg 22 of pocket guide) 6. How much fluid does Mr. G need each day? (1 pt) __2544-3007mL/d_ 1mL fluid per kcal= 2544-3007mL/day (Reference from pg 23 of pocket guide) 7. Please explain why each of the four blood tests listed above changed over time. (.5 pts each = 2 pts) Albumin may have decreased and then increased due to a decreased synthesis rate, an increased degradation rate or a change in fluid distribution. Albumin serum levels are also affected by trauma, which Mr G went through in his MVA as well as metabolic stress. Albumin may likely decrease at admission as well as 4 days post admission as a result of inflammation.

Last Name _______________________ First Name ________________________ Section # ____ It appears that Mr Gs prealbumin levels have been lower than normal on all occasions including the recent increase to 15mg/dL seen in todays blood tests. This could be a result of dehydration. Mr G had a slight decrease in his hematocrit concentration on the day of admission as well as 4 days post admissio=n, this could be a result of anemia, which in turn could be a result of blood loss during his MVA which would explain the increase post admission up to today. Mr Gs hemoglobin content was lower than normal on the day of admission and increased to a normal range upon today. The low levels seen on admission could be a result of anemia due to blood loss during the MVA. 8. List 5 nutrients or dietary components that you might be concerned about for this patient, stating the reason for your concern. (5 pts) For Mr Gs current condition I am concerned most about proper healing of his wounds which can be supported with increased arginine, glutamine, Vitamin A,C and zinc. By encouraging proper healing, Mr G will get to a state where he is then more able to take control of his weight via exercise and diet. 9. What is the appropriate diet order for Mr. G? Why? (1 pt) The appropriate diet order for Mr G at this time would be nutrient dense meals that include the necessary 5 nutrients listed above to promote healing as well as health.

Last Name _______________________ First Name ________________________ Section # ____ 10. Write an ADIME note for Mr. G. Be sure to include a PES statement in the note. (4 pts each = 16 pts) A: Pt is s/p hospitalization due to multiple fx including both legs and right clavicle in MVA. Pt also has multiple bruising over large portions of the body. Pt is on bed rest. Pt is 45yo Mexican American male WDWL current ht=177.8cm, wt=103.6kg, IBW=75.29kg, BMI=32.78kg/m^2. Pt has NKA, no special diet, and no religious or ethnic constraints on his dietary intake. Pt works in computer industry. Pts lab indicates lower than normal alubumin 3.1g/dL, Hct 38% and HgB 12g/dL values upon hospital admittance. Pt present lab values show increased Hct 41% and HgB 15g/dL to normal ranges. Pt present lab value for albumin has decreased to 3.0 g/dL while prealbumin has increased from 10mg/dL on day of hospital admittance to present prealbumin 15mg/dL. EER: 2544-3007kcal EPR: 113-150 grams of Protein D: Use correct PES statement format (put in diagnostic code!!) Physical inactivity (NB 2.1) r/t MVA aeb fx in legs and right clavicle Increased nutrient need (NI 5.1) r/t wound healing aeb body bruising and fx legs and right clavicle. Obesity (NC 3.3) r/t excessive kcal intake and inactivity at job aeb BMI

I: Provide evidence-based information regarding nutritional needs during recovery from MVA. Include wound-healing vitamins (multivitamin, zinc, A, C, E) Consult with nursing/MD to ensure adequate pain coverage Modify oral intake to 6-8 small feedings with increased nutrient density; addition of high protein supplement; pain meds prior to meals and supplements

M/E: 1. 2. 3. 4.

Promote wound healing Encourage weight loss Pt will show understanding of current nutrient needs during healing Encourage exercise when able

Put Typed name date, time and signature at end of note, important for auditing

Last Name _______________________ First Name ________________________ Section # ____ You see Mr. G four months later in the out-patient clinic and he has healed and is ready and motivated to work on his weight. He has maintained his weight at 228#. He states that the accident was a wake-up call and he is ready to change his lifestyle. He is following no special diet. He is able to exercise now and currently he is walking his dog 10 minutes per day after work. A 24-hour recall reveals: Breakfast: (on way to work) McDonalds Egg McMuffin Hash browns x 2 Large coffee 4 creamers 2 packets sugar Lunch: (work cafeteria) Cheeseburger (double) Small salad (lettuce, tomato, ranch dressing) Large diet soda Snack: Guava Jarritos Dinner: (at mothers) Carnitas Corn tortillas (6) Grilled onions & peppers Fresh lime Sliced avocado 4 radishes Pickled carrots 1 can beer 1 can diet soda

11. If Mr. Gs goal is to reduce his weight to 175 pounds in the next 6 months how many kcals should he eat each day? (1 pt) (assume that there are 4.3 weeks per month) __1670.8-1863.8kcal/day___kcals/day 10 x wt(kg) + 6.25 x ht(cm) 5 x age(yr) +5 10 x 103.63kg + 6.25x 177.8cm 5 x 45 + 5 1036.3 + 1111.25 225 + 5=1927.55 1927.55kcal x 1.4-1.5AF x 1.0IF= 2698-2891kcal Reference from Pocket Guide (pg 17) text as well as AF and IF (Pg. 20 of Pocket Guide) 4.3x 6 mo= 25.8 wks to lose 53lbs(24kg) 53/25.8=2.05lbs/wk deficit/day 2.05X 3500kcal=7189.9kcal deficit per wk/7days= 1027.13kcal

(2698-2891) 1027.13= 1670.8-1863.8kcal/day 12. Do you think that a goal of losing this much weight in 6 months, by diet alone, is a realistic one for Mr. G? Why or why not? (1 pt) yes no No I do not think this is realistic. It is recommended to lose 1-2 pounds per week and this would require Mr G to be losing over 2 lbs per week. This rate would eventually slow as his metabolic requirements decrease with a decrease in weight. 13. Mr. G is in which stage of the Stages of Change? Provide evidence for your choice. (2 pts) Stage # _3-4___, __ prep and action________________ I believe Mr G is in a lingo between stage 3 and 4 because he says he is ready to change and technically has set goals to walk his dog for 10 minutes everyday after work and is performing those goals and taking action. He is improving and taking

Last Name _______________________ First Name ________________________ Section # ____ action about exercise but according to the 24 hr diet recall it does not look likes hes taking steps in that area of his life to change. 14. List 4 dietary (food) strategies that Mr. G could incorporate into his eating pattern to make his diet healthier. (1 pt each = 4 pts) 1. instead of 2 packets of sugar in his coffee he can use an alternative sweetener and a lowfat creamer 2. He can swap his large diet sodas with a large water 3. He can choose a lower calorie salad dressing option, ex low fat or low calorie like balsamic 4. He can consume 6-8 small meals/day as opposed to his current eating pattern. 15. List 3 realistic ways for Mr. G to increase his physical activity, aside from going to a gym. (1 pt each = 3 pts) Wear a pedometer Take the stairs instead of the elevator Park further away from work Ride his bike to work 16. List 2 behavioral strategies (other than diet and physical activity) that Mr. G could use to reduce his kcal intake. (1 pt each = 2 pts) 1. Mr G can reward himself after a decided number of pounds lost with new walking shoes or exercise equipment. 2. Mr G can educate himself by evaluating nutrition labels to determine the caloric content and food composition of his groceries. 17. Mr. Gs long-term (outcome) goal is to weigh 175 pounds; he will need measurable short-term goals as well. Please choose one strategy from each of the questions 14-16 and set a measurable goal for each of these that Mr. G can work toward during the two-week period between his appointments with you. (3 pts) SMART Goal= Specific, measurable, achievable, realistic, timely 1. Mr G can swap his 2 sugar packets for an alternative sweetener. He can start by only swapping one packet during his first 2weeks and then begin swapping both packets. 2. Mr G will begin wearing a pedometer and tracking his daily steps. 3. Mr G can reward himself with new fitness apparel for every 5 lbs he loses. 18. If the above interventions do not work and Mr. G reaches a plateau after losing 20 pounds, what do you think the next appropriate step should be and why? (1 pt) Pharmacotherarpy prescriptions because the diet and exercise approach are not working yet he is not obese enough to receive any type of bypass surgery.