Client/Social Hx: Jamar is a 47-year-old African American male. He

Client/Social Hx: Jamar is a 47-year-old African American male. He retired from the military and works as a consultant to a military equipment company. He is divorced with two adult children. His girlfriend lives with him. Chief Complaint: The patient’s coworker became concerned when pt. did not report to work or answer his phone when called. A coworker went to the patient’s home and found him tired and confused. Pt. was taken to ED. Dx: Uncontrolled DM PMH: T2DM x 3 years (takes 850mg bid); hyperlipidemia. Pt reports he hasn’t been taking his medications these past 2 weeks due to work-related stress. Family Hx: Father – HTN; Mother – T2DM ASSESSMENT: Summary of subjective and objective data from chart review and patient/caregiver. A. ASSESS Jamar’s WEIGHT and NUTRIENT NEEDS (5 pts) Ht: 68″ Wt: 207# UBW: 211# Waist Circumference (WC): 41″ % wt change Waist Circumference (WC) Waist:Height Ratio (WHtR) BMI Interpretation of Weight and Waist Estimated energy needs using Mifflin equation and STRESS FACTOR for hospital patients (consider kcal for weight loss); show your work We will use 1800kcal for this case but still show what you get from Mifflin Estimated protein needs (use 20% of 1800kcal): Estimated % CHO (use 50%); Fat needs (use 30%) (show work): (use 1800kcal) Fluid needs (note equation used): Nutrition Hx: Jamar was instructed on a consistent carbohydrate diet for diabetes upon diagnosis. He was just divorced and depressed and has not followed the diet. He was a social drinker and began consuming alcohol daily. He has a new girlfriend who is attentive and wants Jamar to take better care of his health. She is willing to help him change his diet and exercise with him. He has stated that he is afraid and wants to manage his diabetes as he is afraid of getting diabetes complications. He is willing to attend the outpatient diabetes class that is offered through the hospital. He used to drink 3-5 beers every night and has stopped drinking for the past month. B. NUTRIENT ANALYSIS OF DIET RECALL (5 pts) DO NOT USE ESHA to evaluate vitamins/mineral; just macronutrients using Exchanges Use chart below to carry over the exchange, g CHO, PRO, FAT for each food (see bagel as example) Calculate fluids (use mL – 8 oz. = 240mL; 12 oz. = 360mL) – do not count beer Diet History (24 recall): Menu Exchange CHO (g) Protein (g) Fat (g) Fluids Breakfast: 1½ cups Frosted Flakes 8 oz. 2% milk 1 cup canned peaches (water pack) 3 starch 45 g 9g 3g 240mL Lunch (Corporate Cafeteria): Sandwich: 2 slices (2 oz.) white bread 2 Tbsp. peanut butte 1 Tbsp. jelly Side salad: 2 cups mixed salad greens 1 cup croutons 2 Tablespoons salad dressing 8 oz. water Afternoon Snack 1½ oz. pretzels 4 oz. diet soda Dinner (home; his girlfriend cooks): 5 oz. chicken baked with 1 tsp. butter 2 cups rice cooked with 2 teaspoons butter mixed with 1/2 cup peas or corn 4 oz. orange juice Snack: Almonds (12) 4 oz. orange juice Total g CHO/PRO/FAT Total Kcal (total each column of macronutrients) B. NUTRIENT ANALYSIS OF DIET RECALL (5 pts) Take the total grams of CHO, PRO and FAT above. How does pt.’s current diet compare to his macronutrient/energy requirements (using 1800kcal, 225gCHO, 90gPRO, 60gFAT), e.g,, 3200kcal, 177% of estimated needs – 3200/1800 x 100; do same for CHO, PRO, FAT. So, if patient is consuming 320gCHO for example that is (320/225 x 100) = 142% of estimated needs and that will help determine nutrition diagnosis like excessive CHO; also compare fluid total to estimated fluid needs Total g % compared to recommendation CHO = PRO= FAT= % kcal compared to recommendation % fluid needs C. DIETARY ADJUSTMENTS (5 pts) The physician ordered a consistent CHO diet. Write a nutrition prescription using the exchanges: Nutrition Rx (SEE VIDEO FOR # of exchanges to use per day) EXCHANGE TOTAL EXCHANGES FOR THE DAY MILK VEGETABLE FRUIT STARCH PROTEIN FAT write a new menu for pt. Try to keep menu similar but make changes that meet the Nutrition Rx. DO NOT USE CARBOHYDRATE COUNTING (THAT IS A DIFFERENT METHOD THAN THE EXCHANGES). Carry over the exchange group (e.g., fruit) and g of CHO, PRO, FAT for each food item. Also be sure to keep CHO between 45-60 grams/meal. Use fresh fruit and not juice (spikes blood sugar) and add pro/fat with fruit at snacks. FILL IN CHART BELOW MENU MAKEOVER Exchange – specify food group, e.g., 2 STARCH or 1 FRUIT CHO PRO FAT FLUID Breakfast Lunch Snack: Dinner: Snack: Total g CHO/PRO/FAT* Total kcal (%CHO/PRO/FAT) *grams for CHO/PRO/FAT should be within 5 grams of the prescription Pt dx with uncontrolled DM. In addition to his Metformin, he will be covered with rapid acting insulin during his hospital stay. Medications Rx in Hospital Dose Frequency Lispro (insulin)* 0.5 u As needed to control glucose Metformin (Glucophage) 850mg BID (twice/day) Allopurinol (Zyloprim) 300 mg Daily Colchicine 0.6 mg Daily Lipitor 20 mg Daily *You do not need to discuss Lispro in your assessment D. CLINICAL DOMAIN: MEDS & LABORATORY DATA (5 pts) MEDS: List medications; implications and nutrition-related side effects in the chart below (only include medications listed above) Medication Indication (mechanism of action) e.g. Zocor – lipid lowering agent Nutrition side effects (do not list side effects that we cannot treat such as dizziness or rash) and contraindications (such as alcohol): Factors that can affect nutrition intake, GI, vitamins, minerals and labs. How is medication affecting patient? Does he have an abnormal lab or experiencing any of the side effects? Laboratory Normal Jose’s Value Albumin 3.5-5 g/dL 4.9 Sodium 136-145mEq/L 147 Potassium 3.5-5.5 mEq/L 5.7 Chloride 95-105mEq/L 101 HCO3 23-30mEq/L 33 Magnesium 1.3-2.1mEq/L 1.5 Osmolality 285-295 mmol/kg/H2O 360 Glucose 70-110 mg/dL 714 BUN 8-18 mg/dL 31 Creatinine 0.6-1.2 mg/dL 0.8 Phosphate 2.3-4.7mg/dL 4.6 HbA1c 3.9-5.2% 11.2% Cholesterol 120-199mg/dL 190 HDL-C >45 (male) 55 LDL <130 123 LDL/HDL ratio <3.55 (male) 2.26 Triglyceride 40-160mg/dL (male) 185 pH 7.35-7.45 7.5 Hgb 12-16g/dL 11.4 Hct 37-47% 36.2 discuss MCV 78-93mm3 101 together Abnormal Lab Test ¯ or ­ Reason for Abnormality (be sure to include patient's medical problems and meds that may affect lab values)

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