The doctor has asked you to see Mr. James. He is a 50 year-old male admitted to the hospital status post a myocardial infarction. He works in Wall Street as a bond trader and typically has a 12-hour workday. He is a very busy individual and does not visit the physician regularly. His wife was concerned about his health and convinced him to visit a doctor. He was diagnosed with Hypertension. Mr. James usually skips breakfast. His lunch consists of food from a local diner or fast food restaurant. He eats a homemade dinner; snacks after dinner on cakes and cookies while watching television.
Height: 5 feet 9 inches
Weight: 200 lbs.
Diet Rx: Regular
Labs: Normal range
Na: 138 mEq/L 135-145 mEq/L
K: 4.1 mEq/L 3.5 – 5.0 mEq/L
Bun: 15 mg/dL 5 to 20 mg/dl
Cr: 0.7 mg/dL 0.6 to 1.2 mg/dl
Glucose: 103 mg/dL 70 to 100 mg/dL
T-Cholesterol: 250mg/dL less than 200 mg/dL
HDL: 30 mg/dL greater than 40 mg/dL
LDL: 150 mg/dL 60 to 130 mg/dL
Triglycerides: 175 mg/dL less than 150 mg/dL
1. Describe the patient’s nutritional requirements.
2. Describe the patient’s nutritional problems.
3. Identify the nutrition diagnosis and intervention(s).
4. Describe your recommendations for diet and nutrition education.
5. Write a nutrition assessment using S.O.A.P. format.
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