Progress Report Overview

Student: Alexis Clifton

Activity: Hypertension and Dyslipidemia Case Study

Start Time: 11/08/2018 15:53:10

End Time: 11/12/2018 23:39:03

Total Time: 15:02:05

Actions

Note at 11/12/2018 22:59:48 Note at 11/12/2018 23:38:37

Hypertension and Dyslipidemia Case Study
Documentation
Student: Alexis Clifton
Activity Start: 11/08/2018 15:53:10
Activity Completion: 11/12/2018 23:39:03
Activity Completion: 15:02:05

Patient Data

Patient: Greg Anders DOB: 05/20/1958

Age/Sex: 60 yo M MR#: MR285961
Location: Central Clinic

Notes

Note at 11/12/2018 21:22:44

ADIME Note

Basic Information

Date:

11/12/2018 21:22:44

Author:
Alexis Clifton

Patient name:

Greg Anders

Date:

11/12/2018

Assessment

Diagnosis:

Hypertension, Dyslipidemia, CKD stage 3a

Age:

60

Gender:

Male
Race:

Black

Client History

Medical history:

Hypertension x14 years

CKD x8 years

Medical diagnoses:

Dyslipidemia

Family history:

Mother: deceased 69 yo, HTN, CAD, DM, CKD

Father: HTN, prostate cancer
Brother: HTN, obesity

Social history:

Single; currently lives alone after moving to a new residence for a new job as a sales consultant. Patient smokes 1 pack per
day, denies illicit drug use, and drinks 2-3 alcoholic drinks 1-2 nights per week. Tries to eat fruits and vegetables every day.
Drinks 2 cups of coffee every morning. Wants to start a walking routine to improve his weight.

Current medications:

Lisinopril 40 MG oral tablet - dose at 40 mg daily

Amlodipine 10 MG / Atrovastatin 10 MG oral tablet - dose at 10 mg BID Gemfibrozil 300 mg (Apo-Gemfibrozil) - dose at 300
mg daily
Furosemide 20 MG oral tablet - dose at 20 mg daily
Warfarin Sodium 3 MG oral tablet - dose at 3 mg daily

Nutrition-related medications:

N/A

Current supplements:

N/A

Anthropometric history
 Height:

64 in

Weight at admission:

180 lbs

Current Weight:

180 lbs

BMI:

30

% Weight change:

N/A

IBW:

130 lbs

% IBW:

138

Weight assessment:

BMI, %IBW, and waist circumference indicates obesity.

Biochemical history, medical tests, labs, and procedures:

BP taken over time to monitor HTN

Glucose, Serum 110 mg/dL
BUN 20 mg/dL
Creatinine, Serum 1.5 mg/dL
BUN/Creatinine Ratio 11-26
eGFR if African American 58mL/min
Sodium, Serum 136 mEq/L
Potassium, Serum 4.6 mEq/L
Chloride, Serum 103 mEq/L
Carbon Dioxide, Total 25 mEq/L
Calcium, Serum mg/dL
Albumin, Serum 4.2 g/dL
A/G Ratio 1.1-2.5
Lipid Profile:
Cholesterol, total 278 mg/dl (High)
HDL cholesterol 27 mg/dl (Low)
LDL cholesterol 239 mg/dl (High)
Triglycerides 347

Nutrition Focused Physical Exam

Skin Assessment
 Intact

Edema
None

Feeding Ability

Independent

Oral Motor

Intact

Muscle and fat store assessment:

N/A

Food and Nutrition History

Current diet order:

No current diet order.

Assessment of usual intake:

Excessive calories; excessive sodium; high saturated fat; increase in fruits and vegetables necessary; most meals eaten out
Estimated 5,162 kcals a day
Estimated 129g of protein per day

Supplements/herbals:

N/A

Food allergies and intolerances:

Penicillin

Intake and digestive problems:

N/A

Assessment of Nutritional Status/Nutrition Risk

No malnutrition noted
 Nutrition Recommendations

kcal/day based on:

1544 - 1605 kcal/day based on Harris-Benedict and Mifflin-St. Jeor equations

g protein/day based on:

82 g/day based on his chronic kidney disease state

mL fluid/day based on:

1605-2460 mL fluid/day based on 1mL/1605kcal and 30mL/kg x 82kg body weight (30 mL based on age)

Nutrition assessment summary:

Based on usual diet, patient has excessive intake of calories, saturated fat, and sodium with a limited intake of fruits and
vegetables.

Diagnosis

Nutrition Diagnosis:

Excessive caloric intake, Inappropriate intake of saturated fat, Excessive sodium intake, Lack of micronutrient intake

PES Statement:

Overweight related to excessive caloric intake as evidenced by hypertension, BMI of 31, and IBW at 138%.

PES Statement:

Inappropriate intake of types of fats related to excessive intake of processed and fried foods high in saturated fat as
evidenced by hyperlipidemia.
 PES Statement:

Excessive sodium intake related to consumption of processed foods and use of added sodium as evidenced by high
blood pressure of 145/92.

Nutrition Intervention

Nutrition prescription:

Gradually decrease caloric intake to 1544-1605 kcal/day. Increase fruit and vegetable intake and consume small meals
frequently. Decrease sodium intake. DASH diet plan.

Food and nutrition delivery:

Oral

Nutrition education:

Educate patient on how to decrease sodium intake and read labels to avoid excess sodium. Explain nutrient-dense
foods/meals versus caloric-dense foods/meals and how to implement them into daily food choices. Explain proper
portion sizing. Explain the dangers of not making prompt changes to improve patient's problems. Explain DASH diet,
its benefits, and why it is being implemented.

Nutrition counseling:

Discuss food preferences with patient and how he can incorporate them into the DASH diet plan. Discuss with patient
any concerns he has with DASH diet.

Coordination of care:

Collaborate with primary care doctor for DASH diet plan implementation and keep doctor informed of all dietary
changes.
 Monitoring and Evaluation

Food and nutrient intake:

Determine caloric, sodium, and saturated fat intake from daily food logs. Evaluate how patient is doing with DASH diet plan.

Anthropometric measurements

Regularly take blood pressure to monitor hypertension.

Monitor weight with the goal of purposeful weight loss.

Biochemical data:

Evaluate lipid profile, especially LDL and HDL levels with intentions to decrease LDL and increase HDL.

Nutrition focused physical findings:

Measure waist circumference to find waist to hip ratio of patient with intentions of losing central adipose tissue.
Weight loss expected.

Signature/credential/date:

Alexis Clifton, RDN, 11/12/2018

Note at 11/12/2018 23:35:21

Case Study 2 Details

Basic Information

Date: 11/12/2018 23:35:21

Author: Alexis Clifton

Location:

Title: Case Study 2

Note: 1. Define Hypertension and suggest how his high blood pressure would be
classified and discuss how this impacts his risk for future health problems? (4
pts)
Hypertension is a condition of chronically elevated blood pressure.1High blood
pressure occurs when systolic values are 140 or above and/or diastolic values are
90 and above. Mr. Anders has stage 1 hypertension, which is evidenced by his
systolic blood pressure ranging from 145-162 and his diastolic blood pressure
ranging from 92-94. Hypertension, when uncontrolled, leads to myocardial
infarction, stroke, renal failure, and even death.2

2. Define Dyslipidemia? Compare his lab values to the normal values? Interpret
these values. (4pts)

Dyslipidemia is a condition in which LDL levels are elevated and HDL levels
are low, which can increase the risk of atherosclerotic development.1Mr.
Anders’ LDL levels are very high at 239 mg/dl, while his HDL levels are low at
27 mg/dl; his total cholesterol is high at 278 mg/dl. The normal values of LDL
range from 65-180 mg/dl, so Mr. Anders’ LDL levels are very high and should
be dealt with promptly. Ideal HDL levels are above 35 mg/dl, and total
cholesterol levels should be kept below 200 mg/dl. Overall, Mr. Anders lipid
profile is quite concerning.3

3. What is his IBW range, IBW% and BMI? Interpret data. (2 pts)
IBW = 50kg + 2.3kg(4) = 59.2kg = 130 lb
IBW range = 117-143 lb
IBW % = 180lb/130lb x 100 = 138%
BMI = 82kg/1.65m2= 30

Mr. Anders is considered obese in accordance with his BMI value. His IBW
range is 117-143 lbs, but his current weight is 180 lbs. He exceeds his IBW
by 38%, which puts his health at risk.4

4. Estimate his calorie needs (for weight loss) using two methods, estimate his
protein needs and estimate his fluid needs using two methods. (4 pts)

Harris-Benedict: REE = 66.5 + 13.8(82 kg) + 5.0(163 cm) – 6.8(60yo) = 1605

kcal/day
Mifflin-St. Jeor: REE = 10(82 kg) + 6.25(163cm) – 5(60yo) + 5 = 1544
kcal/day
1.0g/82kg = 82 g protein/day (I used 1 g as opposed to 0.8 g because he has
CKD)
1mL/1605kcal = 1605 mL fluid/day
30mL/kg x 82kg = 2460 mL fluid/day

5. Explain the DASH diet? What levels of Saturated fat, cholesterol, fiber,
sodium, potassium, calcium and magnesium are included? What would be
an expected change in his blood pressure and blood lipids if he follows the
DASH Diet? (4 pts)

The DASH diet is composed of a variety of foods that not only reduce sodium
intake, but increase potassium, magnesium, calcium, and fiber intakes
within a moderate energy intake. Saturated fat should be limited to less than
6% of total calories. There are no specifications for cholesterol intake, but
LDL intake would be limited with saturated fat restriction. The DASH diet
provides 30 g fiber, 1200 mg sodium, 4700 mg potassium, 500 mg
magnesium, and 1240 mg calcium.1If Mr. Anders follows the DASH diet, his
blood pressure and blood lipids should lower and reach more normal levels
since electrolyte levels would be regulated, fat intake would be restricted,
and fiber intake would be increased.

6. Analyze his diet using Fitday (www.fitday.com). How many calories and
protein are being consumed? Compare to his estimated needs? How does
his actual diet compare to the DASH recommendations? What
recommendations would you make? (6 pts)

Mr. Anders consumes about 5162 calories and 129 g protein per day. In the
tracked day, he consumed about 3557 more calories than what his
estimated needs are and about 47 g more protein than his estimated needs.
In comparison to the DASH recommendations, Mr. Anders’ actual diet
contains far more calories than what he needs. His diet is also extremely low
in fruits and vegetables, as the only “vegetable” he ate throughout the day
was potatoes in various forms. The DASH recommendations are that a max
of 27% of calories come from fat, but Mr. Anders consumed 39% of his
calories from fat, mostly saturated. The first recommendation that I would
make would be to increase fruit and vegetable intake in foods that Mr.
Anders enjoys. I would suggest that instead of drinking fruit punch in the
morning, he try making a smoothie with spinach, avocado, and berries. In
this way, he would satisfy his sweet tooth, increase his satiety from the
avocado as well as intake some healthier fats, increase his fiber
consumption from the spinach and berries, and contribute to his overall fruit
and vegetable consumption. I would also suggest that Mr. Anders try
replacing some of his potato-based foods with salads or other vegetables
that he enjoys eating. Instead of drinking calorie-dense colas and other soft
drinks, I would suggest that he try stevia-based or other 0-calorie sparkling
beverages to satisfy his desire for carbonation. Instead of consuming rich ice
cream, I would point out to Mr. Anders that there are low-fat frozen yogurt
options available that he could eat instead on occasion. These are just some
of the recommendations that I would make for Mr. Anders to start with,
among others.

7. List and explain all drugs this patient is receiving? Describe any food-drug
interactions for each medication. (3 pts)

Medication Function Drug-Drug Drug-Nutrient

Interaction Interaction
 Used alone or in None applicable Salt substitutes
Lisinopril combination with containing potassium;
other medications to low-sodium diets
treat high blood should be followed
pressure; is an carefully
angiotensin-
converting enzyme
(ACE) inhibitor; works
by decreasing certain
chemicals that tighten
the blood vessels, so
blood flows more
smoothly and the
heart can pump blood
more efficiently
Used alone or in Warfarin Low-sodium diets
Amlodipine combination with should be followed
other medications to carefully
treat high blood
pressure and angina;
is a calcium channel
blocker; lowers blood
pressure by relaxing
the blood vessels so
the heart does not
have to pump as hard
 Used with diet Warfarin Eat a low-fat, low-
Gemfibrozil changes (restriction of cholesterol diet;
cholesterol and fat alcohol should be
intake) to reduce the avoided
amount of cholesterol
and triglycerides in
the blood in people
with very high
triglycerides who are
at risk of pancreatic
disease; also used in
people with a
combination of low
HDL levels and high
LDL levels and
triglyceride levels to
reduce the risk of
heart disease; is a
lipid-regulating
medication; works by
reducing the
production of
triglycerides in the
liver

Used alone or in ACE-inhibitors Sodium-rich and

Furosemide combination with (Lisinopril) potassium-rich
other medications to (bananas, prunes,
treat high blood raisins, orange juice,
pressure; used to etc.) foods should be
treat edema; is a carefully monitored
diuretic; works by due to interactions
causing the kidneys
to get rid of
unneeded water and
salt from the body
into the urine
Used to prevent Amlodipine Vitamin K-containing
Warfarin blood clots from foods can affect how
forming; blood warfarin works and
thinner consistent amounts of
(anticoagulant) vitamin K-containing
foods should be
consumed; grapefruit
and grapefruit juice
should be avoided

8. Go to https://www.kidney.org/professionals/kdoqi/gfr_calculatorEnter age,
 gender race and creatinine this calculate estimate eGFR (Glomerular
Filtration Rate). What is his GFR? What does this mean? If these readings
continue for at least 3 months what would it suggest about the effects of
HTN on his kidneys? (2 pts)

Mr. Anders’ GFR is 58mL/min/1.73m2. The glomerular filtration rate

measures the level of kidney function a person has. Normal adult levels are
above 90, but GFR declines with age, despite being in disease stage or not.
For Mr. Anders, since his GFR is at 58, he is considered to have stage 3a
chronic kidney disease (he only has 58% of his kidney function).5If the GFR
readings continue for at least three months, it is likely that Mr. Anders’
hypertension is affecting his kidneys. Persistent HTN can damage the blood
vessels in the kidneys by stretching them which causes scarring and
weakens the vessels. When the vessels are damaged, the kidneys can stop
removing wastes and excess fluid from the body. The excess fluid in the
blood vessels can raise blood pressure even more, continuing a dangerous
cycle.6

9. Identify appropriate nutritional diagnosis and what domains do they come

from. Write two PES statements. (2 pts)
1. Overweight related to excessive caloric intake as evidenced by hypertension,
BMI of 31, and IBW at 138% (domain: intake).
2. Inappropriate intake of types of fats related to excessive intake of processed
and fried foods high in saturated fat as evidenced by hyperlipidemia (domain:
intake).

10. Identify goals for this client? What interventions would you put in place? How
would you monitor these interventions and his progress? (4 pts)
1. Decrease caloric intake to REE caloric needs (about 1605 kcal/day) within 3
months.
2. Decrease levels of LDL cholesterol to more normal levels (129mg/dL or lower)
and increase levels of HDL cholesterol (40mg/dL or higher) within 3 months.
3. Increase fruit and vegetable consumption in order to increase fiber,
magnesium, calcium, and potassium levels.

To achieve these goals, the DASH diet would be implemented for Mr. Anders.
The diet plan would support each one of the goals by decreasing caloric
intake, decreasing LDL cholesterol levels and increasing HDL levels, and
heavily involve vegetables and fruits. To monitor Mr. Anders’ caloric and
fruit/vegetable intake, daily food logs would be used, and weight loss/gain
would be closely monitored. LDL and HDL levels would be monitored by
checking levels every month via lab tests.

11. Complete an ADIME note in EHRgo. (15 pts)

 Works Cited

1. Nelms Marcia. Nutrition Therapy and Pathophysiology. S.1.: Cengage

Learning; 2019. Pages 293, 302, 310
2. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the
Management of High Blood Pressure in Adults Report From the Panel
Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA-
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 311(5):507-520.
3. Cholesterol test. Mayo Clinic. https://www.mayoclinic.org/tests-
procedures/cholesterol-test/about/pac-20384601. Published March 29, 2018.
Accessed November 13, 2018.
4. UCLA Nutrition Education.
https://apps.medsch.ucla.edu/nutrition/weightassess.htm. Accessed
November 13, 2018.
5. Glomerular Filtration Rate (GFR). The National Kidney Foundation.
https://www.kidney.org/atoz/content/gfr. Published August 22, 2018.
Accessed November 13, 2018.
6. High Blood Pressure & Kidney Disease. National Institute of Diabetes and
Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-
information/kidney-disease/high-blood-pressure. Published September 1,
2014. Accessed November 13, 2018.