Margie Siegel
UIUC Hospital
Acute Care
Mr. Robertson
54396874
9/23/1933
75
11/5/18
Nutrition Assessment:
This is a 30-minute face to face Medical Nutrition Therapy follow-up visit. Patient is a 75-year-
old male referred for dietary counseling by Dr.Smith.
Diagnosis and medical history: His father died from a myocardial infarction at age 55, while his
mother and older brother were both diagnosed with type 2 diabetes in their sixties, patient
referred originally for weight loss and high blood pressure. This is a follow up visit and he has
set goals previously to lose weight, increase physical activity, and decrease sodium intake.
Patient diagnosed with stage 1 hypertension. Patient is diagnosed with type 2 diabetes.
Diagnosed with prostate cancer 5 years ago. The tumor has metastasized, and he will begin
radiation soon. Has seen a dietitian multiple times and was last seen 10 years ago.
Weight History:
Height: 69in/175cm; Current weight: 170lbs/77kg; current BMI is 25.1kg/m2. normal for older
adults (21-27)
Usual body weight: 172lbs/78kg; % usual body weight: 99%
Ideal body weight: 160lbs/72.6kg; % ideal body weight: 106%
-Gained 14 pounds six months ago to 184 pounds
-Lost 14 pounds in the last six months but weight has been stable for two weeks
-Has been losing weight to reach pre-retirement weight of 172 pounds five years ago
-PG-SGA score of 11 (high)
-Mild muscle wasting
-Depression in temple
-Mild fat loss in orbital fat pads
-Acromion and clavicle protruding slightly
-Mild muscle deficit on biceps and triceps
-Interosseous muscle depressed
-Thigh and calf not well developed
-Knee bones prominent
-No edema or ascites
-No evidence of dehydration
Food and Nutrition Related History:
Breakfast:
2 slices multigrain toast
Monounsaturated margarine, salted, thinly spread 2tsp
Jelly, strawberry 3tsp on 1 slice of bread
½ cup of orange juice
Coffee with whole milk (1/2c), sugar (1tsp)
Morning snack:
Coffee with whole milk (1/2c), sugar (1tsp)
Midday meal:
2 slices multigrain toast
Monounsaturated margarine, salted, thinly spread 2tsp
2 slices roast beef, prime (1.5oz)
½ medium tomato (1/4 c)
1 cup low-energy diet soda
Afternoon snack:
Coffee with whole milk (1/2c), sugar (1tsp)
3 or 4 plain water cracker (1oz)
Evening meal:
Monday-Saturday
Steak, fried (4oz) or roast chicken with skin on (with pinch of salt)
1 tsp oil for cooking meat
¼ c potato, steamed
1 tsp monounsaturated margarine
¼ c low-starch vegetables, steamed
Sunday
Pasta cooked (1c)
Ground beef cooked (2oz)
Onion (1oz) cooked in oil (1tsp)
Tomatoes canned (3oz)
Basil (1/2 tsp), Pepper (1 pinch)
Cheddar cheese (1/2 oz)
1 small glass red wine (12%) 3 oz
Evening snack:
Everyday
1 cup water
Saturday-Sunday
2 scoops (1cup) of ice cream, regular fat
-He is eating a low protein diet for someone with cancer
-He is eating a low-calorie diet for someone with cancer
-Has made changes to his diet based on his previous diagnosis’s
-He is eating smaller portions since last visit
Nutrition Impact Symptoms: diminished appetite, leaving meals unfinished, finds the smells of
food unappetizing, fatigue, no longer wants to eat a hot breakfast, no longer will eat greasy
foods,
Activities and Function: No energy for regular physical activity which included cycling and
gardening, gets tired after showering or walking for 2 minutes, no energy to catch up with
friends can only do it once a week.
Social history: Gave up smoking 20 years ago. He and his wife go grocery shopping every
Friday. Wife does the cooking. He describes diet as “good basic meals.” Lives with his wife.
Wife supportive of his changes.
Labs and tests:
Albumin 2.55g/dL moderate depletion
Pre-albumin 8mg/dL moderate depletion
Total cholesterol 155mg/dL normal
TG 116 mg/dL normal
LDL 70 mg/dL normal
HDL 70mg/dL normal
HbA1c 6% normal because he has diabetes
Blood Pressure 130/85 normal high
Current Meds:
Metoprolol (antihypertensive agent)
Simvastatin (lipid-lowering tablet)
Metformin (hypoglycemic agent)
Bicalutamide (anti-androgen medication)
Nutrition Diagnosis
Inadequate protein intake (NI-5.6.1) related to cancer diagnosis and diminishing appetite as
evidenced by 24-hour recall low in protein containing foods and he eats less than his normal
amount of food.
Nutrition Intervention:
Nutrition Prescription
1. 2310-2695 kcals per day (30 - 35 kcal/kg Actual BW) based on weight gain
2. 87-109 g protein per day (1.2 – 1.5g/kg Actual BW) based on needs for chemotherapy
3. 1925-2695 ml fluid per day (25 - 35 ml/kg Actual BW)
-high protein and kcal diet
-energy dense foods
Implementation of Intervention
Mr. Robertson will be given purpose of the nutrition education (E-1.1) for his cancer diagnosis.
This will teach him the risks associated with malnutrition, what foods contain high amounts of
protein, and how to incorporate more protein rich foods into his diet. From this education he will
be given a food journal to track his progress. Mr. Robertson will be referred for Referral to
RDN with different expertise (RC-1.2). This dietitian will be specialized in cancer and will be able
to help him increase his protein and manage his cancer. Lastly, he will be referred for
motivational interviewing (C-2.1). During his motivational interviewing he will be able to set goals
for eating more protein and sticking to his diet.
Dietitian Assessment/Patient Response to Intervention
Fair, patient wants to gain his energy back through diet to be able to enjoy retirement again.
Education Materials Provided
1. High protein foods handout
2. Cancer RDN contact information
Referrals and RD Follow Up Plan for Monitoring and Evaluation
Patient will return in 2 weeks for evaluation of progress towards treatment goals. This
knowledge from receiving nutrition education will be measured by using the parameter
macronutrient intake (FH-1.5) protein intake. He will be given a food journal to write down all the
protein he eats and if he has increased his protein close to the recommended 87-109g per day
he has succeeded. Also, the parameter food and nutrition knowledge/skill (FH-4.1) will be used
to evaluate his knowledge. He will be asked a series of questions about malnutrition and the
risks, protein and energy rich foods, and energy dense foods. If he can recall 80% of the
information, he has succeeded. To evaluate how well his motivational interviewing is going the
parameter adherence (FH-5.1). He will be asked to recall his nutrition goals from his
motivational interviewing sessions and be asked if he has started to meet these goals. He will
also show his food journal to see if he is eating more protein and energy. Referral to RDN with
different expertise (RC-1.2) will be evaluated by asking him if he has seen a cancer dietitian and
if this has helped him increase his protein and learn how to maintain his weight with cancer.
Body composition/growth/weight history (AD-1.1) will be used to measure if he has maintained
his weight. He will be asked to come to the office to be weighed and asked about any weight
changes in the past 2 weeks. If he has maintained his weight, he has succeeded. Provided
patient with contact information and encouraged Mr. Robertson to call with any additional
questions. Patient was agreeable with this plan.
Medical Nutrition Therapy provided using the 2018 evidence-based practice guidelines from the
American Academy of Nutrition and Dietetics.
Margie Siegel
