Name Age 52 Sex

Reason for consultation

His boss has changed his enssurance plan. He has not attended any medical checkup for
Simptoms x
Characteristics
Record
Subjective Medical no prior hospitalizations or chronic illnesses
Surgical x
Family history his father died of AMI (54 age), his brother had heart attack (55 age), his un
Occupation accaunatnt

Environmental factors that

Anthropometrics
Height 1.78 cm
Current weight 96 kg
Previous weight 91 kg
Usual weight x
Theoretical weight 78.9 kg
Indicatiors
BMI 30.3 obesity
Complexion x
Biochemicals
Low Normal
Cholesterol
Cholesterol HDL 32 mg/dl
Cholesterol LDL
Tg
Glucose 95 mg/dl
Creatinina 0.8 mg/dl
 HbA1c
Clinics
BP 139/88 mmHg
HR 76 bpm
RF 20 rpm
Size 178 cm

Current medications x
Supplements/Alternative
therapies x
Dietetics
Objective 24 hrs recall
Breakfast (office) Energy Proteins Lipids Chos
1 bagel 195 7.5 1.2 37.8
2 tsp cream cheese 92 2 9.2 0.8
600 ml coffee 0 0 0 0
60 ml light milk 24 1.9 0.6 2.8

Snack
30g gummies 105 1.3 0 25.5

Lunch (restaurant)
2 slices of pepperoni pizza 750 26 30 90
1 can of coke 144.6 0 0 36.9

Dinner
1 hamburger (1 meat) 332.5 15.5 15 32
1 cup french fries 207.5 4 7.5 30
1 cup of vanilla ice cream 482.4 8.5 26.4 56.7
720 ml of beer 309.4 0 0 25.5
TOTAL 2642.43 66.61 89.92 337.99
% Adequacy of energy 156.50% 105.50% 160% 145.60%
Water intake: 1.730 L in total
 Distribution of energy
Macronutrients %
CARBOHYDRATES 51.2
LIPIDS 30.6
PROTEINS 10.1
Total 91.9

Requierments estimation
Energy Formula
Correlation Factor 96 kg -- 30 BMI (24.9 * 96) / 30
x ------------ 24.9
Harrys Benedicts 66.5 + [13.75 x (78.9kg)] + [5 x 178cm]- [6.78 x 52years]

Proteins High protein diet 2.0 grams/kg

Carbohydrates
50-55% 211 g- 232 g

Analysis Lipids
13-30% 46.9 g - 56 g

Liquids 1.6 L

Nutritional diagnosis
Problem Cause
Excesive high fat intake lack of time and nutritional education
High calorie intake bad time administration
 Objectives of nutritional treatment
Reduce kilocalories throughout the day.
Reduces the percentage of fat consumed throughout the day.
Increase consumption of fruits and vegetables.
Cover the lipid recommendation.
Reduce consumption of simple sugars.

Dietary of lifestlyle intervention

Meal plan via equivalents.

Alimentary estrategies
Have 3 meal times with 2 snacks.
- Reduce consumption of saturated fats.
- Increase consumption of fruits and vegetables.
- Give preference to the consumption of drinking water and reduce carbonated drinks
- Reduce HC consumption
Plan
Reduce alcohol consuption

Education

Nutritional guidance for managing diet at home and invitation to undergo a cardiovascular check-up
Patient equivalent plan and an example menu
Recommendations on foods to prefer and which to avoid
Nutritional guidance on how to prevent diabetes, and how to lower cholesterol and lipids in blood
Explain how calculate each portion of protein, lipid and carbohydrate

Monitoring
Valoration per month:
Anthropometrics
Biochemicals
Clinical
Diet
Lifestyle
 Actual status Date
tation

attended any medical checkup for 3 years

pitalizations or chronic illnesses

e time, high stress, use of car

cs

91 kg
x
78.9 kg

obesity
x
Date: x
Normal High
260 mg/dl

158 mg/dl
350 mg/dl
5 mg/dl
.8 mg/dl
 6%

Observations on quality:
Lack of vegetables, high simple CHOs, excess of sugar, no natural
water intake, he prefers carbonate beverages

Observations on quantity:
According to the 24 hrs recall, the pacient have a consume of 2,642 kcal
(66.6 protein grams, 82.92 lipid grams and 337.99 chos grams).
nergy
% grams
51.2 338
30.6 89.9
10.1 66.6
91.9

mation
Total
78.9

1,688.80

157.8 grams
63.12 grams

osis
Evidence
nutritional education high cholesterol levels
156.50% more than he should consume
 treatment

ervention

d 63 grams of proteins (15 VET). Covering approximately 1600 to 2000 ml of water.

egies