Running head: CASE STUDY 7

Lesson 7 Case Study

Determine Basic Concepts of Medical Nutrition Therapy
Angela Martin
United States University

CASE STUDY 7

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Case Study

1. From the information provided, what should be documented in the Medical Record?
Medical records should contain information about Hilarys lab reports and Hilarys
immunization and health history form that will reveal that he suffered complications following
routine outpatient surgery, had three light to moderate strokes and her blood sugars were over
250mg/dL. Other things included in Hilarys medical records are documents received from other
clinics which will reveal that she has blurred vision and paralysis on the right side, has trouble
swallowing and seems to choke on occasion when taking medications. Other information that
will become part of Hilarys medical record is her previous health records made by her past
medical practitioners which will reveal that Hilary was diagnosed with insulin dependent
diabetes 10 years ago. Her doctor describes her blood glucose control as excellent. She followed
a carbohydrate counting diet, took 3 insulin injections daily, exercised regularly and monitored
her blood glucose 4 times per day (Duyff, 2011).
2. How old was Hilary when she was diagnosed with insulin dependent diabetes?
Hilary was diagnosed with insulin dependent diabetes 10 years ago. Since the case
reveals that she was born in 1975 and today is 2012. So Hilary was diagnosed with insulin
dependent diabetes in 2002, while she was twenty-seven years old.
3. What is Hilarys IBW?
Hilarys Ideal Body Weight is 56 kg based on the fact that she is currently weighing 41 kg
and her height is 164 cm.
4. What is Hilarys percentage IBW?
The Percentage Ideal Body Weight can be calculated by taking a ratio of actual weight
and Ideal body weight.
Percentage of Ideal Body Weight = Original Weight/ Ideal Weight * 100
Percentage of Ideal Body Weight = 41 kg / 56 kg *100
Percentage of Ideal Body Weight = 73.21%

CASE STUDY 7

5. Evaluate her diet using the recommendations of the Choose MyPlate. Compare her
intake by food group. How is Hilary doing?
Choose MyPlate offers realistic insights to the food industry, nutrition educators, health
professionals and individuals that are looking forward to help individuals assemble healthier
diets with tools and resources for user-friendly nutrition information, nutrition education and
dietary assessment (United States Department of Agriculture, 2012). MyPlate demonstrates five
food groups that form a healthy diet such as, fruits, protein foods, grains, vegetables and dairy.
Based on the information presented in the case study, Hilary is having a nutrient-dense
breakfast as she is having egg (dairy and proteins), toast (carbohydrates), orange juice (Vitamin
C) and coffee (caffeine). Moreover her lunch is also a combination of healthy food and nutrients
such as spinach salad (vitamin K, vitamin A, manganese, folate, magnesium, iron, copper,
vitamin B2, vitamin B6, vitamin E, calcium, potassium, and vitamin C) and mushrooms (Dietary
Fiber, Protein, Vitamin C, Folate, Iron, Zinc and Manganese, and a very good source of Vitamin
D). Lastly, Hilary is balancing her dinner plate with a mix of protein (salmon), vegetables
(potatoes and green beans) and dairy foods (cake and milk).
Choose MyPlate
Recommendations
Food
Servings
Breads/cereals 100% whole-wheat bread, bagels, or
Fruit
Vegetable

Hilarys Diet
Servings
Toast in Breakfast

English muffins
Fruits and Fruit Juices
Dark-green vegetables, starchy

Orange Juice in Breakfast

Spinach (Dark-Green Vegetables),

vegetables, red and orange vegetables,

Potato (Starchy Vegetable), Green

beans and peas

Beans (Beans and Peas)
Meat
Seafood, Chicken and Beef
Salmon
Milk
Milk, Yoghurt, Cheese and Soymilk
Milk and Cheese
So according to MyPlate recommendation, Hilary is doing quite well in her food intake.
She is focusing on fruits in her breakfast by having orange juice, she is varying her vegetable

CASE STUDY 7

intake in her lunch and dinner as she have mushrooms, spinach salad, mashed potatoes and
green beans. Moreover Hilary is going lean in her protein options as she is having salmon at
dinner and egg at breakfast. Hilary is also focusing a lot in having calcium and nutrient rich food.
One aspect on which Hilary can improve her Food Plate is incorporating more whole grains in
her diet.
6. What should be checked on MDS Section K?
Coughing or choking during meals or when swallowing medications.
7. Practice writing a chart note for this client.
Subjective
Patient has high blood sugar level; she reports blurred vision and paralysis on her right
side. Patient is reportedly having trouble in swallowing medicine.
Objective
Vital signs: Height 164 cm, Weight 41 kg, Wrist Circumference 12 cm, Hgb 13 grams,

HCT 35%, Alb 2.0 and Blood Pressure 120/70.

General: 37 year old, pleasant personality, well groomed, good hygiene, and makes good
eye contact. Wheatish complexion, jet black and silky, straight, long hair. Mental status:

Alert and aware of time and space, responds effectively to commands.

Endocrine: Excessive thirst, swelling in lymph nodes.
Neurological: No signs of mental deficits noted
Assessment
Monitor blood sugar level after every hour.
Plan
Diet modification and increase in insulin.

Running head: CASE STUDY 7

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References

Duyff, R. L. (2011). American dietetic association complete food and nutrition guide. Houghton
Mifflin Harcourt.
United States Department of Agriculture. (2012). Choose MyPlate. How many vegetables are
needed daily or weekly?.