Patient Summary
JT is a 52-year-old Hispanic man who consults a new physicianfor a routine physical examination because his employer hasrecently changed their health insurance plan. He has not seen aphysician for the past 3 years.
Past Medical History
JT has no prior history of hospitalizations or chronicillnesses. He is not taking any medications or over-the-counterdietary or herbal supplements, and he has no known foodallergies.
Family History
JT’s family history is positive for heart disease. His fatherhad a fatal heart attack at age 54, and his father’s brother had aheart attack at age 55. JT’s uncle is currently being treated forhypercholesterolemia. There is no family history of hypertension,diabetes, or obesity.
Social History
JT works as an accountant and reports a high stress level bothat work and at home. His work commitments do not allow him muchfree time so he frequently orders lunch in and eats at his desk.After a long day at work and his 45-minute commute home, JT feelstoo tired to exercise.
Over the past 3 years, he has experienced a 12-pound weightgain. JT attributes this to his sedentary, high-stress lifestyle,and to dining out with clients on average 2 to 3 nights per week.JT is a nonsmoker. He drinks a 20-ounce cup of regular coffee everymorning and two alcoholic beverages every evening. JT is marriedand has one daughter who is currently in her junior year ofcollege.
Dietary Analysis:
Total calories: 2730 kcal
Protein: 106 g (16% of total calories)
Fat: 108.5 g (33.5% of total calories)
Saturated fat: 47 g (15.5% of total calories)
Monounsaturated fat: 36 g (12% of total calories)
Polyunsaturated fat: 10 g (3% of total calories)
Cholesterol: 313 mg
Carbohydrate: 299 g (44% of total calories)
Dietary fiber: 11 g
Soluble fiber: 5 g
Sodium: 2680 mg
Physical Examination
Vital Signs
Temperature: 98 °F (37 °C)
Heart Rate: 76 BPM
Respiration: 20 PM
Blood pressure: 139/88 mmHg
Height: 5′10″ (178 cm)
Current weight: 212 lb (96 kg)
BMI: 30.4 kg/m2
Weight 2 years ago: 200 lb (91 kg)
Waist circumference: 42 inches (107 cm)
Laboratory Data
JT’s lipid profile, after a 12-hour overnight fast, provided thefollowing laboratory values:
Patient’s Lab Values Normal Values
Total cholesterol: 260 mg/dL desirable <200 mg/dL
HDL-C: 32 mg/dL desirable ≥40 mg/dL
LDL-C: 158 mg/dL desirable <100 mg/dL
Triglycerides: 350 mg/dL desirable <150 mg/dL
Plasma glucose: 95 mg/dL 70 to 99 mg/dL
His PES statement is Overweight/obesity (N.C.3.3)related to excessive kcal intake as evidence by 2730 kcal/daily anda BMI of 30.4 kg/m2 would be categorized as class 1obesity.
- Write an intervention statement for JT, what would a dietitianrecommended as realistic goals for this patient to focus on as wellas what would the patient (JT) do.
Dietitian:
JT:
