I.

PATIENTS PROFILE
Name: Patient G
Age: 64 years old
Gender: Male
Status: Married
Height: 170 cm
Weight: 190 lbs.
Attending Physician: Dr. San Vicente
Medical Diagnosis: ACS-unstable angina HCVD
Diet Rx: Low fat low salt
Past medical history: HPN

II. NUTRITION ASSESSMENT

A. ANTHROPOMETRIC
Measure/index Result Normal value/Reference value Remarks

Weight 86kg(190lbs)
Height 170 cm
BMI 29.8 18.5 – 24.99 Overweight

DBW 63.6kg(140lbs) 57.5 – 70.3

TER 1900

B. BIOCHEMICAL
Measure/index Result Normal value/Reference value Remarks

Triglycerides 2.11 <1.69-2.25 mmol/L High

Creatinine 117 62-106 umol/L High
Lymphocyte 47 High

PSA 13.74 0 – 4 ng/ml High

Urinalysis

RBC 2.0 0 High

Mucus tread 18 High

 C. CLINICAL
Area Findings
Skin Normal
Musculoskeletal Without difficulty
Abdomen Flabby
Gastrointestinal No complains
Cardiac and Chest pain
respiratory
Eyes Normal
Ear Normal

D. DIETARY
The patient usually eat fish, chicken, pork, beef and veggies once a day. During
breakfast the patient eats rice, foods that was left last night. During lunch the
patient eat fried meats, sinigang and juice. During dinner the patient usually eat
same food during lunch. He drinks coffee 2x/day.

Assessment:
Height: 5’ 7” (170 cm)
Weight: 86 kg (190 lbs.)
BMI: 29.8 Overweight
DBW: 63.6 kg (140lbs)
TER: 1900

BMI: 86/ 2.89 = 29.75 = 29.8

DBW= 170 - 100= 70- 7.0 = 63 kg

DBW : NDAP : 112 + (7x4) = 140 lbs / 2.2 = 63.6 kg

TER: 63.6 x 30 = 1,908 = 1,900

CHO: 1,900 x .60 = 1140 / 4= 285 g

PRO: 1,900 x .15 = 285 / 4 = 71.25 = 70 g
FATS: 1,900 x .25 = 475 / 9 = 52.78 = 50 g
Assessment Diagnosis Intervention Rationale Monitoring and
Evaluation
 High protein  Low Protein Creatinine  Check his
intake related Intake level is High food intake
to eating meat using 24-
above hour recall
recommended
allowance.
 High calorie  Normal To reduce 
intake related Calorie weight of 1 lbs
to eating in intake with per week
fast food regular
chain exercise
regularly as
evidence by
BMI of 29.8
kg.
 Excessive fat  Low fat To lower his
intake related intake triglycerides
to eating fried
foods as
evidence by
elevated
triglycerides
of 2.11
mmol/L.
 Excessive  Low Fat/Salt To lower his
sodium and blood pressure
fat intake
related to
eating Na and
fat above
recommended
allowance as
evidence by
blood
pressure of
140/90 mHg
 Food and  Awreness on To be able to
nutrition food intake practice proper
related diet and good
knowledge eating which
deficit related promotes good
unawareness nutrition
of his diet as
evidence by
high blood
 pressure and
chest pain/
angina.

Assessment:
Height: 170 cm
Weight: 86 kg (190 lbs.)
BMI: 29.9 Overweight
NDAP :
112 + (4x7) =

DBW: 63.9 kg (140lbs)

TER: 1900

Intervention:
 Low Protein Intake

Encourage the patient to exercise an appropriate that will help him loose his weight
Encourage eat an appropriate diet and prescribe to help him

Monitoring :

 Check his food intake using 24-hour recall

 Monitor the weight through having him weigh in a weighing scale

 Monitor the Dietary intake using a 24-hour food recall .
 Monitor the Creatinine and RBC counts through biochemical examination
 Monitor the activity by giving exercises that is accurate to the
 Monitor the Physical ….. by undergoing Physical examination.
 Monitor if there are changes in th calorie intake of the patient by checking if there are
improvement on the weight of the patient or if the patient lose weight leading to his
DBW.
 Monitor if the prescribed diet were taken by the patient by verifying it on his food Diary.
