Student Name: Taylor Reid Patient Name: Manny Lopez

Nutrition Assessment:

Client History:
-46 y/o obese Hispanic Male with type II diabetes
-Admin dx R/O MI
-Married and has 2 children
-Family hx of heart disease
-Smokes 2 PPD
-Stressful occupation-Accountant

Food & Nutrition History:

-Low sodium (3gm)
-Diabetic 1800-calorie diet
-Medications: Micronase for DM
-Wife cooks, buys, and plans meals
-Typically wife cooks baked or fried foods
-Skips breakfast
-Snacks in-between meals on ice cream, potato chips, or pretzels
-Barriers: not ready to change, wife wants him to change and follow diet, pt. states he does
not follow diabetic low sodium diet
-Physical activity includes playing basketball, football, or softball on weekends with his
children

Anthropometrics:
-230#
-510
-IBW=166#
-IBW %= 138%
-Waist Circumference 44
-Recent weight gain of 55# in over 5 years

Biochemical/Tests/Procedures:
-As of 1/21/92-
-Glucose 250 (H)
-BUN 40 (H)
-Na 133
-K 4.3
-CL 101
-LDL/HDL 36/30

As of 1/22/92-
-Glucose 120
-BUN 42 (H)
-Na 138
-K 4.3
-CL 102
-LDL/HDL 37/36

Nutrition Focused Physical Findings:

-BP: 130/90
-Confused
-Lethargic
-Good appetite

Comparative Standards:
-Est. Needs=1800 kcal diabetic diet
-Total Protein= 94g/day
-Total Fat= 60g/day
-Total Sat Fat= 20g/day
Assessment Statement:

Mr. Lopez is a Hispanic 46 y/o male that was admitted to the hospital for R/O MI and was
requested to see the RD on physician referral concerned about weight and uncontrolled
diabetes. Pt. is married to wife and has 2 children who keep him busy on the weekends
when they play basketball, football, or softball. Mr. Lopez works a stressful job as an
accountant. He has a strong immediate family h/o heart disease. Mr. Lopez has glucose of
120, BUN 42, Na, 138, K 4.3, and an LDL/HDL of 37/36. The glucose may be controlled due
to hospital stay. Upon admit to hospital, glucose was 250. Pt. shows a good appetite but is
over consuming est. needs of 1,800kcal, 94 g/protein/day, 60g/fat/day, and 20g/sat.
fat/day, as evidenced by word of mouth and obese category (33 BMI). Mr. Lopez consumes
mostly baked or fried foods that are cooked by his wife. He typically skips breakfast and
snacks in between meals on ice cream, potato chips, or pretzels. Wife expresses she wants
her husband to follow the diabetic diet but pt. not complying.

The overconsumption of calories and incomplete physical activity has led to an increase of
55# over the past 5 years. Mr. Lopez weighs 230#; BMI 33; which is considered obese. Mr.
Lopez is 138% of his IBW. Pts blood pressure is adequate as of now, 130/90.

Mr. Lopez appears to be in the pre-contemplation stage. Mr. Lopez is aware he needs to
lose weight and has several barriers; stressful work environment, food environment, and
family traditions.

Pt. would benefit from diabetes education, how to cook healthier Hispanic dishes, and how
to incorporate physical activity into his schedule more to decrease his uncontrolled
diabetes.