Intern: Samantha Jamieson

CASE STUDY:
Dietitian: Jerolyn Goodman
MS. M
 ASSESSMENT

70 year old female

Self-Reported Ht: 5 ft 2 in (62 in, 157.5 cm)
Self-Reported Wt: 140 lbs (62.5 kg)
BMI: 25.6 (overweight)
Ideal Body Weight: 117 lbs (119%)
Primary Health Concern: Arthritis-Osteo
Other Health Concerns: Eye problems-Cataracts, Weakness, Fracture-
foot, hand, toe, Confused/Forgetful, GERD, Hypertension, Mental Health
Depression
 ASSESSMENT

Social History: No caregiver, daughter comes once a month to take her to grocery
store
Mobility: Uses a walker and a motorized scooter
Food Security: Daughter takes her to grocery store once a month, has a Braums
grocery store down the street
Estimated kcal need: 1330 kcal (Mifflin-St. Jeor)
Estimated protein need: 68.8 (kg x 1.1)
Estimated fluid need: 1330 mL (1 mL/kcal)
 ASSESSMENT

Fluids: Tea, Coffee, Water, Milk (MOW), Coke

Health Self-Rating: Fair
Client was unhappy with her state of living and current weight
Dentition: Fair; has upper full dentures and partial lower plate
GI: Reflux
Physical activity: walks with rollator, has power chair, throws ball for dog multiple
times a day
No use of smoke/tobacco but did report an occasional alcoholic beverage
 ASSESSMENT:
MEDIC AL HISTORY

Fracture of right wrist

Fracture of left foot

Emergency colon surgery: of colon

removed

Right and left cataract removal

Acid reflux

History of ADHD and depression

 ASSESSMENT: MEDICATION
Trintellix (antidepressant)
20 mg daily
Adderall (ADHD medication)
30 mg daily
Hydrocodone (Pain medication)
10 mg daily
Acetaminophen (Pain medication)
325 mg daily
Alprazolam (Anxiety medication)
2 mg daily
Tagamet/cimetidine (Antacid)
Fentanyl patch (Pain medication)
50 mcg 3x day
 A S S E S S M E N T: D I E TA RY
RECALL
Breakfast:

Mini cupcakes

Slice of cake

4 oz of tea or 6 oz of coffee

Lunch:

Black Forest ham lunch meat

Chicken or cheese sandwich

MOW tray

Dinner:

Grooves crackers and Chips

Ramen soup

PB and honey

Sausage
 P E S S TAT E M E N T # 1

Excessive energy intake related to

food-and nutrition-related
knowledge deficit concerning
energy intake as evidenced by BMI
>25
 P E S S TAT E M E N T
#2

Inadequate mineral
intake (Calcium) related
to food-and nutrition-
related knowledge deficit
concerning food and
supplemental sources of
calcium as evidenced by
multiple fractures and
hypertension.
 I N T E RV E N T I O N

Nutrition Education:
Foods for bone health
Low sodium for Hypertension
Benefit of physical activity
Importance of appropriate fluid intake
Recommendations:
Eat or drink 3 servings of calcium daily
Try cereal bars or protein bars in place
of cake for breakfast
Limit intake of salt
 MONITORING/EVALUATION: FOLLOW UP PHONE CALL

Client has not made progress

Continued to talk to me about how she wanted to get back to her size when she was younger

Has added more calcium to her diet

Cereal and milk for breakfast