Dietetics Case Study: Acute MI

Questions
1. In your own words, define Myocardial Infarction.
- MI is when a blood vessel or an artery is clogged which blocks blood flow to the heart,
causing the heart to struggle to do its job (contract and pump blood). Lack of blood flow
to the heart diminished the blood (and oxygen) that can be delivered to the rest of the
body and therefore can prove fatal if untreated.

2. What signs and symptoms of a MI was Mrs. Bromberg experiencing?

- The patient complains of chest pain that is in the center of her chest and radiating to her
left shoulder, nausea, shortness of breath and sweating. She reports the symptoms
starting about 3 hours ago.

3. Mrs. Bromberg was admitted through the emergency with a suspected acute MI and
given IV morphine for pain. She was then taken to the Cath lab and an Angioplasty showed she
had a totally occluded LAD artery. A stent was placed in the left anterior descending artery and
the patient was sent to the cardiac floor. Explain what a Cath Lab is and what a stent is.
- A cath lab is an exam room in a hospital with diagnostic imaging equipment used to
visualize the arteries of the heart and the chambers of the heart and treat any stenosis or
abnormality found.
- A stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to
keep the passageway open.

4. What risk factors (modifiable and not modifiable) did Mrs. Bromberg have for a MI?
- Modifiable: Hypertension and hyperlipidemia as well as a BMI of 29.7 which makes her
overweight
- Non-modifiable: Her diet - she consumed grapefruit while on medications that interacted
with it; if she does this regularly, it could be a problem because it counteracts her
medication. She also consumed a large amount of cholesterol in her 24 hour recall.

5. Calculate and assess her BMI

- 173 / 2.2 = 78.6/64 x .0254 = 78.6/1.625 = 78.6/2.64 = 29.7
- She is considered overweight (.2 away from obesity)

6. What is her IBW and % of IBW?

- She is 5’4 (4 x 5 = 20 + 100) = 120 pounds
- 120 IBW / 173 CBW = 144%

7. Using the Mifflin-St Jeor equation, determine her REE. Determine what, if any, activity
factor you would use and determine her total kcals for the day. Compare the Mifflin-St Jeor
calculation to 25 kcals per kg. Which one will you use? Also determine what her protein and
fluid needs are for the day.
 - Calories: Mifflin St. Jeor: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) -
161
- (10 x 78.6) + (6.25 x 162.6) - (5 x 55) - 161 = 786 + 1,016 - 275 - 161 = 1,366kcals
- 1,366 x 1.375AF = ​1,878 calories
- Minus 250 calories for weight loss
- ~1,628 calories
- Protein: 78.6 x .8 = ​63 grams​ of protein
- Fluids: 1mL per kcal = ​1.8L

8. Look at her laboratory values in the medical record. Which labs indicated that she did in
fact have a MI?
- Her CK-MD, LDL, total cholesterol, myoglobin, and Troponin I.cardiac were all high

9. What questions do you need to ask Mrs. Bromberg during your nutrition consult?
- Do you regularly consume grapefruit products? Do you monitor your cholesterol intakes
daily? Do you take your medication exactly as directed? Have you tried losing weight in
the past? How many servings of fruits and vegetables do you consume in a day?

10. Using Standardized language, list at least three possible Nutrition Problems (one from
each of the diagnosis domains).
- Intake: Intake of types of fats in consistent with needs
- Clinical: Predicted food medication interaction (grapefruit and statin)
- Behavioral: nutrition related knowledge deficit

11. Review the information and select the best problem from the ones you listed above and
complete a PES statement.
- Nutrition related knowledge deficit related to a healthful diet (for her current health
conditions) as evidenced by a 24 hour recall consisting of high cholesterol and foods that
interact with her medications.

12. What Nutrition Prescription would you recommend for Mrs. Bromberg?
- Regular 1,600 calorie diet low in saturated fats, cholesterol, and sodium, high in fiber
and with 1.8L of fluids.

13. How could you explain this so Mrs. Bromberg understands?

- Diet plays an essential role in preventing heart disease. The saturated fat and
cholesterol that is found in animal products such as meats, cheeses, and butters can
add to the cholesterol and fat levels in your blood. Consuming too much of these,
creates a sticky buildup that leads to a blockage in the arteries that restricts blood flow to
your heart, causing a heart attack overtime. The medications you are on help prevent
these problems, but consuming foods like grapefruit will counteract all of their abilities
entirely, as if you had never taken them at all.
- It is important to consume a diet that is high in soluble fiber. This type of fiber helps the
body reprocess cholesterol so that less of it is used to clog arteries. Foods like breads,
 oatmeal, and fruits contain soluble fiber. It is also helpful to consume less animal
products that will contribute to cholesterol and fat buildup in the blood. Lastly, it is highly
recommended that you cease consuming grapefruit products to avoid it;s interaction with
your medications so that they can do their job.

14. Based on your PES, establish an ideal goal (based on the signs and symptoms) and an
appropriate intervention (based on the etiology).
- Goal: Consume meat during only one meal per day and cease grapefruit product
consumption. Increase soluble fiber consumption as well.
- Intervention: Adjust to a healthful diet in conjunction with her conditions of heart disease,
hypertension, and hyperlipidemia.

15. Outline what other healthcare professionals are important to work with to provide the
best care for Mrs. Bromberg.
- Pharmacist - to prescribe the proper medications for her conditions and discuss drug
nutrient interactions
- Doctor - to monitor her progress and healing from stent placement
- Nurse - to monitor her healing progress, administer medications and take vitals during
her hospital stay
- Cardiologist- to monitor heart stability and recovery

Writing an ADIME note for Acute MI

ADIME: Sarah Bromberg

Client history: History of Present Illness: Middle-aged female of Polish descent who was brought
to the ER by her husband after having sudden chest pain what she describes as severe, "as if
someone was squeezing my chest." She reported that the pain was radiating to her left shoulder
and left side of her neck, and that she was having trouble breathing. She reports palpitations
and nausea as well. The patient was placed in a telemetry monitored ER room and the ER staff
followed ACS Protocol. After medications and oxygen her symptoms were not relieved, although
she reported that the chest pain had lessened. I was called in for an emergent consult.

Past Medical History: No history of similar episodes. He has hypertension and hyperlipidemia,
both treated with medications. She has osteoarthritis in both hands.

Past Surgical/Hospital History: Tonsillectomy/Adenoidectomy as a teen, appendectomy 10

years ago.

Social History: Married with two adult children and four grandchildren. Patient is a history
professor at a local university. She walks 3-4 times a week and does photography as a hobby.
Home Medications: Metoprolol 100 mg at bedtime, Atorvastatin 40 mg daily, Daily multivitamin,
Calcium/Vitamin D, vitamin, Ibuprofen as needed, Benadryl as needed

Biochemical: Labs and Diagnostics: Chest x-ray displaying silhouette. ECG: Abnormal, acute MI
suspected. Labs: Glucose 122, Creatinine 1.1, Lipid elevated, Myoglobin 75, Troponin I 75,
CK-MB 4.4, CPK 100.

Anthropometrics: 173lbs, 64”, BMI is 29.7

NFPE: Physical examination:

Vital signs upon arrival to ER: 98.1 F, 78, 24, 154/88, 93% on 2 L of oxygen, 173 lbs, 64 ins,
pain 7/10.
HEENT: Atraumatic, normocephalic.
Neck: Veins flat. No significant carotid bruits.
Lungs: Clear bilaterally, tachypneic, shallow.
Heart: RRR, no murmur, S1 and S2 regular.
Abdomen: Soft, nontender. Bowel sounds present.
Extremities: No edema. Pulses are palpable. No clubbing or cyanosis.
CNS: Normal.

Food & Nutrition history: She drinks 1-2 glasses of wine per week, denies smoking or illegal
drug use. She is Jewish and follows all traditions. She states that she eats kosher. Seems to
consume a lot of meat and other animal products.

Comparative standards:
- Pharmacist - to prescribe the proper medications for her conditions and discuss drug
nutrient interactions
- Doctor - to monitor her progress and healing from stent placement
- Nurse - to monitor her healing progress, administer medications and take vitals during
her hospital stay
- Cardiologist- to monitor heart stability and recovery

Calorie needs: Calories: Mifflin St. Jeor: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in
years) - 161
- (10 x 78.6) + (6.25 x 162.6) - (5 x 55) - 161 = 786 + 1,016 - 275 - 161 = 1,366kcals
- 1,366 x 1.375AF = ​1,878 calories
- Minus 250 calories for weight loss
- ~1,628 calories

Protein needs: 78.6 x .8 = ​63 grams​ of protein

Fluid needs: 1mL per kcal = ​1.8L

P: Nutrition related knowledge deficit

E: related to a healthful diet (for her current health conditions)

S: as evidenced by a 24 hour recall consisting of high cholesterol and foods that interact with
her medications.

Nutrition prescription: *NPO until after surgery - then clear and full liquids as tolerated.

Regular 1,600 calorie diet low in saturated fats, cholesterol, and sodium, high in fiber and with
1.8L of fluids.

Intervention: Adjust to a healthful diet in conjunction with her conditions of heart disease,
hypertension, and hyperlipidemia.

Goal: Consume meat during only one meal per day and cease grapefruit product consumption.
Increase soluble fiber consumption as well.

Indicator: Consume less than 10% of calories from saturated fat and consume less than 200mg
of cholesterol per day. Increase fiber consumption to at least 30 grams per day. Monitor through
a food diary and follow up with RDN in two weeks.

Criteria: Monitor to see patient’s lab values (lipids, myoglobin, troponin, CK-MB and CPK) go
down to relatively normal ranges.

ADIME: Richard

Client history: History of Present Illness:

Patient is a 61 y/o male with a history of hypercholesterolemia, borderline hypertension and

obesity presented to ER with approximately one hour of palpitations and chest pain. He
described the pain as pressure or a burning sensation across the precordium spreading to his
neck. He also reports dyspnea and a feeling of air hunger that does not fully resolve with rest.
He states that he had ran about a block to catch a bus after being late for his normal bus. When
he sat down the palpitations and dyspnea started and they did not resolve by the time he got to
work 25 minutes later. When he arrived at work he was late for a meeting. As he entered the
meeting, he saw a table of all of the department heads and became nauseated and felt as if he
was going to pass out.

Past Medical History: Hypercholesterolemia, borderline hypertension, sleep apnea with C-PAP
at night. Motor vehicle accident 23 years ago where he sustained a fractured clavicle, left side
atelectasis and fractured sternum. He has no further complications from his injuries.
Past Surgical History: Abdominal hernia repair, Tonsillectomy/Adenoidectomy as a child.

Social History: Patient has a long history of obesity. He lives a sedentary lifestyle with inactivity.
He is not a smoker and occasionally uses alcohol in social situations. He is recently divorced
and has 3 children ages 12, 15, and 17 years old that do not live with him. He states that they
live in the same town but he only sees them 2 or 3 times per month. He works as a newspaper
editor at a local publishing company. He states his job is high stress. He has heard rumors
about the company being in a poor financial situation and there is a possibility of lay offs in the
future.

Family History: Patient's father died from cardiovascular disease at the age of 60. His mother
has had breast cancer with treatment and has been in remission for 6 years.

Biochemical: 12 lead EKG: Initial readings are within normal limits with no ST elevation noted.

Chest X-Ray PA/LAT: Appears normal, other than a slightly enlarged cardiac silhouette.

Laboratory Data:

Hemoglobin 15.0

Hematocrit 45.0

Red Blood Cells 5.0

Platelets 168,000

White Blood Cells 5,300

BUN 18

Creatinine 1.0

CO2 25

Glucose 118

Chloride 102

Potassium 4.6

Sodium 138

Troponin-1 0.030

CK-MB 3.0
Anthropometrics: Height: 73 inches, Weight: 275 pounds, BMI: 36.3 (obesity class 2)

NFPE: General: Obese male in acute distress.

Vital Signs: Blood pressure: 132/82, Heart Rate: 88, Temperature: 98.6 orally, Respirations: 20,
Height: 73 inches, Weight: 275 pounds; Pain: 1/10.

HEENT: Sclera non icteric, no vision problems. Hearing is normal with no hearing loss.
Tympanic membranes are visible bilaterally. Throat unremarkable.

Neck: Supple with no jugular vein distension. No lymphadenopathy.

Integumentary: Pale in color, moist, otherwise unremarkable.

Cardiovascular: Tachycardic. No murmurs, rubs, or gallops present. Regular rhythm.

Respiratory: No adventitious sounds. Clear bilaterally. Shallow breaths, tachypniec.

Gastrointestinal: No organomegaly. Bowel sounds present x4 quadrants. Non-tender and

non-distended abdomen.

Genitourinary: Unremarkable.

Extremities: Trace bilateral ankle edema.

Neurovascular: Cranial nerves II-XII intact. Alert and oriented x4.

Food & Nutrition history: Consumes mostly convenience foods (fast foods) that are high in
cholesterol, saturated fat, and sodium. Little to no fruit / vegetable consumption.

Comparative standards:
Doctor- to monitor patient’s health status and to take action if it worsens
Pharmacist - administer the correct medications and discuss what medications interact with it
Nurse - to monitor patient’s wellbeing and administer correct medications
Cardiologist - to perform cardiac assessments on the patient regularly

Calorie needs: Mifflin St. Jeor: (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5
- (10 x 94) + (6.25 x 185.4) - (5 x 61) + 5 =
- 940 + 1,158.8 - 305 + 5 = 1,789.8 kcals or 1,800 calories
- 1.2AF x 1,800 = 2,160 - 300 = ​1,860 calories
- Adjusted IBW = 106 + 6 x 13 = 184
 - 275 - 184 x .25 + 184 = ​206.8 ​/ 2.2 = 94kg

Protein needs: .8g x 94kg = ​75 grams

Fluid needs: 1mL per kcal = ​1.8L

P: Excessive fat intake

E: related to nutrition related knowledge deficit on proper food choices

S: as evidenced by a 24 hour recall high in saturated fat, cholesterol, and sodium.

Nutrition prescription:
Regular 1,800 calorie diet consisting of 10% or less of calories from saturated fat, less than 200
mg cholesterol, and less than 2 grams of sodium with 1.8L fluids.

Intervention: Educate the patient on a proper diet related to heart disease and hypertension in
the form of low cholesterol, low sodium, and low saturated fat meal and snack suggestions.

*See if the client knows how to cook. This may be a problem if he is only consuming
convenience foods. If he cannot cook, suggest cooking classes or give heart healthy recipe
handouts for him to try.

Goal: Consume the recommended amount of calories, cholesterol, saturated fat and sodium.
Eat at home more if possible.

Indicator: Keep a food diary or log foods consumed into an app for measurement of specific
problem nutrients.

Criteria: Weight will be reduced as well as abnormal lab values. Follow up with a dietitian in 2
weeks.