Taylor Palm and Jesse Tannehill Case Study

Weight in kg= 118.18 kg

Height in cm= 180.34 cm
BMI=36.36
IBW=189.2
Energy Requirements= 3,115.28 kcal/day
Total Intake
Kcal= 3,875 kcal
Protein= 125 g
Carbohydrates= 479 g
Total Fat= 172.2 g (40% cal)
SOAP Assessment
S- Patient referred to dietitian by doctor. Has family history of fatal heart attacks in
their late 50s. Patient is prediabetic and has elevated cholesterol levels (lab work
left at home.) Patient is very sedentary as he sits at his desk most of the day, works
late hours and does not exercise. Patient takes no medications or supplements.
Dietary recall reveals his kcal for the day are roughly 3,875 kcal with protein at
125g, carbohydrates at 479 g and fat is at 172.2 g. If this dietary recall for the day
is representative of every day he is far exceeding his energy requirements.
O- 28 year old male, large frame, 511, 118.18 kg (260 lbs). BMI= 36.36, IBW=
189.2 lbs. Energy requirements currently are 3,115.28 kcal/day.
A- Patient is 70.8 lbs over IBW and is classified as Class II obese according to his
BMI (36.36.) His dietary recall and lack of physical activity suggest he is consuming
760.72 kcal above his energy requirement per day. According to his dietary recall,
he is consuming 60 g of saturated fats (38 g above daily limit) and 7,461 mg of
sodium (5,161 mg above daily limit). He is meeting his requirements for dairy,
vegetables and grains; however his protein (59% of target) is low and fruit is
practically nonexistent (2% of target). Patient may be at risk for heart attack given
his elevated cholesterol, family history and high fat diet.
P- Due to obesity and risk of heart attack, patient is advised to reduce daily
saturated fat intake to below 22 g and overall fat by 10%. *In order to reach a
healthy weight, we recommend the patient should reduce daily calorie intake by
1,511.4 calories per day for a total daily consumption of 2,363.6 calories/day, which
is 751.68 kcal below his energy requirements. This will result in weight loss of
roughly 1 lbs per week. This will put him at his ideal body weight in approximately
47 weeks. We also recommend an increase in physical activity to 150 minutes per
week. We also advise an increase in fruit consumption.

*According to formula on slides for calorie needs for weight loss in obese patients

ADIME Assessment with PES

A- Weight 118.18 kg (260 lbs). 24 hour dietary recall revealed consumption of 3,875
kcal. Macros are relatively high: Protein 125 g, Carbohydrates 479 g, Total Fat 172.2
g
D- Excessive food consumption that may lead to comorbidities of diabetes and
heart disease is the main issue.
(P- Obese, High cholesterol, Family history of heart attack, Pre-diabetic
E- Related to overeating and lack of physical activity
S- Cholesterol levels elevated and pre-diabetic)
I- Nutrition counseling for patient is recommended. Goals prescribed involve
reducing cholesterol levels as well as overall calorie intake to 2,363.6 kcal/day to
begin weight loss for obesity and increasing physical activity to 150 minutes a
week.
M/E- Will monitor calorie reduction and weight loss in one month. Request updated
lab work on progress of reducing cholesterol levels for next appointment. Request
three-day dietary recall of the week before appointment.