Introduction: Ms. B.L. presents to her primary healthcare provider for a routine physical examination. She has been seen by the nurse practitioner in this clinic before; however, she has not been in for a complete physical examination in the past 2 years. You have not seen this patient before but have had the opportunity to review her medical records. You note that on her last visit, her blood pressure was 142/90 and her weight was 198 lbs. Her medications have not changed since that visit.
Chief Complaint
"I need to lose some weight and I can't do it by myself. I'm always tired and out of breath and my back and knees are killing me. I'd like to have stomach staples, is possible."
History of Present Illness
B.L. is a 57-year-old Hispanic female of Puerto Rican heritage who states that she maintained her ideal weight, which she believes is about 115 lbs. until she was divorced 15 years ago. "I was in the military years ago and was very trim at that time." She has been continually gaining weight, mostly through "comfort eating" after her divorce. She also admits to nibbling on snacks while at work, mostly high calories foods like brownies and other sweets. She states that when she diets, she is able to lose weight over the first couple of months and then gains it all back, plus a bit more. She is tearful as she discusses her weight struggles. "I realize that my weight is affecting my health and I want to lose some weight and keep it off for good."
Past Medical History
Hypertension
Osteoarthritis of (B) knees & lower back
Gall stones, treated with lithotripsy
Depression
Hypothyroidism
Past Surgical History
Total abdominal hysterectomy (20 yrs)
(B) carpal tunnel release (3 yrs)
Family History
· Father died at age 65 from complications after a traumatic fall; had "heart trouble" and hypertension.
· Mother died at age 80 from pneumonia following a hip fracture.
· One brother who died at age 67 from bladder cancer.
· One son and one daughter; both alive, well, and without any health problems.
· States both her mother and grandmother were heavy but not obese.
· No other family members have a significant medical history.
Social History
· Divorced woman who lives with her 20-year-old daughter.
· Has never smoked; denies illicit drug use.
· Drinks red wine 3x.wk
· Has worked for the past 11 years as a data entry clerk; states that her physical activities are limited by her weight.
o States she feels insecure at work because she is the only one in her department without a college degree; "I always have to prove myself."
· Previously enjoyed walking for exercise; now feels she is limited by knee and back pain, limited mobility, and breathlessness.
· Except for her daughter, she reports few social interactions and states she rarely has friends or family members to her house.
· Reports she watches a lot of television and feeds the birds and squirrels for enjoyment. Also enjoys reading and crossword puzzles.
Current Medications
Levothryroxin 150 mcg po q.day
Aceatminophen 500 mg po PRN
Hydrochlorothiazide 12.5 mg po q. day
Benazepril 10 mg po q. day
Doxazosin 4 mg po q. bedtime
Imipramine 100 mg po q. day
Physical Examination
BP=158/94
P=92 and regular
RR=30
SaO2=96%
T= 97.5OF/36.4O C
Height 61 inches
Weight 290 pounds
Waist=48"
Hips=39"
General
Alert, well groomed; in no acute distress
HEENT
Head: Normocephalic, atraumatic; scalp clear
Eyes: conjunctiva clear, PERRLA
Ears: TMs pearly, positive light reflexes; canals clear
Nose: turbinates normal, no erythema or drng
Throat: clear, tonsils 2+, uvula midline. No JVD.
Neck
Supple, full range of motion; no lymphadenopathy
Chest
Symmetric, tachypnea.
Lungs
Clear to auscultation
Cardiac
Normal S1/S2, no murmurs heard
Abdomen
Obese; non-distended, non-tender. Positive BS x 4
MSK
Varicosities (B)LE; distal CMS intact
(B) knees ROM limited by pain, bony crepitus
Back
ROM limited by pain; pain with palpation L3-L5
Neuro
A & O x 3;cranial nerves II-XII intact. Sensory and motor nerves intact, DTRs 2+/4, strength of all major motor groups 5/5
Skin
Keyboard Shortcuts
Warm and dry; clear.
1) What other questions would you have for BL at this point? (10 points)
2) Calculate B.L.'s BMI. What is the significance of this number? How would you use this finding in educating B.L.? (5 points)
3) In order to provide a thorough health assessment of BL, what diagnostic tests (if any) would you order for at this time? What diagnostic tests would you order in the future? (10 points)
B.L. Laboratory Test Results
Na=140
AST=14
K=3.4
ALT=29
Cl=107
Bilirubin, total=0.9
HCO3=29
Cholesterol=314
BUN=15
LDL=195
TSH=6.8
Cr=0.8
HDL=14
T4=1.8
Glucose=126 (fasting)
Triglycerides=219
Other Diagnostics
UA
WNL
4) In reviewing the findings from her physical examination and diagnostic workup, which results are abnormal and concerning to the NP?
5) Of the problems identified above, which is the most concerning for this patient?
6) Thoroughly explain the pathophysiology for each of the problems identified for this patient. What key information would you want to be sure to share with this patient?
7) What are the 5 primary goals/outcomes to include in a comprehensive plan of care for this patient?
8) Outline a comprehensive care plan for this patient. Include information related to diet, exercise, medications, additional diagnostic evaluations, and follow-up appointments.
9) In working with this patient, what health consequences would you want to discuss with her if she chooses to not to engage in the plan you outlined for her?