Introduction

According to Guidance, N. I. C. E. (2014), Obesity is a great threat to the Western world in terms of the morbidity and mortality it brings to this population. Obesity is a multidimensional problem and it can be managed using prevention, correction, population-based and individual approaches. This paper uses the individual approach because it argues the case of a female Hispanic patient Mrs. G who is obese. To measure out this obesity, the measurement is the body mass index (BMI). The BMI has codes know as BMI codes that define obesity level which correlates to the primary, secondary and differential diagnosis of a patient. With these MBI codes and the treatments that follow, it is possible to come up with a management plan for mature and aging patient who is obese. This is clearly brought out in the SOAP note writing, which is a basically a review of the patient’s case study. Put in one statement, this paper will diagnose this case study and produce a management plan that applies the national diabetes guidelines and demonstrate mastery of SOAP note writing.

Assessment

Before the patient was assessed and producing the three diagnosis (primary, secondary and differential), the medical expert concerned had to take into consideration that negative feelings would be induced from explaining what obesity is (Flegal et al.’s 2013). Denial, anger and surprise were expected from the patient who was fundamental to getting involved in changes. On the medical practitioner’s part, s/he had to provide details on benefits of weight loss, proper dieting and exercise. Further, this health expert would dig into the patient history and open that discussion by asking what motivates the patient to what to lose weight. The practitioner explored the aged patient’s perspective of weight and why she gained weight and went a step further to exploring her eating behavior. This practitioner conducted the activity with a general knowledge on patterns of eating, exercise and weight.

Mrs. G had to be made aware of medication that may worsen weight gain such as oral hypoglycaemic agents, antidepressants and anticonvulsants. There were also situations she was to be informed to possibly affect weight, such as hypothyroidism, polycystic ovary syndrome or growth hormone deficiency. As a result of this preceding information, the health expert examined and found the patient’s height 5’2”, weight 185 pounds, blood pressure BP 128/80 (regular), pulse rate 76 (regular), and respiration rate 20 (regular). The assessment also revealed the patient to be allergic to NKDA, cats and latex (inferred in Flegal and colleagues 2013).

The crescendo of the assessment was the lab work of primary, secondary and differential diagnosis (Charo & Lacoursiere, 2014). The primary diagnosis was complete blood count (CBC). The CBC had an ICD 10 code for a new patient which is 99386. The analyzed CBC revealed white blood cells WBC (5,000/mm3), hemoglobin Hgb (12.8 gm/dl), red blood cell RBC (4.6 million), hematocrit Hct (41%), MCHC (34 g/dl) and RDW (13.8%). After this, there was the secondary diagnosis of the same patient who was now an established patient. Therefore her ICD 10 code for secondary diagnosis was 99396. The secondary diagnosis involved urinalysis (UA). The UA had two negative findings of Leukocyte esterase, ketones and nitrates. The patient’s urine was acidic (pH 5), a specific gravity of 1.015 and extra protein and glucose as well.

Third diagnosis which was differential had comprehensive metabolic panel (CMP). The CMP was a panel of 14 tests to give the current condition of the patient’s metabolism case, including wellness of the kidneys, acid-base balance and blood level of glucose and of proteins. The ICD code for this level was 99403. Thus, the assessment takes us into evidence-based practices (Charo & Lacoursiere, 2014).

Evidence-Based Practice (EBP)

The national guidelines body for evidence-based practice (EPB) is the National Institute for Health and Care Excellence (NICE). The NICE guidelines (2014) advocate for the body mass index (BMI) usage to examine overweight and obese persons. This body of evidence recommends waist circumference measurement to augment in such persons as with a BMI below 35 kg/m2. NICE also measure adiposity indirectly and thus requires care during interpretation. The 2014 NICE guidelines advocate for dietary intake with the assistance of expert and vigorous follow-up. The health professional in that year were advised to undertake particular training and function within multidisciplinary teams. The NICE guidelines of that same year recommend low-fat diets and strongly warned against nutritionally unbalance food intake, due to its long-term ineffectiveness. It provides diets with low calorie content but also reveals they are possibly nutritional inadequate.

According to the expert advice, these guidelines (2014) propose that adults are to half an hour of moderate-intense activity for five days in the minimum per week. To avoid obesity completely would mean this exercise is taken to 45-60 minutes, especially without adjustments already made on calorie intake. For persons who were once obese but have lost weight, they should do 60-90 minute workout everyday to prevent relapse. In behavioral interventions therapies, NICE guidelines (2014), advocate for a properly trained professional. NICE (2014) guidelines recommend several strategies. It advocates for self-awareness to a behavior, stimulus control, goal setting, slow eating rate, exploration and involvement of social support. It also recommends strategies of problem solving, assertiveness, modifying thoughts, reinforcing changes, and relapse prevention.
The bariatric surgery role by the 2014 guidelines is greatly emphasized. According to the Guidelines, it is an alternative only upon satisfying the whole criteria that follows. BMI is to be 35-40 kg/m2 with other substantial disease that is incremental upon weight loss. Each and every suitable non-surgical measure is attempted and there is adequate effect. The patient is intensively being managed through a specialist service. The individual is perceived qualified for surgery or anesthesia. The patient should seriously stick to a long-term follow-up, say for two years, during the specialist service

Plan: Diagnostics

CBC test was diagnosis for cells that constitute the one’s blood, including WBCs, RBCs and platelets. CBC test other purposes are to check for leukemia, explain other health symptoms such as tiredness, MCHC and MCH. These details help the nurse or doctor to have more information on the patient’s health. Urinalysis is a urine test in disease diagnosis. The purpose of urinalysis is to determine if it has abnormal materials that indicate a disease. Urinalysis helps the health expert to detect substances usually not found in urine such as blood, protein, glucose. CMP is 14-test panel that diagnosis the current condition of a patient’s metabolism. The purpose of CMP fourteen-fold test, besides determining current status, is to monitor known situations like hypertension and that of medications use to check for kidney-related challenges.

Plan: Medications

While orlistat, sibutramine, rimonabant and liraglutide are medications for obesity, the most developed medication of all is orlistat. For that purpose, it is precisely orlistat to prescribe its mode of dosage to the patient. Orlistat is an over-the-counter (OTC) drug prescribed to inhibit 30% of fat absorption in a patient’s dietary intake. The OTC dose is thrice a day at 60mg, plus pharmacist treatment to about six months. It is always the duty of a pharmacist to verify the patient’s BMI on all occasional that request is made (Apovian et al. 2015).

Plan: Education

Diagnosis on obese (I) has a possibility of no comorbidities which results in reconsidering diet and exercise. But this grade I obesity has another possibility feature of comorbidities that regards dieting, some activity and the drug treatment post-lifestyle changes evaluations. On obese (II), no comorbidities consider the exact same second possibility of obese (I). The other possible diagnosis of obese (II) is comorbidities which also consider surgery referral apart from diet, activity and drug treatment. Grade III obesity diagnosis needed dieting and activity through a unique weight management program. Obese (III) also begins drug treatment post-analysis of lifestyle changes and more than that, is a referral to surgery. Education informs that Apovian et al.’s (2015) anti-obesity medication is considered after the medical expert exhausts the preliminary options of diet; behavior intervention therapy and exercise are tried and analyzed. Such medication is able to maintain weight loss instead of continual weight loss. The only drug found in the Great Britain’s market for obesity management is orlistat. Because this patient was elderly, she needed vitamins as well as mineral supplements augmented. Patients with type diabetes are prone to lose weight more slowly and in that case suitable allowance is needed. There should be a regular relook into severe effects and lifestyle reinforcement. For those taken out of anti-obesity medication, they are assisted to have self-confidence as their probability to make changes is sometimes low.

The health practitioner targets both dietary changes and the onset of exercise (Apovian and colleagues, 2015). Weight loss minus exercise is difficult. For this reason early intervention prior to exercise is greatly constrained by morbid obesity among others that avoids physical exertion. The original target is to attain a day-to-day 600 kcal of energy needs via change in diet and exercise. But exercise has two warning signs for realistic expectations. One warning sign is that over-ambitious program is a failure in waiting. Another warning sign is that insufficient program will bestow no merit.

Plan: Referrals

An important referral for consideration is to a specialist obesity service named tier 3. The referral is important when there are hidden causes that require investigating. For cases of complex comorbidities that are unmanageable in primary and secondary care. In the instance of a failed conventional treatment in primary and secondary care, this referral is necessary. This referral is deemed value if the case comes to a specialist interventions, for instance, surgery.

Plan: Follow Up

The health expert was so interested in the patient’s health progress that he treated follow-up so seriously to this chronic disease of obesity. The patient would revisit after every two weeks and the interval grew to a month and more as time elapsed. Because this patient eventually was diagnosed for bariatric surgery (Stroh et al. 2015), there are stringent recommendations that needed continuous input for the next two years. The whole point was to once-and-for-all clear off the “yo-yo dieting” that makes the weight fluctuate upwards and downwards.

Medication Costs

Obesity is a leading preventable chronic ailments and it definitely affects monthly medication costs. At the present, these costs vary from $12.25 billion to about $17.5 billion per month. Moreover, obesity is related to job absenteeism that costs about 358 million monthly. Obesity also lowers work productivity that costs employers about $42/ obese worker in a month. When these figures are added together, the total cost on obesity alone is approximately $15,223 million per month.

SOAP note
Patient Information:

Mrs. G, 52, female, Hispanic, Insured
CC Mrs. G comes for a sick and reports that of late, she is highly fatigued and barely has energy. Her post-menopause state has contributed weight gains too and she is trying to cut it down through a two-day weekly gym visit. But the gym visit has so far added little to her weight loss and she complains more of hunger and thirst after these exercises. So, she visited to explain her tiredness and the need for weight loss advice. In addition, she mentions that it is like she has bladder problem as well because she wakes up more often to urinate, which she finds so irritating.
HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example:
Onset: Lately
Characteristics: Associated with feeling fatigued, tiredness, more hunger and thirst, and urination irregularities
Duration: steady weight gain, since last year
Aggravating Factors: Gym adds hunger and thirst, her menopause stage
Relieving Factors: Easily falls back to sleep
Treatment: None reported
Current Medications: Tylenol daily for knee pain. Daily multivitamin.
Allergies: NKDA, allergic to cats and latex
PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to date.
SocHx: works from home full time as a telemarketer. Married, lives with husband. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use.
FamH: parents alive, well, child alive, well. No siblings.
GYN hx: G1 P0. 1 child, full term, weight 9lbs 2 oz. LMP 15months ago. No history of abnormal PAP
ROS:
HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
Physical exam:
Vital signs: BP 128/80; pulse 76, regular; respiration 20,regular
Height 5’2”, weight 185 pounds

General: obese female in no acute distress. Alert, oriented and cooperative.
CV: S1 and S2 RRR without murmurs or rubs
Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.

EKG: normal sinus rhythm

Diagnostic results: Labwork

CBC	WBC	5,000/mm3
	Hgb	12.8 gm/dl
	Hct	41%
	RBC	4.6 million
	MCV	92 fl
	MCHC	34 g/dl
	RDW	13.8%
UA:	pH	5
	Specific gravity	1.015
	Leukocyte esterase	Negative
	Nitrates	Negative
	1+ glucose 1+ protein
	Ketones	Negative

CMP
	Sodium	142
	Potassium	4.4
	Chloride	101
	CO2	29
	Glucose	90 – fasting
	BUN	12
	Creatinine	0.7
	GFR	est non-AA                     88 mL/min/1.73
	GFR	est AA                     101 mL/min/1.73
	Calcium	9.4
	Total protein	7.6

	Bilirubin Total	0.7
	Alkaline phosphatase	72
	AST	25
	ALT	29
	Anion gap	8.11
	BUN/Creat	17.7
	Hemoglobin A1C	7.6%
	TSH	2.25
	Free T4	0.65
	Cholesterol: TC	228 mg/dl
	LDL	143 mg/dl
	VLDL	36 mg/dl
	HDL	37 mg/dl
	Triglycerides	232

A.
Differential Diagnoses

Primary Diagnosis CBC (ICD 10 code 99386)

Secondary Diagnosis UA (ICD 10 code 99396)

Differential Diagnosis CMP (ICD 10 code 99403)

1. Behavioral intervention therapy (NICE Guidelines)

Diagnostics: list tests you will order this visit

Rx: Orlistat (medication), 60mg 3x 1 day for two weeks, the available OTCdrug, others withdrawn ; Bariatric surgery (treatment) after 2 years, the best way to manage obesity after all other criteria fail.

Education: NICE Guidelines

Referral/Consults: Specialist service

Follow up: Revisit after two weeks for checkup, then after a month till the patient heals. 

References

1. Apovian, C. M., Aronne, L. J., Bessesen, D. H., McDonnell, M. E., Murad, M. H., Pagotto, U., ... and Still, C. D. (2015). Pharmacological management of obesity: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism, 100(2), 342-362.
2. Charo, L., and Lacoursiere, D. Y. (2014). Introduction: obesity and lifestyle issues in women. Clinical obstetrics and gynecology, 57(3), 433-445.
3. Flegal, K. M., Kit, B. K., Orpana, H., and Graubard, B. I. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. Jama, 309(1), 71-82.
4. Guidance, N. I. C. E. (2014). Obesity: identification, assessment and management of overweight and obesity in children, young people and adults. CG189. London.
5. Stroh, C., Benedix, F., Meyer, F., and Manger, T. (2015). Nutrient deficiencies after bariatric surgery-systematic literature review and suggestions for diagnostics and treatment. Zentralblatt fur Chirurgie, 140(4), 407-416.