Question

Ms. Smokey 62 y/o white female

HPI—Here for a screening annual physical

Current Health Data:

Takes HRT, but she does not know the name of them

No known allergies

Screening tests/Last PE—in 2015 and was told that “all was normal”

Immunizations—had a Td at age 50 after an injury; takes flu shot every year

LMP was at age 54

PMH—childhood illnesses—none; only hospital stay was when she had her son, who is age 32

PMH—Osteopenia

Sexual Hx—sexually active since age 24—3 lifetime partners; widowed since last year; in a new relationship for last 2 months

Psych—sad sometimes, but no prior diagnosis of Depression

FH—Father is 82 y/o has HTN, Hyperlipidemia, COPD; Mother died at age 73—with HTN and a CVA

Personal/Social HX—she works as a junior high school teacher; she is a social smoker—2-3 cigarettes every week or so; drinks 1 glass of white wine every evening with dinner

ROS—unremarkable except for some vaginal dryness

PE: 98-70-14 130/90   BMI 36

Profile:

Age/Gender/Race risks-

Personal/Family risks-

Prevention Needs:

Screening Needs:

Counseling Needs:

Chemoprophylaxis/Immunizations:

Prevention Deficits:

Screening Deficit-

Counseling Deficit-

Chemoprophylaxis/Immunizations Deficit-

Obesity Management Plan

7.0.3

Answer 1

PROFILE

Age/race/gender risks:

The person is a risk for developing osteoporosis with an increase in age because she already has a history of osteopenia which is a hallmark for osteoporosis.

According to race white people are at high risk to get heart diseases.

Personal/ family risk:

Base on the personal risks for developing COPD or respiratory problem due to smoking, HTN, hyperlipidemia, and CVA because of obesity, smoking and family history of HTN and CVA

PREVENTION NEEDS

Screening Needs: There is a need for the lung's function and heart function for any presence of HTN, thrombus, emboli, hyperlipidemia by a laboratory blood test. There is a need to screen for mental health

Counseling needs: there is a need to counsel regarding diet modification and lifestyle modification.

Immunization: Immunization is not necessary for now.

PREVENTION DEFICIT

Screening deficit: not deficit because she is doing an annual check-up

Counseling deficit: There is a deficit in the counseling that is why she is obese, smoking, consuming alcohol. There is a need to concern about it.

Immunization deficit: not the deficit.

OBESITY MANAGEMENT PLAN

Ask

- asked for permission to talk about the bodyweight

- Explore the readiness of the person to reduce the weight

Assess

- Assess the height and weight

- Calculate BMI. BMI is 36 which is overweight for the person.

- Explained the impact of obesity on health for increase risk of heart diseases like cardiac stroke.

Advise

Diet modification: Advice the importance of diet modification. Advice to take a low-fat diet, more fruit, and vegetables

Exercises: Advice to performed at least 30-minute exercise in the morning and afternoon to burn the fats.

Lifestyle modification: Advice to stop smoking and drinking alcohol every day.

Agree

Agreement with the person to reduce BMI to normal by 6 months

Arrange or assist

Weight checking: Assist the person in weight checking every day

- Planned the diet which is low in fat and gives to the person for every meal with the help of a nutritionist.

- Assist the person in doing exercise every day. teach the various kind of exercises to perform with the help of a physical therapist or instructor.

-Provide a counselor for counseling to maintain mental health.

- encourage to stop smoking and alcohol by reducing the dose day by day.

- Arrange for follow up or evaluation should be done to understand any changes in the weight.

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