WEEK NINE CASE STUDY
- Edwardo is a 21-year-old Mexican American male who is about to embark on a rigorous exercise program to lose weight. He works as IT support for an organization, a position that requires most of his shift to be seated in his chair with a headset, responding to IT requests online for the duration of his shift. He is a full-time graduate student in an IT program at the local university. He goes out with friends once weekly “for some fun and relief”, he drinks socially, one to two beers with his friends, does not smoke or use recreational drugs. He takes no medications, has not had a physical since he enrolled in his first college program and that consisted of completing a form. He played football in high school but has had no time for sports since enrolling in his first college program. He considers his studies the most essential aspect for his focus. His parents are healthy and invite him over once weekly for “one good meal” and he takes groceries offered by his mother home so that he has food in his apartment. His parents want to help him stay healthy since he has little time to grocery shop, and often gets a burger on the way home from classes. He sleeps well, feels “sluggish” sometimes, especially during his bus ride to and from work. This concerned him and so he has managed to find time to go to a gym for exercise. He hopes to feel better and lose at least 30 pounds by working out at the gym. He went to visit a personal trainer for the first session and is surprised to hear his trainer suggest that he go to his primary healthcare provider for a checkup first. He began thinking about his parents and their health habits. Both are working full-time and active and healthy, eat nutritious meals, which he enjoys when he has the time to visit, and they take no meds. He has no brothers or sisters. He is concerned that maybe he will not enjoy the health of his parents and maybe he is doing something wrong since he should have inherited good health from his parents. You learn this during your introductory conversation with him and now you must determine where to begin with this “healthy” young man and apparently, his trainer. You applaud his new plan for exercise and begin to discuss with him some health goals and objectives.
B/P 124/70 H/R 70 R 18 WT 200 pounds HT 70 inches
- Based on the provided patient information, think about the health history you would need to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
- Identify three to five possible conditions that may be considered in a differential diagnosis or at risk for the patient or that you share with him he is at risk for having.
Consider clinical guidelines that might support each diagnosis.
- Develop a realistic preventive health treatment plan for the patient that includes health promotion and patient education strategies for special populations. How would you categorize him as “special population”? Use social determinants of health, information that you gather during your assessment, to guide your realistic preventive health plan.
- Determine if you will refer Edwardo back to his trainer for full approval of an exercise program or will you follow up with him first, or concurrently, or tell him that he should not enter an exercise program now (share your reasoning for your decision). This is primarily a PREVENTIVE health assessment. You will want to provide an evaluation, but no pathology must be found; however, a preventive health plan is a must. Social determinants of health must be considered. Referrals or none? Patient education. How would you plan to work with the trainer who provided this referral?
This is a different kind of case study, however, one you may encounter and one that is really important for you to be able to work through. Enjoy!
PREVENTATIVE HEALTH AND ASSESSING, DIAGNOSING, AND TREATING SPECIAL POPULATIONS
Certain groups of patients have concerns that may be specific to their particular population. Conditions related to men’s or women’s health, older adults, college students, LGBTQ individuals, athletes, those with particular cultural beliefs or concerns, or those undergoing palliative or end-of-life care would all fall under this category. Individuals may identify with more than one category.
For this Assignment, you practice assessing, diagnosing, and treating disorders seen in special population patients.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To Prepare:
- Review this week’s Learning Resources. Consider preventative health and assessing, diagnosing, and treating special populations.
- Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
- Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
- Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
- Develop a preventative health treatment plan for the patient that includes health promotion and patient education strategies for special populations.
Complete:
Use the Focused SOAP Note Template to address the following:
- Subjective: What details are provided regarding the patient’s personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
- Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
- Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
- Reflection notes: Describe your “aha!” moments from analyzing this case.
Expert Solution Preview
Based on the provided patient information, the health history I would need to collect from the patient includes:
1. Detailed information about his dietary habits, including his intake of fast food and processed foods, as well as the frequency and portion sizes of his “one good meal” with his parents.
2. History of physical activity and exercise prior to starting his current rigorous exercise program.
3. Any symptoms of fatigue, sluggishness, or other concerns that he has experienced.
4. Family history of medical conditions, such as cardiovascular disease, diabetes, or obesity.
5. Information about his sleep patterns, including duration and quality of sleep.
6. History of any previous medical conditions or injuries.
7. Psychosocial history, including stress levels and coping mechanisms.
In order to gather more information about the patient’s condition, appropriate physical exams and diagnostic tests may include:
1. Routine blood work to assess lipid profile, blood glucose levels, liver function, and kidney function.
2. Body composition analysis, such as measuring body mass index (BMI), waist circumference, and body fat percentage.
3. Blood pressure measurement.
4. Cardiorespiratory fitness assessment.
5. Assessment of muscular strength and flexibility.
6. Assessment of sleep patterns using a sleep diary or an activity tracker.
7. Psychological assessment for stress levels and mental well-being.
Three to five possible conditions that may be considered in a differential diagnosis or at risk for the patient include:
1. Overweight/obesity: Due to his sedentary lifestyle, lack of exercise, and unhealthy eating habits.
2. Metabolic syndrome: Due to his high body weight, lack of physical activity, and potential risk factors such as family history.
3. Nutritional deficiencies: Due to his inconsistent eating patterns and reliance on fast food.
4. Sleep apnea: Due to feelings of sluggishness and fatigue, especially during his bus ride.
5. Sedentary lifestyle-related musculoskeletal issues: Due to prolonged sitting and lack of physical activity, he may be at risk for developing musculoskeletal pain or postural imbalances.
Clinical guidelines that might support each diagnosis include:
1. The National Heart, Lung, and Blood Institute guidelines for the treatment of overweight and obesity.
2. The American Heart Association guidelines for the diagnosis and management of metabolic syndrome.
3. The Academy of Nutrition and Dietetics guidelines for healthy eating and managing nutritional deficiencies.
4. The American Academy of Sleep Medicine guidelines for the diagnosis and treatment of sleep apnea.
5. The American College of Sports Medicine guidelines for physical activity and exercise prescription for sedentary individuals.
For Edwardo, as a “special population,” I would categorize him as a college student with limited time and resources for grocery shopping and meal preparation. Social determinants of health, such as his access to nutritious food, time constraints, and financial limitations, must be considered when developing a realistic preventive health treatment plan.
The preventive health treatment plan for Edwardo would include:
1. Nutrition education and meal planning guidance to help him make healthier food choices and incorporate more fruits, vegetables, and whole grains into his diet.
2. Time management strategies and stress reduction techniques to help him balance his work, studies, and exercise program.
3. Assistance in setting realistic and achievable exercise goals, including guidance on integrating physical activity into his daily routine (e.g., taking the stairs instead of the elevator, walking or cycling to work or school).
4. Collaboration with his trainer to develop an exercise program that is appropriate for his current fitness level and health status, with regular follow-ups to monitor his progress and address any concerns.
I would refer Edwardo back to his trainer for full approval of the exercise program. However, I would also schedule a follow-up appointment with him to discuss the results of the diagnostic tests and physical exams and tailor the exercise program based on his individual needs and goals. This approach ensures that his exercise program is safe and effective, taking into consideration any underlying health conditions or limitations identified during the assessment. It also allows for ongoing communication and collaboration between the healthcare provider and the trainer to ensure a comprehensive approach to his preventive health plan.
