Case Presentation #1:
(Authors' Plan of Care)

A New Paradigm Application

.....Subjective Infomation:

  • Alex L. 38 y/o white male. Presents to your primary care office for a pre-employment physical.
  • Health maintenance: non-smoker, 1-2 beers twice a month, plays in a racquetball league 2 nights a week, wears seat belt. Last physical 2 years ago. No history of restricted dieting, weight-cycling, or recent weight loss/gain.
  • Eating pattern (a typical 24 hour period):
    • 7 AM: Cheese Danish, 2 cups coffee
    • Noon: Big Mac, large order fries, large Coke
    • 3PM: Large apple
    • 6 PM: Grilled BBQ chicken, baked potato with butter, asparagus, water
    • 9PM: Apple pie ala mode, milk
  • Social history: married x14 years, 2 school-age children, +family and social support, +stress related to recent unemployment secondary to corporate merger.
  • Past medial history: appendectomy @ age 18 without complications, last Td @ 36 y/o
  • Family history: father deceased age 48 with MI, mother L&W age 60 with Type 2 diabetes
  • Medications: Tylenol 3-4 times/mo for HA
  • NKDA
  • ROS: unremarkable

     

Objective Information:

  • Ht: 70"
  • Wt: 189 lbs
  • BMI: 27
  • BP: 158/92 recheck 154/90
  • P: 86
  • R: 14
  • HEENT: WNL
  • Lungs: CTAB
  • Heart: RRR without murmur
  • Peripheral vascular: WNL
  • Abdomen: WNL
  • Neuro: WNL
  • MS: WNL

     As a provider, what are you concerned about?

    • Diet high in fat and low in fruits and vegetables
    • High stress r/t unemployment
    • First-degree relatives with history of MI before age 55, and Type 2 diabetes
    • Elevated blood pressure at this visit

    What are you reassured by?

    • Plays racquetball 2x/wk
    • No tobacco
    • ETOH in moderation
    • +Family/social support
    • Unrestrained eating pattern (no history of dieting/weight cycling)
    • Physical exam WNL

    What other information would be necessary?

    • More details of physical activity patterns
    • What is/are this client's primary concern(s)?
      • What does the client believe your role is?
      • What does he expect of you?

Assessment:

What are your primary diagnoses?
  • R/O hypertension
  • Alteration in nutrition: high fat intake and low fruit/veggie intake
  • Potential for increased physical activity

Considering this client's potential diagnosis of hypertension (to be confirmed) and the presence of 2 risk factors for cardiovascular disease (male, +family history), interventions should focus on lifestyle. This is especially important given the additional diagnoses related to nutrition and activity patterns. Notice how the plan of care is not dependent on weight loss.

 Plan:

What is your plan of care?
  • Appropriate assessment and follow-up to R/O hypertension
  • Empower the patient to establish goals, and develop an individualized plan according to his personal priorities (Unit IV Lesson A)
    • Focus on the development of healthy, unrestrained eating (Unit IV Lesson C)
      and/or
    • Promote increased physical activity (Unit IV Lesson D)
  • Consider on-going collaborative relationship with plan evaluation & revision at each visit

 E-Mail Joyce and Angie

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© Spring 1998