Case Presentation #2:

 A New Paradigm Application

..... The following case is designed to help you visualize how the new paradigm might be implemented when assisting a client with weight-related concerns. Review the following client data, then consider how you would answer the questions provided. When you are ready, compare your plan of care with that of the authors'.

Subjective Infomation:

  • Wanda T. is a 42 y/o female. Presents to your primary care office requesting Meridia to "help stop her yo-yo dieting". States she would like to reach goal weight of 120 lbs to "look great and feel better".
  • Health maintenance: non-smoker, non-drinker, has intermittently participated in aerobic dance classes for weight loss throughout adult life (currently sedentary), wears seat belt. Last physical 6 months ago. States weight 115 lbs with first diet at age 18 (wanted to lose 5 lbs). Repeated weight losses/gains since that time.
  •  Eating pattern frequently alternates between restricted caloric intake (approximately 1000 kcal/day) and periods described as "out of control" with intakes up to 4000 kcal/day. Cycles initially lasted as long as 2-3 weeks, but now occur every few days. Has difficulty recalling specific foods and amounts. Denies purging behaviors and history of eating disorders.
  • Social history: married x 22 years, 1 independent adult child, husband encourages weight loss, works full time as a nurse in a local hospital.
  • Past medial history: C/S (breech) 21 yrs ago, fx L femur in MVA age 30.
  • Family history: father with asthma, maternal grandmother died age 68 Alzheimer's.
  • Medications: ASA or Tylenol 4-5x/mo for HA or pain.
  • NKDA.
  • ROS: unremarkable.

Objective Information:

  • Ht: 64"
  • Wt: 144 lbs
  • BMI: 24
  • BP: 112/68
  • P: 80
  • R: 16
  • 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?

What are you reassured by?

What other information would be necessary?

 

Assessment:

What are your primary diagnoses?

How do you proceed in the formulation of a solid plan of care based on the new paradigm?

Plan:

What is your plan of care?

 

To view how the authors would use the new paradigm approach to assist this client, click "next" below.

 

NEXT

 

 

© Spring 1998