Chief Complaint (CC): Thepatient complained about the size of the body
History of Present Illness(HPI):
A female patient aged 21 yearswith a big body size unable to walk perfectly complains ofoverweight. She claims of the body size although to her it is not aburden. She is too dormant in life doing things too slowly.
Medications: Hasnot taken any drug so far
Allergies: noknown allergies to medications.
Past Medical History (PMH):Coronary heartdisease
Social History (SH): Haspoor socializing and interaction capability with the fellowcolleagues
Immunization History: Upto date.
Family History: Thefather had coronary heart disease and Type II diabetes and died atthe age of 45 years.
Both parents had big bodiesand died of overweight related problem.
BMI was 38.7, No sign offever.
The heart rate was higher andthe blood pressure recorded as 121/68.
Lungs appear normal. Lungsounds are clear to auscultation bilaterally.
Pulse rate is not rhythmicaland is uneven.
Weight of 120kg
Skin appears normal. It is notpale. It ambulates easily.
Waist circumference is larger.
Short in height about 1.4meters
The patient is well hydrated.
Thediagnosis results show that the patient has obesity. She also suffersfrom coronary heart disease as a result of the condition.
Obesity-BMI (Body mass index) is mostly used in measuring whether a person ishaving obesity or not. It varies from age and sex of the person. Thefemale have a lower BMI as compared to the male. In this case, theBMI is measured and the value obtained compared to the normal rangeat the age of the 21 years. A BMI of 38.7 is very high for a personat the age of 21. This, therefore, shows that the patient hasobesity. The BMI is above 30 falling within the range of obese.Therefore, this is the most probable diagnosis.
Excesscholesterol- excessLDL also regarded as bad cholesterol can raise the risk of onedeveloping a heart problem.Given that thelevel of cholesterol is linked to obesity, it is important toconsider high cholesterol as part of the possible diagnoses.
Cholesterollevel diagnosis- In this case, the level of cholesterol in blood isassessed and measured. It is compared to the normal level ofcholesterol in blood. Cholesterol is carried by lipoproteins in theblood for utilization from liver to peripheral tissues to the liverfor degradation. When the level of cholesterol in blood is too high,it causes blockage of coronary artery leading to the heart problems.This condition may become worse if not handled early as it may causedeath.
Overweight-it is possible forthe patient to have excess weight and not be obese. BMI diagnosis wasthe primary diagnosis measure that was undertaken. Cholesteroldiagnosis measures level of cholesterol, which is only the result ofobesity. Therefore, BMI will assist determine the primary diagnosis.
Thepatient was administered with the Lorcaserin taken twice in a day.This medication serves a purpose to reduce the appetite while makingthe patient still feel satisfied. Other drug like Xenical was alsogiven to the patient to facilitate the body not to absorb any more ofthe fat and cholesterol into the blood. The body already has more ofthe cholesterol than is required. The medications were to be startedimmediately. This ensures that the patient loses some weight as wellthe decrease in the cholesterol level in the blood. Non-pharmacological strategies include the patient avoiding overfeedingso that the body can be in position to break its own leading todecrease in the obese condition (Wright& Aronne, 2012).
Alternativetherapies includethe patient undertaking a lot of exercises in the gym or school tolet out excess fat and restore the normal body condition.
HealthPromotion strategies– the family should be educated on how to keep a healthy life. Thisincludes taking a balanced diet. The education on the significance ofexercise should be done to keep the body optimum. This way, theexcess components get extracted through sweat. Education on theminimum use of cholesterol helps in the management of the heartrelated diseases like coronary heart disease (Fung,2016).
Thepatient also needs to be referred to a consultant for advice. Thespecialist will encourage the patient to socialize with others andeven play with them since this will be part of his exercise.
Followup activities include the parents observing that the patient does allthat is required (Steelman& Westman, 2016).Regular testing is also needed to check the rate of effectiveness ofthe medication. If there is need to change the drugs for whateverreason, the patient will be informed.
Reflectionnotes: It ispossible that obesity leads to the heart related disorders due to thehigh levels of cholesterol circulating in the body. It is thereforeimportant that the cholesterol level be tested.
Whiletreating obesity, reduction in the cholesterol level should beobserved. When a different patient is involved, I will measure theweight and analyze it differently since the age may not be the sameas the initial patient.
Iwill include data of the heart pulse and the fat content in the bodyparticularly cholesterol. I will examine kidney and liver functioningsince they contribute on the cholesterol synthesis and degradation inthe body. I will also assess for the arteriosclerosis due to highcholesterol level in the blood.
Fung, J. (2016). TheObesity code: Unlocking the secrets of weight loss. NewYork: Greystone Books Limited.
Rippe,J., & Angelopoulos, T. (2012). Obesity: Prevention and treatment.New York: CRCPress.
Steelman,M., & Westman, E. (2016). Obesity:Evaluation and treatment.Essentials New Delhi: CRCPress.
Wright, S. & Aronne, L.(2012). Causes ofobesity. AbdomRadiol, 37(5),730-732.