Patient Information:
Initials Mr. E, Age- 42 years, Sex- male, Race- Hispanic
S.
CC (chief complaint): Mr. E. comes to the clinic with a plan of embarking on a rigorous exercise program with the ultimate goal of losing weight.
HPI:
Location: N/A
Onset: N/A
Character: N/A
Associated signs and symptoms: N/A
Timing: N/A
Exacerbating/relieving factors: N/A
Severity: N/A
Current Medications: No current medications.
Allergies: No known food or drug allergies.
PMHx: The patient’s immunization history is in line with the immunization schedule. His last immunization was a tetanus shot which he was given in November 20th 2021.
Soc & Substance Hx: The patient is a tax accountant. He is a single man who has never been married and lives in a condominium. He denies substance and alcohol use. He has not been physically active for the past 10 years. He is responsible for all his grocery shopping and meal preparation. Has gained a lot of weight due to his nature of work that requires him to sit all day behind his desk.
Fam Hx: His parents are alive. The grandparents died from natural causes of death. He has one sibling aged 36 years who is alive and healthy.
Surgical Hx: Has no prior surgical procedures
Mental Hx: Has had no diagnosis for mental health illnesses like anxiety or depression. Has no ideation for suicide or homicide.
Violence Hx: Has no concerns over his personal, home, community or sexual safety.
Reproductive Hx: He is not dating and is not sexually active.
ROS:
GENERAL: Has too much weight gain. No fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not sexually active. Has no penile discharge
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: BP 128/80, Temperature 37 Degrees Celsius, R.R 18, Weight 190 pounds, Height 5’3
General: Too much weight gain
Diagnostic results:
Body mass index calculator- a body mass index of between 25 and 30 indicates that a person is overweight.
A.
Differential Diagnoses:
Over weight
Overweight is a condition characterized by a body mass index of or more than 25kg/m2.
Obesity
Obesity is defined as having a body mass index of 30kg/m2 or more (Fruh, 2017).
P
Based on the patient’s medical and social history, the patient is overweight. He has been gaining a lot of weight which has been linked to his nature of work that entails sitting on his desk for many hours. The primary reason why he visited the hospital was to have a medical checkup first before embarking on a rigorous exercise program. He aims to lose 30 pounds by working out at the gym.
Both overweight and obesity are health conditions that can easily be managed with a combination of medications and behavior modifications. The Food and Drug Agency recommends Orlistat for the management of obesity (Qi, 2018).
Non-pharmacological interventions that can be used to manage the patient’s weight besides exercise and activity would involve healthy feeding patterns. Diet-related changes would include cutting calories, consuming m
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