Case Study For Obesity Assignment Paper

Introduction

Mrs. Burke, a 68-year-old Caucasian female, presents with a complex case consisting of a constellation of health indicators. She reports a history demanding a comprehensive care plan. With a BMI of 49.4, a waist circumference of 52 inches, and a history of smoking since the age of 16, Mrs. Burke has a health risk history of several risk factors for developing cardiovascular diseases and metabolic disorders. For instance, she reports alarming fasting cholesterol levels. Secondly, she has an associated family history of coronary artery disease, type 2 diabetes, and hypertension (Liguori et al., 2020). The familial risk of developing multiple chronic diseases has accentuated the urgency for providing her with proper care interventions. The purpose of this case study is to explore the multifaceted health challenges faced by Mrs. Burke. Mrs. Burke’s examination extends to the interplay of genetic predispositions for developing chronic illnesses, lifestyle choices, and environmental factors that could exacerbate the development of chronic diseases (Gordon et al., 2020). The study is directed at formulating a comprehensive care plan that can address Mrs. Burke’s immediate health issues and foster long-term well-being by digging into her past medical history, social lifestyle conditions, and presenting complaints (signs and symptoms)Case Study For Obesity Assignment Paper.

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Case Summary or Synopsis

Mrs. Burke, a 68-year-old Caucasian female, is 5′ 6” and weighs 306 pounds, presenting a BMI of 49.4. She has a waist circumference of 52 inches. High waist circumference indicative of abdominal adiposity. It is important to note that abdominal adiposity offers a greater risk of cardiovascular diseases. Mrs. Burke also has exacerbating factors of chronic illness, such as a long-term history of smoking 1 and 1/2 packs daily since adolescence. Her high fasting cholesterol levels reveal concerning levels.

Additionally, Mrs. Burke has a fasting glucose of 120 mg/dl. Higher glucose level highlights potential metabolic disturbances such as diabetes. Having lived in a family with a history of coronary artery disease, type 2 diabetes, and hypertension puts Mrs. Burke at a higher risk of developing these chronic illnesses (Liguori et al., 2020). It is essential also to note that Mrs. Burke’s grandmother succumbed to colon cancer with concurrent emphysema. In addition, her grandfather suffered from renal insufficiency due to type 2 diabetes. The higher familial risk of developing multiple chronic illnesses and intricate health dynamics underscore, which calls for the need for a meticulous and holistic approach to her care (Danese & Widom, 2020)Case Study For Obesity Assignment Paper. Finally, for total patient treatment, she needs a complete healthcare approach that will extend from individual health profiles and familial predispositions to developing chronic diseases.

Discussion

Additional Subjective Data

Additional subjective data is crucial in ensuring a comprehensive understanding of Mrs. Burke’s health. The other personal data will involve an exploration of Mrs. Burke’s dietary habits, exercise routine, and stress levels (Danese & Widom, 2020). Collecting new information on nutritional habits will help in gauging the lifestyle factors influencing Mrs. Burke’s weight and cholesterol levels. Secondly, additional information will explore Mrs. Burke’s smoking history in detail. Smoking history will be directed in assessing any past cessation attempts of smoking. Uncover her awareness of familial health conditions and her perceived barriers to a healthier lifestyle. Additionally, digging into Mrs. Burke’s social health care support system, mental health, and medication adherence is very important in understanding the social determinants of her health conditions (Gordon et al., 2020)Case Study For Obesity Assignment Paper. Collecting new subjective data enhances the contextual understanding of Mrs. Burke’s health, hence aiding in the formulation of a targeted and patient-centered care plan.

Physical Assessments Needed

Specific physical assessments are imperative for Mrs. Burke, such as a thorough cardiovascular examination to assess her heart function and identify potential signs of coronary artery disease. Secondly, a physical assessment should be undertaken on the respiratory functions to help in determining Mrs. Burke’s lung health since she has a long-term history of smoking (Danese & Widom, 2020). In addition, Mrs. Burke needs a comprehensive musculoskeletal assessment to unveil mobility challenges associated with her weight. She also required detailed skin assessments for signs of metabolic syndrome. Lastly, evaluating abdominal girth and performing a neurologic evaluation will help to rule out any obesity complications. The need for physical examination is to help create comprehensive medical care support for the patient and eliminate medical errors during treatment (Liguori et al., 2020)Case Study For Obesity Assignment Paper.

National Guidelines

National guidelines play an important role in creating room for a unified care plan system. For instance, the American Heart Association (AHA) guidelines offer insights into managing dyslipidemia and cardiovascular risk (Liguori et al., 2020). Secondly, the National Institute on Aging (NIA) guidelines help in addressing health concerns related to aging. Given Mrs. Burke’s BMI and obesity-related issues, the policy by the Centers for Disease Control and Prevention (CDC) on obesity management becomes pertinent in offering care to Mrs. Burke. The American Diabetes Association (ADA) guidelines provide an essential care plan system that governs her treatment plan, such as managing glucose levels (Gordon et al., 2020)Case Study For Obesity Assignment Paper. The need to align treatment interventions with national standards is to help create a detailed care plan with an evidence-based care approach, thus resulting in positive outcomes.

Primary Diagnoses of the Patient

The primary diagnoses for Mrs. Burke include severe obesity (BMI 49.4) with abdominal adiposity, dyslipidemia, i.e., elevated cholesterol, triglycerides and LDL, low HDL, and impaired fasting glucose (Berkowitz & Garrett, 2020). Additionally, the smoking history raises potential risks for respiratory and cardiovascular complications. Finally, a family history of coronary artery disease, type 2 diabetes, and hypertension also contribute to her overall health risks of chronic diseases.

Differential Diagnoses

Differential diagnoses include metabolic syndrome due to a combination of obesity, dyslipidemia, and elevated fasting glucose. Non-alcoholic fatty liver disease (NAFLD) could be considered due to obesity. Congestive heart failure and chronic obstructive pulmonary disease (COPD) should also be considered due to her family history and smoking habit (Berkowitz & Garrett, 2020)Case Study For Obesity Assignment Paper. Finally, depression and anxiety disorders should be considered in assessing her mental health well-being.

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Diagnostic Tests to Confirm or Rule Out Each Condition

For accurate diagnosis, additional tests such as waist-to-hip ratio measurement and HbA1c should be performed (Lang et al., 2021). The main primary tests to investigate NAFLD include liver function tests and abdominal ultrasound. Other cardiovascular tests should consist of echocardiography, EKG, and X-ray. Secondly, pulmonary function tests should also be performed to assess the respiratory health. Depression and anxiety screenings and consultations with mental health professionals should be conducted to boost analyzing psychological health.

Recommended Treatment

For severe obesity, treatment involves a multidisciplinary approach, such as lifestyle modifications involving a tailored diet and exercise plan (Gordon et al., 2020). Secondly, the patient can be booked for elective bariatric surgery based on further assessment. Dyslipidemia management involves administering statins, drugs, and lifestyle changes. Pharmacotherapy can aid in smoking cessation. Diabetic control requires medications and lifestyle adjustments (Lang et al., 2021)Case Study For Obesity Assignment Paper. Finally, the patient should be booked for psychological support and counseling.

10-year Risk Assessment According to the ASCVD Risk Calculator

The ASCVD Risk Calculator considers age, gender, race, cholesterol levels, blood pressure, and smoking history (Bloem et al., 2020). Inputting the patient’s data into the calculator will provide an estimate of the patient’s risk for a cardiovascular event.

Evaluation/follow-up plan

The follow up process ensure that the patient is signed up for routine glucose, cholesterol, and weight monitoring. Secondly, follow up plan monitors the patient for adherence to drug regimens and lifestyle adjustments (Gordon et al., 2020). In addition, Mrs. Burke need appointments with a behavioral health professional, endocrinologist and registered nutritionist to ensure a comprehensive patient’s health in a collaborative approach.

Patient Education

According to Danese and Widom (2020), patient education is essential for lifestyle adjustments. The main focus of patient education should include quitting smoking, maintaining a healthy diet and getting regular exercise. According to Rowland et al. (2020)Case Study For Obesity Assignment Paper, it is imperative that patient education is guaranteed for patient drug use and possible adverse effects. Education should expand on explaining patient complications, such as chest pain and respiratory distress. The need for patient education is to promote awareness about the impact of mental health and treatment regimens. Patient education also equips the patient with the knowledge to participate actively in her care.

Healthy People 2030 Objectives

Healthy People 2030 objectives relevant to Mrs. Burke’s case include reducing the prevalence of obesity, improving cholesterol levels, and enhancing cardiovascular health (Rowland et al., 2020). Secondly, the objectives aim at promoting smoking cessation, which helps to reduce the patient’s tobacco use. Additionally, goals target mental health promotion and psychological well-being (Bloem et al., 2020).

Legal/ethical considerations

Legal and ethical considerations in healthcare practice encompass respecting patient autonomy, ensuring confidentiality, and obtaining informed consent. Mrs. Burke’s obesity management is sensitive and should be approached with empathy and cultural competence. Smoking cessation efforts need to respect her autonomy (Agrawal & Prabakaran, 2020)Case Study For Obesity Assignment Paper. Ethical considerations should also extend to potential stigmatization and, therefore, require a non-judgmental and supportive environment for care support. The treatment plan should comply with HIPAA privacy regulations, which aid in handling sensitive health information (Smith et al., 2020). An ethical approach underpins the foundation of adequate care provision and compassionate patient-centered care.

Involvement in the Circle of Caring

Applying the Circle of Caring model to Mrs. Burke’s case extends the sphere of influence beyond conventional healthcare providers (Smith et al., 2020). Engaging Mrs. Burke and her family in decision-making is paramount to ensure a patient-centric medical care approach. Introducing a patient advocate helps to facilitate effective communication and empower Mrs. Burke to express her concerns and medication preferences. In addition, healthcare professionals such as registered dietitians help to structure the patient for personalized nutrition counseling (Smith et al., 2020). Secondly, a physical therapist is recruited in the treatment plan to help with tailored exercise programs for the patient. The patient also requires a counselor to assist the patient with a smoking cessation program. Collaboration between the patient and community support groups or educational program initiators helps the patient by enriching the patient’s social and emotional well-being (Chute & French, 2019)Case Study For Obesity Assignment Paper. Finally, the inclusion of family members in discussions and planning promotes a comprehensive understanding of Mrs. Burke’s health journey, thus fostering a united front in the pursuit of optimal healthcare.

Billing Codes Recommendations

Billing codes should accurately reflect the diverse services involved in the patient’s care. The need for billing codes is to ensure comprehensive assessment, Evaluation, and Management (E/M) in accordance with the code number 99204 for new patients (Lang et al., 2021). Subsequent office visits and follow-up consultations can be billed using appropriate E/M codes based on the complexity of the patient care encountered during the care provision process. Billing code procedures include lipid panels (CPT codes 80061, 83721), fasting glucose tests (CPT code 82947), and BMI assessments (CPT code 99401) should be included in the patient evaluation process. In addition, smoking cessation counseling can be appropriately coded using CPT codes 99406 and 99407 (Smith et al., 2020)Case Study For Obesity Assignment Paper. It is important to note that referrals to specialists are necessary and should be accompanied by respective codes.

When applying the codes, it is vital to ensure that regulations are assigned to the patient in cases where extensive counseling or coordination of care is involved (Gordon et al., 2020). Finally, one should provide meticulous documentation to support the selected codes to guarantee accurate reimbursement.

Conclusion

Mrs. Burke’s case demands a comprehensive and collaborative approach through the epitomized Circle of Caring model. The system not only engages healthcare professionals but also advocates for patients, healthcare dietitians, and counselors. The need for the Circle of Caring model is to form a robust support patient care network and ensure a patient-centered treatment approach. The recommended billing codes accurately capture the diverse services involved in reflecting the intricate nature of the patient’s care. Immediate health emphasizes fostering long-term well-being through lifestyle modifications and sustained support. Mrs. Burke’s journey to optimal health is a testament to the importance of inclusivity and partnership among various stakeholders.

References

Danese, A., & Widom, C. S. (2020). Objective and subjective experiences of child maltreatment and their relationships with psychopathology. Nature human behaviour, 4(8), 811-818.

Liguori, C., Pierantozzi, M., Spanetta, M., Sarmati, L., Cesta, N., Iannetta, M., … & Mercuri, N. B. (2020). Subjective neurological symptoms frequently occur in patients with SARS-CoV2 infection. Brain, behavior, and immunity, 88, 11-16.

Rowland, S. P., Fitzgerald, J. E., Holme, T., Powell, J., & McGregor, A. (2020). What is the clinical value of mHealth for patients?. NPJ digital medicine, 3(1), 4.

Gordon, W. J., Landman, A., Zhang, H., & Bates, D. W. (2020). Beyond validation: getting health apps into clinical practice. NPJ digital medicine, 3(1), 14.

Smith, W. R., Atala, A. J., Terlecki, R. P., Kelly, E. E., & Matthews, C. A. (2020). Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic. Journal of the American College of Surgeons, 231(2), 216-222.

Agrawal, R., & Prabakaran, S. (2020). Big data in digital healthcare: lessons learnt and recommendations for general practice. Heredity, 124(4), 525-534.

Chute, C., & French, T. (2019). Introducing care 4.0: an integrated care paradigm built on industry 4.0 capabilities. International journal of environmental research and public health, 16(12), 2247.

Bloem, B. R., Henderson, E. J., Dorsey, E. R., Okun, M. S., Okubadejo, N., Chan, P., … & Munneke, M. (2020). Integrated and patient-centred management of Parkinson’s disease: a network model for reshaping chronic neurological care. The Lancet Neurology, 19(7), 623-634.

Lang, M., Lemieux, S., Hébert, J., Sauvageau, G., & Zawati, M. N. H. (2021). Legal and ethical considerations for the design and use of web portals for researchers, clinicians, and patients: scoping literature review. Journal of Medical Internet Research, 23(11), e26450.

Berkowitz, I., & Garrett, J. R. (2020). Legal and ethical considerations for requiring consent for apnea testing in brain death determination. The American Journal of Bioethics, 20(6), 4-16. Top of Form

For this plan of care/case study, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 6-7 pages, which does not include the cover page and reference page(s).

I. Introduction (including purpose statement)

II. Case Summary or Synopsis

Include a short (75-100 word) description of the patient in terms of age, sex, race, height, weight, marital status, occupation, social/cultural history, previous hospital admissions, and chief complaint on current visit. This serves to orient the reader to the case study patient and provides an overview of the clinical issues of the patient.
III. Discussion Questions and Answers

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IV. Conclusion

Regarding APA format, please use the following as a guide:

Include a cover page (this is not part of the 6-7 page limit)
Include transitions in your paper (i.e., headings or subheadings)
Use in-text references throughout the paper
Use double-spaced, 12-point Times New Roman font
Apply appropriate spelling, grammar, and organization
Include a reference list (this is not part of the 6-7 page limit)
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e., NCSBN, AANP) Case Study For Obesity Assignment Paper

Case Study #3

Mrs. Burke is a 68 y.o. Caucasian female. She is 5’6” tall and weighs 306 pounds. Her waist circumference is 52 inches and her BMI is 49.4. Mrs. Burkes’ fasting cholesterol panel indicated that her total cholesterol was 260 with her triglycerides 350 mg/dl; her LDL was 180 mg/dl; and her HDL was 36 mg/dl. Her fasting glucose was 120 mg/dl. She has smoked 1⁄2 pack per day of cigarettes since she was 16 years old. VS: BP 136/84; P 74; R 18. Family history was positive for living parents with CAD; type 2 diabetes; and hypertension. Her grandmother died from colon cancer and had emphysema. Her grandfather had renal insufficiency as a complication from type 2 diabetes.

Mrs. Burke presents today for a follow-up regarding her laboratory tests and wellness exam she received last week.

Case Study Questions:

What additional subjective date should you obtain from the patient?
What additional physical assessments need to be completed for this patient?
What National Guidelines are appropriate to consider?
What are the primary diagnoses of the patient? What is your prospective list of differential diagnoses?
What additional diagnostic tests would you perform to confirm or rule out each condition?
Based on your evaluation and current research, what treatments would you recommend?
What is her 10-year risk assessment according to the ASCVD Risk Calculator?
What is the evaluation/follow-up plan for the next office visit? Will you consider a consultation?
What else should you teach the patient? Are there any Healthy People 2030 objectives that you should consider?
Are there any legal/ethical considerations?
Using the circle of caring, what or who else should be involved to hear the patient’s voice, getting him/her and family involved in the care to reach optimal health?
What billing codes would you recommend? Case Study For Obesity Assignment Paper