Educating the Patient on Obes

Describe your clinical experience for this week #7.

The conclusion of this clinical rotation was very rewarding as I have become very comfortable with seeing patients independently and providing treatment, education, and follow up care. I appreciate the variety of experiences I was able to encounter. I realize this community needs healthcare providers to advocate for them and improve the quality of health in the population. It further motivates me to complete our degree and become one of those providers.

One patient that was seen was G.F., a 60-year-old, Cuban-American male, who presented to CHI for lab results.

S.) “I am here for my cholesterol results”. HPI: 60-year-old Cuban-American male presents with a long history of obesity with sedentary lifestyle. He has missed several years of well visits because of his schedule and that he wanted to achieve a more optimal weight before examination. The patient reports his diet is “better than it used to be” but admits to drinking beer, 2 cans nightly with a heavy meal late at night when retuning from work as a computer engineer. Pt. states he spends two hours sitting in the car for a long work commute and then sits at a desk for 8-9 hours. Family Hx: pt. reports a family history of hyperlipidemia and cardiovascular disease in both of his parents. Social Hx: Pt. denies smoking or using illicit drugs. He has caffeine 2 cups daily while working. Reports beer consumption 2 cans 7 days per week. States he has good friends and is close with his family. Pt. admits he does not exercise on weekends because he is tired. Sleep: pt. sleeps 5-6 hours per night but still feels tired during the day. Surgical hx/Medication/Allergies: Pt denies any medical or surgical history, takes no medication, and denies any allergies to food/drugs/environment. ROS was performed. Fasting diagnostic labs revealed triglycerides 256. LDL > 190. HDL 35. With total > 245. A1c was 5.8.

O.) V/S, height, weight, BMI were obtained. A head-to toe physical examination was performed. The physical exam was unremarkable with the exception of obesity and mild, eruptive xanthomatosis around his orbital area bilaterally.

A.) Diagnosis: Dyslipidemia (Hyperlipidemia). According to Hollier (2018), hyperlipidemia is characterized by elevated levels of blood lipids: cholesterol, phospholipids, and/or triglycerides. Etiologies include inherited disorder of lipid metabolism, high intake of dietary fats, obesity with sedentary lifestyle, DM, excessive caffeine and alcohol, and metabolic syndrome. Differential diagnosis would be considered by determining the cause of secondary hyperlipidemia as it may relate to pregnancy, hypothyroidism, diabetes, or a non-fasting state when sampled, none of which pertain to this patient.

P.) Lifestyle changes and lowering LDL are the primary focus for G.F. We discussed in length about behavioral modifications that could have significant impact to his long-term risks. We discussed treatment options based on the tools provided by the American College of Cardiology (ACC) and his 10-year risk calculation of development for atherosclerotic CVD (ASCVD). We discussed short and long term goals with regard to diet modifications. According to Kennedy-Malone et al. (2019), it is recommended to reduce total fat to 25% of calories and saturated fat to less than 7%. The Mediterranean diet has been shown to decrease cholesterol by emphasizing fruits, vegetables, whole grains, nuts, and healthy fats like olive oil and avocado. However, at this stage given his numbers, age, weight, ethnic background, family history, and lifestyle, it is recommended that in addition to diet and exercise G.F. needs to be starting on a statin to effectively assist in lowering his cholesterol. He was prescribed Lipitor and educated on alcohol cessation as well as follow up visits to recheck his serum lipid levels.

The challenge I encountered was that, like so many of us, changing lifestyle habits is very difficult if he does not have the support to do so. His work hours are long and his job indeed sedentary. Every alternative we discussed to encourage more movement or diet change the patient seem to counter with statements that would eliminate healthier choices as an option. In conclusion he was referred to a nutritionist with the hope that education will help to support a healthier lifestyle. The patient is to return in 6 weeks for follow up.

References

Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates.

Kennedy-Malone, L., Lori Martin Plank, & Evelyn Groenke Duffy. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company.

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