Wellness Assessment: Patient Case Study

Topic: Wellness Words: 707 Pages: 2

Table of Contents

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Assessment Questions
Opportunities
References

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Situation	Luciana Gonzalez – 32-year-old female patient – Hispanic. Came in for comprehensive health assessment for new employment insurance.
Background	The patient requires a comprehensive physical. Height: 5’4 Weight: 185lb BMI 31.8. No known allergies. Family history – no known diseases. Social history – Works a stable job. Denies alcohol, smoke exposure, drug use. The patient describes diet as normal and well, denies binge eating. Immunizations up to date. No relevant past medical history. No current medications. During history, the patient noted an increased frequency of urination and minor discomfort. Occurred previously for which she was prescribed medication. Labs were drawn including CBC, BMP, HbA1C, lipid profile, and urinalysis. HbA1C at maximum indicator for normal levels. All other bloodwork normal except for urine – cloud, pH 4.9, WBC:5, positive for bacteria 5+
Assessment	Vitals: BP: 124/82, P: 56, R: 22, Temp. 98.8, SpO2: 98% Skin: warm and dry. Nevus Flammeus on right side of the face Head: normocephalic, atraumatic, no deformities, symmetric Ears: External auditory canals intact Eyes: PERRLA intact, utilizes glasses for reading Mouth: tongue pink, symmetrical, clear mucosa, no swelling/ulcerations Neck: Thyroid firm and acceptable, no nodules Musculoskeletal: bulk and appropriate – normal stability, full ROM Cardiac – regular rate and rhythm Respiratory – clear lung sounds Abdomen – flat, symmetric, no scars or deformities, no masses or tenderness, no rebound tenderness. Gynecological exam recent.
Recommendation	Urinary symptoms are sign of a UTI. Recommended an antibiotic regime for 10-14 days to treat it. Since the condition has occurred in the past, potentially recommend seeing a urologist. Recommend incorporating the daily exercise of 60 minutes several days a week. Consider consultation with a nutritionist. Aimed at reducing BMI which is currently at the levels of obesity.

Assessment Questions

A holistic assessment question regarding the patient’s UTI would be, “Are you experiencing frequent repeat infections?” This is an important question as it can provide vital input on potential signs of abnormalities either in the health of the patient or their behavior. It can be a matter of hygiene and proper care as well as potential signs of hormone imbalance and maybe anatomical irregularities which do require treatment or prophylactic measures.

Another question would be, “Can you describe your typical daily diet, are you eating a healthy, varied diet?” The patient does have a BMI which is just borderline obese, indicating that there is a caloric imbalance. The patient is relatively young, and the obesity may impact their health later on middle-age adulthood. Many adults do not have varied diets with a healthy mix of protein, fat, and carbohydrates. Many miss out or overestimate the amount of healthy foods while consuming fast- or pre-packaged foods. Diet is essentially at the core of an individual’s weight trajectory and overall health status.

Finally, a question should be posed, “How much time and effort are you dedicating to physical activity?” This continues to build on the conversation around obesity. The patient works a sedentary job and likely spends the majority of the day sitting down. There is no indicator that that the patient engages in regular physical activity, but this type of question can identify the current trends and set new ones by providing recommendations. Potentially activities that the patient enjoys can be discussed to promote adherence and motivation.

Opportunities

Considering the patient seems to be at risk of repeat UTI, this may be an opportunity to address prevention measures with the patient that are recommended. The Cleveland Clinic (2020) recommends taking measure including practicing good hygiene, changing urination habits, partaking more fluids, and potentially changing forms of birth control and undergarments. Both changes in habits as well as some medication can be helpful in addressing repeat infections, but health recommendations indicate that lifestyle changes can significantly prevent UTI.

The BMI level of the patient indicating obesity at age 32 is concerning. This can be an opportunity to educate the patient regarding the obesity epidemic and potential health impacts including diabetes, cardiovascular issues, and cancer among others, even at slightly higher than healthy BMI levels. It is a complex issue that will require a multifaceted approach including nutrition and exercise, and a generally healthy lifestyle. The key for the patient is to change their habits and adopt a healthy eating plan, potentially utilizing weight management programs if it benefits them (NIDDK, 2020).

References

Cleveland Clinic. (2020). Urinary tract infections: Prevention. Web.

NIDDK. (2020). Treatment for overweight and obesity. Web.