Introduction

According to Guidance, N. I. C. E. (2014), Obesity is a great threat to the Western world in terms of the morbidity and mortality it brings to this population. Obesity is a multidimensional problem and it can be managed using prevention, correction, population-based and individual approaches. This paper uses the individual approach because it argues the case of a female Hispanic patient Mrs. G who is obese. To measure out this obesity, the measurement is the body mass index (BMI). The BMI has codes know as BMI codes that define obesity level which correlates to the primary, secondary and differential diagnosis of a patient. With these MBI codes and the treatments that follow, it is possible to come up with a management plan for mature and aging patient who is obese. This is clearly brought out in the SOAP note writing, which is a basically a review of the patient’s case study. Put in one statement, this paper will diagnose this case study and produce a management plan that applies the national diabetes guidelines and demonstrate mastery of SOAP note writing.

Assessment

Before the patient was assessed and producing the three diagnosis (primary, secondary and differential), the medical expert concerned had to take into consideration that negative feelings would be induced from explaining what obesity is (Flegal et al.’s 2013). Denial, anger and surprise were expected from the patient who was fundamental to getting involved in changes. On the medical practitioner’s part, s/he had to provide details on benefits of weight loss, proper dieting and exercise. Further, this health expert would dig into the patient history and open that discussion by asking what motivates the patient to what to lose weight. The practitioner explored the aged patient’s perspective of weight and why she gained weight and went a step further to exploring her eating behavior. This practitioner conducted the activity with a general knowledge on patterns of eating, exercise and weight.

Mrs. G had to be made aware of medication that may worsen weight gain such as oral hypoglycaemic agents, antidepressants and anticonvulsants. There were also situations she was to be informed to possibly affect weight, such as hypothyroidism, polycystic ovary syndrome or growth hormone deficiency. As a result of this preceding information, the health expert examined and found the patient’s height 5’2”, weight 185 pounds, blood pressure BP 128/80 (regular), pulse rate 76 (regular), and respiration rate 20 (regular). The assessment also revealed the patient to be allergic to NKDA, cats and latex (inferred in Flegal and colleagues 2013).

The crescendo of the assessment was the lab work of primary, secondary and differential diagnosis (Charo & Lacoursiere, 2014). The primary diagnosis was complete blood count (CBC). The CBC had an ICD 10 code for a new patient which is 99386. The analyzed CBC revealed white blood cells WBC (5,000/mm3), hemoglobin Hgb (12.8 gm/dl), red blood cell RBC (4.6 million), hematocrit Hct (41%), MCHC (34 g/dl) and RDW (13.8%). After this, there was the secondary diagnosis of the same patient who was now an established patient. Therefore her ICD 10 code for secondary diagnosis was 99396. The secondary diagnosis involved urinalysis (UA). The UA had two negative findings of Leukocyte esterase, ketones and nitrates. The patient’s urine was acidic (pH 5), a specific gravity of 1.015 and extra protein and glucose as well.

Third diagnosis which was differential had comprehensive metabolic panel (CMP). The CMP was a panel of 14 tests to give the current condition of the patient’s metabolism case, including wellness of the kidneys, acid-base balance and blood level of glucose and of proteins. The ICD code for this level was 99403. Thus, the assessment takes us into evidence-based practices (Charo & Lacoursiere, 2014).

Evidence-Based Practice (EBP)

The national guidelines body for evidence-based practice (EPB) is the National Institute for Health and Care Excellence (NICE). The NICE guidelines (2014) advocate for the body mass index (BMI) usage to examine overweight and obese persons. This body of evidence recommends waist circumference measurement to augment in such persons as with a BMI below 35 kg/m2. NICE also measure adiposity indirectly and thus requires care during interpretation. The 2014 NICE guidelines advocate for dietary intake with the assistance of expert and vigorous follow-up. The health professional in that year were advised to undertake particular training and function within multidisciplinary teams. The NICE guidelines of that same year recommend low-fat d