Unformatted text preview: Running head: WEEK 6: SUMMARY 1 Week 6: Case Presentation
Chamberlain University
NR603: Advanced Clinical Diagnosis and Practice Across Lifespan
March 2018 SOAP Week 6
Patient Information:
S.C., 48-year-old female, Caucasian, insurance unknown.
(S) Subjective:
CC: "increasing weight despite dieting"
HPI: 48-year-old white woman complaining of increasing weight gain despite diet over past 4 months.
Has less energy than usual, decreased interest in usual activities, less able to complete routine tasks, and
generally slowed up. Dissatisfied with her overall appearance and inability to lose weight.
Current Medications:
Denies prescription medication. Takes daily multivitamin for last month.
Allergies: NKDA.
PMHx: HTN.
PSHx: Denies past surgeries. Hospitalization for childbirth x2. G2P2.
Childhood Illnesses: None reported.
Immunization Hx: Unsure of immunization status. No recent influenza, tetanus.
Other Screenings: Not reported.
Soc Hx: The patient reported that she had recently quit smoking ‘cold turkey’ and had successfully
maintained abstinence for four months. She reported quitting smoking following the death of her
mother because she died of cancer. She quit smoking without any professional help and without the use
of any nicotine replacements or medications to assist with the smoking cessation. she began smoking at WEEK 6: SUMMARY 2 age 18, that she had successfully quit smoking upon becoming pregnant at age 24, but resumed when
she returned to work 11 years ago. She reported a daily smoking frequency of 15 to 20 cigarettes per
day. She reported no serious efforts to stop smoking during the past 11 years prior to this recent period
of complete abstinence.
Lives with husband and children. The patient completed college and a master's degree in education and
had been employed as a special education teacher in the same job for 11 years
Fam Hx: Mother dies of cancer.
ROS:
CONSTITUTIONAL: No reports of fever, chills. Reports a weight gain of 25 pounds in past 6 months.
HEENT: Vision may be less acute, hearing normal, no dizziness.
SKIN: Denies itchiness, rashes or dryness.
CARDIOVASCULAR: Denies chest pain, dyspnea on exercise/at night, swelling ankles.
RESPIRATORY: Denies cough or wheezing.
GASTROINTESTINAL: The patient reported an onset of “eating binges” at approximately age 16. Reports
skipping breakfast, eating a “normal” lunch, eating a dinner with her family. Approximately 30 minutes
after the evening meal and spanning the two hours before bedtime, included: a roll of Ritz crackers
with 6 ounces of cheese, 2 doughnuts, 4 handfuls of Chex mix, and ½ of a large (12 oz.) Cadbury candy
bar. Denies abdominal pain, nausea, vomiting and indigestion. No dark or bloody stools.
GENITOURINARY: None reported.
NEUROLOGICAL: Denies LOC, numbness and tingling.
MUSCULOSKELETAL: None reported.
HEMATOLOGIC/LYMPHATICS: None reported.
PSYCHIATRIC: None reported.
ENDOCRINOLOGIC: None reported.
ALLERGIES: None reported. O:
Vital signs: B/P 146/92, HR 60, T 98.0F, RR 12.
Height 5’4”, weight 230 pounds
BMI: 39.5
PHYSICAL EXAM
GENERAL: Looks older than age, overweight, well groomed. Intelligent and cooperative.
HEENT: atraumatic, normocephalic, EOMI, PERRLA. Mucosa moist. Neck: Supple with no
masses/tenderness/lymph nodes. Normal thyroid. WEEK 6: SUMMARY 3 LUNGS: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on
chest.
HEART: Heart S1 and S2 noted, RRR, no murmurs, noted. No parasternal lifts, heaves, and thrills.
Peripheral pulses equally bilaterally. No edema in lower extremities.
ABDOMEN: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly
noted.
NEUROLOGICAL: Alert, oriented, appropriate behavior, good recall of information, appropriate affect and
speech. Normal gait. Light touch and pin prick sensation intact.
Diagnostic results:
PHQ-P score of 15. This score indicates that the patient is experiencing some depressive symptoms
which may be separate of the diagnosis or in conjunction with it.
A:
PRIMARY PRESUMPTIVE DIAGNOSIS:
Binge eating disorder (F50.81) – Binge eating disorder (BED) is defined primarily by recurrent episodes
of binge eating without the regular use of inappropriate compensatory weight control methods (such as
purging) that characterize bulimia nervosa. It is also defined as eating unusually large amounts of food
while experiencing a subjective sense of loss of control. As opposed to binge eating in bulimia nervosa,
binge eating in BED occurs in the absence of regular inappropriate compensatory behaviors, such as
self-induced vomiting, fasting, or laxative misuse, aimed at preventing weight gain. For diagnosis of
BED, binge eating is required to occur at least once per week over 3 months and in association with
behavioral abnormalities and marked distress [Hil15]. Behavioral signs of BED include recurrent
episodes of binge eating, eating much more rapidly than normal, a sense of lack of control during binge
episodes, eating large amounts of food when not physically hungry, hiding food and eating in secret,
eating until feeling uncomfortably full, and eating throughout the day with no planned mealtimes
[Smi161].
Although the cause of BED is not completely understood, several mechanisms associated with an
abnormal response to stress are thought be involved. These include an abnormal activation of the
hypothalamic-pituitary-adrenal axis that interferes with feelings of hunger and fullness, a genetic WEEK 6: SUMMARY
predisposition that results in food addiction, low levels of serotonin that lead to compulsive eating, and
depression that leads to emotional eating [Smi161].
SECONDARY DIAGNOSIS:
Obesity (E66.9) – Obesity is defined as a BMI of 30.0 or higher. Obesity is frequently subdivided into
categories: Class 1: BMI of 30 to < 35; Class 2: BMI of 35 to < 40; Class 3: BMI of 40 or higher. Class 3
obesity is sometimes categorized as “extreme” or “severe” obesity (CDC, 2017). This patient’s BMI is
39.5. (P) Plan:
Diagnostics:
1. Lab work including CBC, lipids, glucose, UA and chemistry may be used to rule out other organic
causes. In a patient with BED these results may show an elevated bicarbonate, decreased
potassium and decreased sodium level [Smi161].
2. Chest x-ray may show an abnormal lung status or enlarged heart [Smi161].
3. There are several different diagnostic tools and self-reporting tools available to assist in
diagnosis: Eating Disorder Examination-Questionnaire (EDE-Q), the Binge Eating Disorder Test
sub factor of the Bulimia Test-Revised and the Patient Health Questionnaire-Eating Disorder
module (PHQED). The PHQ-ED was shown to have a high true negative rate but a low positive
predictive value. The self-reported EDE-Q and Questionnaire for Eating and Weight PatternsRevised were found to correlate well with the clinician-administered Eating Disorder
Examination-Interview in identifying BED in a population of obese individuals [Mon16].
4. PHQ-9 is effective in diagnosing depression symptoms.
Pharmacological management:
New: 4 WEEK 6: SUMMARY 5 Although medication is efficacious for treating binge eating disorder, it is generally regarded as less
efficacious than psychotherapy. Most patients may prefer psychotherapy; however, pharmacotherapy
may require less time or be less expensive. It is therefore reasonable to use pharmacotherapy as first-line
treatment for patients who prefer medication and decline psychotherapy, as well as patients who do not
have access to psychotherapy [Sys17]. First line medications include SSRIs or SNRIs.
Rx: Fluoxetine 20 mg tablet
Sig: Take one tablet once daily
Dispense: 30 Refills: 3
Continued:
Multivitamin.
STOP TAKING:
None.
Education
Patient Education: Begin an aerobic exercise routine with a goal of 30 minutes per day of aerobic exercise which
may include brisk walking, jogging, swimming or biking. Exercise can be divided into ten or fifteen-minute increments to build up to 30 minutes per day or to fit into daily schedule.
Maintain a healthy diet. Include fruits and vegetables, whole grains, nuts, legumes, low fat dairy, fish and healthier oils. Limit sweets and added sugars sodium and salt, processed meats.
Educate about recognizing physiologic, not psychological, cues for hunger/fullness. Referrals/Consults Referral to mental health clinician for evaluation and treatment of BED, related symptoms, and
comorbid mental health conditions (e.g., depression, anxiety). Cognitive behavioral therapy (CBT) is recommended treatment with best outcomes.
Referral to a dietitian for evaluation and education on nutrition, appropriate portion size, and meal planning.
Referral to Licensed Clinical Social Worker (LCSW) who is located in the office because it is a
patient centered medical home. Immediate referral to the LCSW allows the patient to establish WEEK 6: SUMMARY 6 basic goals and coping skills that will be necessary to begin treatment of both the underlying
depressive symptoms and the BED. This is necessary now due to the positive PHQ-9 and the
delay in establishing with a mental health provider qualified to treat eating disorders.
Follow-up Plan
1. Complete all lab work.
2. Return in 1 week to assess for medication tolerance and to determine whether to step up
medication or change. Analysis
The underlying pathophysiology of BED is still unknown, although other conditions such as
anxiety and depression may contribute to it. Current pharmacological treatment includes treatment of
any underlying organic causes and first line treatment is an SSRI or SNRI with the most effective choice of
Fluoxetine. This medication can be started at a low dose of 20 mg daily with an increase of 20 mg every
1-2 weeks to a maximum dose of 60 mg daily or until a therapeutic effect has been achieved [Sys17].
Cognitive behavioral therapy has been proven as an effective modality of treatment for BED for patients
who are willing to engage in and perform the work required by CBT, or at least sufficiently motivated to
begin the process as motivation can be addressed during treatment. Goals for treatment with CBT may
include reducing the patient’s: binge eating episodes; psychiatric comorbidity such as anxiety, WEEK 6: SUMMARY 7 depression, or substance use disorder; concerns with body image (ie, enhancing self-acceptance)
[Sys171].
Current treatment guidelines further enforced 2006 recommendations for CBT, while
interpersonal therapy (IPT) and dialectical behavioral therapy have also shown marked improvements in
patients with BED. In 2010 Sibutramine was withdrawn from the market based on safety concerns
related to increased risk of heart attack and stroke. Additional pharmacology treatments found to be
effective include imipramine, sertraline and citalopram/escitalopram and topiramate [Yag12].
The patient did not return to the office during the clinical time spent there, however the primary
care physician did receive a consult report from the mental health provider stating that the patient was
tolerating their medications and had agreed to participate in CBT.
This is the first case of binge eating disorder I experienced. My preceptor also had very minimal
experience with it. He explained that it is often underreported therefore underdiagnosed. Now that I am
aware of the different screening tools available for eating disorders, I will be more likely to utilize them in
the future. The PHQ-9 tool is a common screening tool used, however in this case the patient had a
positive screen however, with further discussion, she was not truly depressed, just upset by her own
behaviors. Eating disorders affect 30 million people each year. This is something advanced practice
nurses should be aware of in primary care.
This office visit was billed as a 99215. The patient was an existing patient in the office. At this
visit she presented with an acute complaint that required an extensive history and exam to eliminate all
organic causes and a highly complex medical decision making. She required greater than 50 minutes of face
to face counselling in addition to multiple referrals. The ICD10 codes were billed as Binge eating disorder
(F50.81) and Obesity (E66.9). Depression was not added as a diagnosis as the depressive symptoms were
not true depressive symptoms and were only related to the low self-esteem. In addition, Body dysmorphic
disorder (F45.22) was also considered and rejected as a diagnosis. Body dysmorphic disorder is
characterized by preoccupation with nonexistent or slight defects in physical appearance, such that patients
believe that they look abnormal, unattractive, ugly, or deformed, when in reality they look normal [Phi16]. WEEK 6: SUMMARY 8 While the patient is unhappy with her current physical features related to the obesity, she does not avoid
mirrors or fixate on unrealistic features. Reference List
Centers for Disease Control and Prevention. (2017). Defining adult overweight and obesity. Retrieved
from (Links to an external site.)Links to an external
site.
Hilbert, A. (2015). Binge-Eating Disorder. In Encyclopedia of Feeding and Eating Disorders. Singapore:
Springer. doi:
Montano, C. B., Rasgon, N. L., & Herman, B. K. (2016). Diagnosing binge eating disorder in a primary care
setting. Postgraduate Medicine, 128(1), 115-123. doi:10.1080/00325481.2016.1115330
Phillips, K. (2016). Body dysmorphic disorder: Epidemiology, pathogenesis, and clinical features. In D.
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