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Weight management clinic for the treatment of a 14-year-old female with sudden weight gain.

Case Presentation

Susie is a 14-year-old obese African-American female presenting to a weight management clinic per her mother's persuasion. Her mother reports that she has had extreme fatigue, significant weight gain, shortness of breath, and snoring during hours of sleep. Susie refuses to go outside and interact with neighborhood friends due to being "too tired." Her mother states, "She goes to school then comes home to watch television and eat." She reports that Susie has been experiencing these symptoms over the past six months. During the past year, Susie's parents divorced, and Susie lives with her mother in a new location as well as school district.

Past Medical History

Susie has an unremarkable past medical history and denies any other complaints. She denies any food or drug allergies. She denies smoking, alcohol and drug use, and sexual interactions. This is her first visit to the weight management clinic. Susie is up to date on all her immunizations, including the flu vaccination. Overall, Susie has always been healthy. Susie's mother reported that she is unsure what is causing these changes in her daughter.

Development and Growth History

Susie's mother reports a normal growth pattern during her life as far as she knows. She noticed about two years ago that Susie had breast buds and that her weight had increased. Susie began her menstrual cycle at age 13 years.

Family and Social History

Susie's family medical history consists of diabetes, obesity, and hypertension. Both of Susie's grandmothers are obese, with a body mass index (BMI) greater than 35 kg/m2. Susie visits her father every other weekend. Her mother reports that while Susie is at her father's house, she eats high-calorie fast foods and does not exercise. Susie has one older brother and one older sister who are married and no longer live in the house. In the past, Susie was involved in extracurricular activities, but these all stopped following the divorce. She attends a new public

school where she has few friends.

Nutritional History

Susie consumes a significant amount of "junk food" consisting of fried foods, pizzas, and potato chips daily. Susie states, "I love candy of any kind." She consumes at least three to four sugary soft drinks daily. Susie voices that she is always hungry. She denies eating any type of vegetables other than potatoes. Her mother reports an increasing visible weight gain in Susie since she started her menstrual cycle one year ago.

Physical Assessment Findings

General appearance: Susie comes to the weight management clinic today in no apparent distress. She is awake, alert, and oriented to person, place, and time. She is cooperative and appropriately responsive to questions.

Vital Signs: Temp: 98.2, Height: 63 in, Weight: 77.1 kg (170 lbs), HR: 82, RR: 16, BP: 136/90. Her BMI is 30.1.

HEENT: Normocephalic, conjunctiva clear, sclera red bilaterally, EOMI, PERRLA, TM pearly gray with normal cone of light, no TM inflammation. Negative for sinusitis, rhinitis, uvula midline, symmetric palate, neck supple. No lymphadenopathy. Thyroid not palpable. Trachea midline, and full range of motion of neck.

Integumentary: Skin warm and dry to touch without lesions and/or cuts. No bruises, rashes, or scars noted.

Respiratory: Normal shape of chest with no obvious deformities. Respirations even and non-labored. Breath sounds clear bilaterally upon auscultation. No stridor, wheezes, crackles, or rubs. Good air movement.

Cardiovascular: Regular rate and rhythm, no murmur, positive cap refill, 2+ pulses in all extremities noted.

Abdomen: Abdomen is soft, nontender, and non-distended. Active bowel sounds in all four quadrants. No hepatosplenomegaly.

Neurological: Oriented to person, place, and time. Speech and cranial nerves intact.

Musculoskeletal: Full range of motion. 5/5 strength UE/LE bilaterally. No edema noted.

Genitalia: Tanner stage IV noted. Extensive assessment not completed at this visit. Denies dysuria and/or urgency.

Psych: Mood stable.

What Do You Suspect?

Susie is a 14-year-old obese female being seen for her increasing weight gain since the beginning of her menstrual cycle.

Differentials

Obesity Grade 1: A condition with a BMI of 30.0 to 34.9 kg/[m.sup.2] is classified as obesity grade 1, which puts the individual at a moderately increased risk for various diseases, such as bone and joint problems, shortness of breath, restless sleep and/or breathing difficulties, liver disease, gallbladder disease, hypertension, hyperlipidemia, diabetes, heart disease, and depression (Golden, Schneider, & Wood, 2016). Psychosocial concerns associated with obesity during the childhood years are also significant. These include depression, poor self-esteem, and poor quality of life (Strauss & Pollack, 2003).

Diagnostic tests are crucial for prompt intervention and improved outcome. Height, weight, and BMI should be plotted on the 2000 Centers for Disease Control and Prevention (CDC) growth charts and compared to previous health data (Kuczmarski et al, 2000). BMI in children ranging between the 85th to 94th percentiles is overweight, and greater than the 95th percentile is obesity. A thorough physical examination and review of systems are vital in identifying any underlying physical concerns and/or psychosocial concerns.

Type 2 diabetes: Type 2 diabetes is an elevated glucose level related to insulin resistance and/or insulin production impairment. Type 2 diabetes is often referred to as insulin resistance. Common risk factors of type 2 diabetes in children include obesity, decreased physical activity, family history, and ethnic group (Cash & Glass, 2011). Common symptoms for adolescent children include weight gain, increased hunger, blurred vision, fatigue, poor healing, darkened pigmentation, and excessive thirst and urination.

Diagnostic tests are imperative for prompt and effective treatment. Therefore, laboratory diagnostic blood tests should include a hemoglobin A1c (HbA1c) greater than or equal to 6.5%, fasting glucose greater than or equal to 126 mg/dL, random glucose greater than or equal to 200 mg/dL, 2-hour and a plasma glucose greater than or equal to 200 mg/dL. A urinalysis can also be obtained to identify glucose and/or ketones, as well as a complete blood count for the identification of elevated glucose and/or underlying infection (Copeland et al., 2013). Based on diagnostic blood tests, current recommendations include initiating insulin for HgbA1c greater than 9% and a random glucose greater than 250 mg/dL in conjunction with lifestyle modifications, or initiating Glucophage[R] 500 mg one tablet daily and a lifestyle modification program, including dietary, exercise, glucose monitoring, and diabetes education/counseling (Copeland et al., 2013).

Susie's blood tests consisted of a random blood glucose of 94 mg/dL, urinalysis negative for glucose and ketones, and a HgbA1c of 5.1%. Her complete blood count was insignificant. Her BMI was 30.1 kg/[m.sup.2], and her blood pressure was elevated at 136/90. Susie had a positive family history for obesity, she reported continuous hunger, and her activity tolerance was decreased.

Management Plan And Recommendations

Susie was diagnosed with obesity stage 1. According to obesity guidelines, at least 5% to 10% weight loss has significant benefits, such as glucose, triglycerides, cholesterol, and blood pressure reductions (Garvey et al., 2016). Therefore, the implementation of an intensive behavioral therapy (IBT) plan is recommended. IBT consists of healthier lifestyle strategies, with the ultimate goal of a 5% to 10% weight loss (Garvey et al., 2016).

The recommended IBT plan includes the following:

* Physical activity:

--Engage in 30 to 60 minutes of moderate exercise per day and/or utilizing the stairs at school if available for at least four days/week.

--Start low and go slow, such as starting at 15 minutes then 30 minutes then 50 minutes based on individual tolerance.

--Exercise options: Park or get dropped off at a distance from school door, shopping door; swimming; climbing stairs; dancing; walking the dog; bicycling.

* Self-monitoring:

--Weigh in at least weekly Remember, gain a pound, lose a pound!

--Monitor what you eat and your activities.

--Monitor calories - 1,500 to 1,800 kcal per day based on individual needs.

* Ongoing healthy nutrition:

--Meal replacement daily plus two meals daily.

--Food journaling.

--Avoid skipping meals.

--3 healthy snacks daily (< 100 kcal).

--64 oz. of water daily (diet green tea, zero calorie flavored water, unsweetened tea or coffee, or plain water).

--Avoid fried foods, sugary drinks, creamy sauces and dressings, sweets.

--Moderation is key--Portion sizes.

* Behavioral intervention and support:

--Stress management.

--Frequency of encounters with health care team.

--Low levels of sedentary behavior (television, computer, cell).

Susie will return to the weight management clinic every two weeks. She and her family will also enroll in healthier lifestyle education classes. Susie is instructed to lose 1 to 2 pounds per week. Individuals implementing a healthier lifestyle can improve their overall well-being. Consuming fewer calories, making smarter food choices, and exercising daily can reduce the risk of chronic diseases and promote overall health.

References

Cash, J.C., & Glass, C.A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company.

Copeland, K.C., Silverstein, J., Moore, K.R., Prazar, G.E., Raymer, T., Shiftman, R.N., & Flinn, S.K. (2013). Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics, 131(2), 364-382.

Garvey, W.T., Mechanick, J.I., Brett, E.M., Garber, A.J., Hurley, D.L., Jastreboff, A.M..... Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines. (2016). American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocrine Practice, 7(22, S3), 1-203.

Golden, N.H., Schneider, M., & Wood, C. (2016). Preventing obesity and eating disorders in adolescents. Pediatrics, 138(3), e20161649

Kuczmarski, R.J., Ogden, C.L., Guo, S.S., Grummer-Strawn, L.M., Flegal, K.M., Mei, Z., ... Johnson, C.L. (2000). CDC growth charts for the United States: Methods and development. National Center for Health Statistics. Vital Health Statistics, 11(246). Retrieved from https://www.cdc.gov/nchs/ data/series/sr_11 /sr11 _246.pdf

Strauss, R.S., & Pollack, H.A. (2003). Social marginalization of overweight children. Archives of Pediatric and Adolescent Medicine, 157(8), 746-752.

Critical Thinking Case Studies is designed to test your problem-solving and decision-making abilities. Instructions: Read the symptom(s) above. Then, outline how you would assess and manage the problem. Finally, compare your rationale and decision to that listed in the shaded area.

If you are interested in author guidelines for this column or would like to submit material, contact: Tedra S. Smith, DNP, CRNP, PNP-PC; Pediatric Nursing; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; pnjrnl@ajj.com

Mary Annette Hess, PhD, FNP-NC, CNS, is an Assistant Professor and Family Nurse Practitioner, University of Alabama at Birmingham, Birmingham, AL.

Laura Steadman, EdD, MSN, CRNP, RN, is an Assistant Professor and Family Nurse Practitioner, University of Alabama at Birmingham, Birmingham, AL.
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Title Annotation:Critical Thinking Case Studies
Author:Hess, Mary Annette; Steadman, Laura
Publication:Pediatric Nursing
Geographic Code:1USA
Date:Jan 1, 2017
Words:1770
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