Miranda

<div class="yourchoice objective"><strong>I.</strong> History - Meet Your Patient </div>[[History Objectives]] <div class="container"> <div class="inner"> <div class="ehr"> <div class="header patientimg"> <h4>Patient Information</h4> <div class="patientname"></div> </div> <div class="content"> <p><strong>Personal Hx:</strong> 35-year-old female office worker</p><p><strong>CC:</strong> Needs routine physical, prompted by sleep problems</p><p><strong>HPI:</strong> Complains of not being able to get a truly "refreshing" night's sleep for over a year.</p><p><strong>Past Medical Hx:</strong> Non-smoker, negative screens for mental health disorders</p><p><strong>Height:</strong> 5'4"</p><p><strong>Weight:</strong> 225 lbs</p><p><strong>BMI:</strong> 38.6 kg/m2</p><p><strong>Waist:</strong> Not recorded</p><p><strong>BP:</strong> 132/86</p><p><strong>Pulse:</strong> 86</p><p><strong>Respiration:</strong> 18/min</p><p><strong>Medications:</strong> Multivitamin, IUD</p></div> </div><div class="note">Ms. Jones is much larger than the last time she was in the office. Her weight used to fluctuate from normal to overweight, but not to this degree. The last recorded office visit was five years ago.</div> <div class="dialogue-container"> <div class="provider-dialogue"><p><em>[Extending a hand-shake]</em> Good to see you, Ms. Jones. </p> </div> <div class="patient-dialogue"><p> You, too! Long time, no see.</p> </div> <div class="provider-dialogue"><p> I'm glad you came back. I hear you've been having some sleep problems. What's going on? </p> </div> <div class="patient-dialogue"><p> I just can't seem to get a good night's sleep. I feel so tired all the time.</p> </div></div><div class="note">After continuing a friendly chat with Ms. Jones, and re-checking her blood pressure after a longer wait in the exam room (128/79), her chief complaint is explored extensively. Her main symptoms are snoring loudly and feeling tired during the daytime. As part of the discussion, you want to gather more information to see if her excess weight could be contributing to her sleep problems.</div> </div> <div class="navigation"><div class="question">Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="continue">[[Do you mind if we talk about your weight gain]] </div> <div class="continue">[[Can we explore any life changes when you noticed your sleep problems]] </div> <div class="continue">[[Sleep problems can range from pulmonary and renal disease to sleep apnea]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Meet Your Patient</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Do you mind if we talk about your weight gain</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Do you mind if we talk about your weight gain? </p> </div> <div class="patient-dialogue"> <p> I'm a little uncomfortable talking about my weight. Why do you ask?</p> </div> <div class="provider-dialogue"> <p>I've noticed an increase since you were last here. I'd like to see if anything has changed that might also impact your sleep, like diet, habits, exercise. Would you mind talking about those things?</p> </div> <div class="patient-dialogue"> <p> No, I don't mind talking about that. Nothing has really changed dramatically. I typically skip breakfast and eat a quick lunch at work, usually from the cafeteria. I eat a big supper with my family most nights and I snack throughout the day. I'm super weak with sweets. I might have some candy and a soda or two to wake me up in the afternoon.</p> </div> <div class="provider-dialogue"> <p>Many of us struggle with sugar. It gives a quick boost of energy, but soon wears off, triggering more sugar consumption and the caffeine. The caffeine in sodas could contribute to your sleep problems, and the sugar as well.</p> </div> <div class="patient-dialogue"> <p> <em>[Looking a bit skeptical]</em> Are you sure? It's just a few sodas.</p> </div> </div> </div> <div class="navigation"><div class="question">What is the best way to continue the conversation now that Ms. Jones appears skeptical?</div> <div class="continue">[[Change the topic and ask about breakfast]] </div> <div class="continue">[[Keep on topic about caffeine and sugary drinks]] </div> <div class="continue">[[Acknowledge her skepticism and ask her thoughts]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Question - A</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Can we explore any life changes?</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Can we explore any life changes around the time you noticed the sleep problems?</p> </div> <div class="patient-dialogue"> <p> Yes, of course. I had just gotten my new job a little over a year ago. It keeps me pretty busy, but I like it a lot.</p> </div> <div class="provider-dialogue"> <p> Good, glad to hear that. </p> </div> <div class="note"><em>[There is a brief conversation about what she does and that she has made some great friends at her new job.]</em></div> <div class="provider-dialogue"> <p>So, you noticed the sleep problem around this time. Any ideas why?</p> </div> <div class="patient-dialogue"> <p> Well, my dad died several months before I started my job. He had pancreatic cancer, but ended up dying from a stroke. And my mom finished up treatment for cervical cancer within that same year. You can say that it's been a pretty stressful couple of years.</p> </div> <div class="note"><em>[Ms. Jones' eyes begin to water and her chin is quivering.]</em></div> </div> </div> <div class="navigation"><div class="question">Ms. Jones seems to be getting emotional, how should you proceed at this point in the conversation?</div> <div class="continue">[[Acknowledge her emotion]] </div> <div class="continue">[[Quickly segue to the physical]] </div> <div class="continue">[[Continue reviewing history]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Question - B</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Sleep problems can range from pulmonary and renal disease to sleep apnea</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Sleep-related problems can vary widely, from pulmonary and renal diseases to gastroesophageal reflux and sleep apnea.</p> </div> <div class="patient-dialogue"> <p> <em>[Looking a little distressed]</em> That's a pretty wide range of problems there.</p> </div> <div class="provider-dialogue"> <p>We will definitely need to explore further to find the cause of your sleep problems.</p> </div> </div> </div> <div class="navigation"><div class="question">Appearing distressed about the possible causes of her lack of sleep, what is the best way to proceed with Ms. Jones?</div> <div class="continue"> [[Use medical terms to explain common reasons for sleep disruption]] </div> <div class="continue">[[Inquire about her thoughts on the chief concern]] </div> <div class="continue">[[Start reviewing her recent history]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Question - C</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Acknowledge her emotion</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p><em>[Handing Ms. Jones a tissue]</em> I'm so sorry to hear that. It does sound like a difficult and stressful time.</p> </div> <div class="patient-dialogue"> <p> <em>[Wiping her eyes and nose]</em> My dad was so wonderful. </p> </div> <div class="provider-dialogue"> <p>It sounds like it was quite a loss. Are you doing okay? </p> </div> <div class="patient-dialogue"> <p> It has been a really difficult year. But, I have all my family nearby, so they are very helpful. We get together a lot, especially my sister and I. She stays over a lot now and is the one who encouraged me to see someone. She said it looks like I'm gasping for air in my sleep sometimes.</p> </div> <div class="provider-dialogue"> <p>We'll definitely need to look into your gasping for air. It's good to hear that your family is close and care so much about you. </p> </div> <div class="note"><em>[The interview is continued and more information is gathered about what her sister has observed. Sleep apnea is suspected.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - B1</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Quickly segue to the physical</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I see that is an upsetting topic. <em>[Handing Ms. Jones a tissue]</em> We can move on to the physical if you would like.</p> </div> <div class="patient-dialogue"> <p> Yes, please do. I've cried so much recently, it's embarrassing.</p> </div> <div class="provider-dialogue"> <p>No need to be embarrassed, but let's see if we can track down what is going on. I already have some vitals from the staff earlier, but I want to add a waist measurement as well. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - B2</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Continue reviewing history</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You are a strong woman, though. You'll get through this.</p> </div> <div class="patient-dialogue"> <p> Thanks. I'm doing my best.</p> </div> <div class="provider-dialogue"> <p>Tell me more about your family. Are there any other health problems in your family history?</p> </div> <div class="patient-dialogue"> <p> My mom takes medicine for her blood pressure and cholesterol. She has for a while now. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - B3</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Change the topic and ask about breakfast</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I see you don't think sodas are a big contributor to your sleep problems. What about breakfast? Do you notice any changes if you eat breakfast in the morning? </p> </div> <div class="patient-dialogue"> <p> I just don't have time. I have so much going on these days. I very rarely eat breakfast.</p> </div> <div class="provider-dialogue"> <p>How about you add in breakfast to your routine? All the literature I've read says that eating breakfast has nutritional and health benefits. </p> </div> <div class="patient-dialogue"> <p> I'm not a morning person, I would need something quick.</p> </div> <div class="provider-dialogue"> <p>It can be as simple as a few boiled eggs and an apple or maybe some oatmeal. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History Discussion - A3</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Keep on topic about caffeine and sugary drinks</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I agree that it does seem like a small issue, but you would be amazed how much caffeine and sugar can impact your sleep.</p> </div> <div class="patient-dialogue"> <p> I know. I'm just really stressed these days and a soda can do wonders to improve my mood. I just can't cut it out right now.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - A2</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Acknowledge her skepticism and ask her thoughts</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I see that you're a little skeptical about sodas being a source of your sleep problems. Can you tell me what you think is going on?</p> </div> <div class="patient-dialogue"> <p> I'd say stress is a pretty big contributor. My dad died last year and I haven't really felt 100% since then.</p> </div> <div class="provider-dialogue"> <p>I'm so sorry to hear that. </p> </div> <div class="patient-dialogue"> <p> If I could just get a good night's sleep, I would feel so much better.</p> </div> <div class="provider-dialogue"> <p>We are going to do everything we can today to address your sleep problems. How are you coping with the loss of your dad?</p> </div> <div class="patient-dialogue"> <p> My sister comes over almost every night and we have our wine and cheese hour. We have grown closer since it happened.</p> </div> <div class="provider-dialogue"> <p>It's nice that you have each other.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - A1</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Use medical terms to explain common reasons for sleep disruption</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>There are more common reasons for sleep disruption. Obesity is a major cause and sleep problems are often a result of sleep apnea. Do you know what sleep apnea is? <em>[Ms. Jones interrupts, shakes her head no]</em> Apnea is the cessation of respirator function, meaning your airflow can be disrupted while you are sleeping.</p> </div> <div class="patient-dialogue"> <p> So, does that mean I'm not breathing when I am sleeping? That is a scary thought. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - C1</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Start reviewing her history</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Before we talk about the reason you are having difficulty sleeping, we should get more background information.</p> </div> <div class="patient-dialogue"> <p> <em>[looking more relieved]</em> Okay, that sounds good.</p> </div> <div class="provider-dialogue"> <p> Tell me about the job you have now. </p> </div> <div class="patient-dialogue"> <p> I started my job a few years ago and it keeps me really busy. I work with some great people and I get to interact with a lot of people during the day, so I enjoy what I do.</p> </div> <div class="provider-dialogue"> <p>I'm glad to hear your job is going so well. How has your family been?</p> </div> <div class="patient-dialogue"> <p> <em>[Her eyes are now tearing]</em> My dad died last year and my mom just finished up treatment for cervical cancer. I guess I have been pretty stressed lately. It still upsets me sometimes, obviously. But, I'm not a complete mess like I was last year. My family has grown closer since it happened.</p> </div> <div class="provider-dialogue"> <p>Your family sounds very supportive. That's wonderful you have that.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - C3</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Inquire about her thoughts on the chief concern</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Let's talk about your sleep problems. What do you think is going on?</p> </div> <div class="patient-dialogue"> <p> I've been talking to my sister and she thinks it might be stress. We've had a lot of family stuff this year and it has taken a toll. My dad died early last year and my mom just finished treatment for her cervical cancer. I'm not sleeping, my sister is having relationship troubles, I could probably keep going. Just a lot of life stuff, you know?</p> </div> <div class="provider-dialogue"> <p>Losing a parent is very difficult. What things are you doing to take care of yourself?</p> </div> <div class="patient-dialogue"> <p> My sister and I see each other a lot. We have this wine and cheese hour almost every night. Sometimes we watch movies and sometimes we talk about life. My family is very close. It helps me a great deal.</p> </div> <div class="provider-dialogue"> <p>It sounds like you have a great support system.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[History Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Discussion - C2</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary A</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Do you mind if we talk about your weight gain?</div><p>The initial direction to talk about weight gain without first offering concern caused Ms. Jones to put up a few barriers, resulting in her not wanting to talk about her weight and her skepticism of the suggestions about caffeine and sugar contributing to her problems. While weight gain is an important assessment to consider in this encounter, it can be explored while collecting the patient's history. Weight gain can be the result of:</p><ul><li>Illness</li><li>Moving less because of pain</li><li>Depression</li><li>Change in social circumstances causing a change in dietary habits</li><li>Other factors</li></ul><p>For patients who have gained a significant amount of weight since their last visit, collecting an accurate history prior to an assessment is valuable. <em>"Can we explore any life changes when you noticed your sleep problems?"</em> was a better first choice in this situation.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What is the best way to continue the conversation now that Ms. Jones appears skeptical?</div> <div class="response"><strong>You chose:</strong> Acknowledge her skepticism and ask her thoughts</div><p>The patient's comfort level was taken into account very well and the dialogue led to building rapport with Ms. Jones. This also led to gaining useful information from her recent history.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - A1a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice objective"><strong>II.</strong> Physical Exam </div>[[Physical Exam Chapter Objectives]] <div class="container"> <div class="inner"> <div class="results"><p>To begin the physical, a review of systems (skin, HEENT, cardiovascular, respiratory, etc) is performed and reveals most systems unremarkable and WNL, but the following are noted:<p><ul><li><strong>General Appearance:</strong> African-American female, casually dressed, well-groomed, average height, alert, appears distressed when talking about the current stressors in her life.</li> <hr> <li><strong>Neck</strong>: Some tension in neck muscles and excess adiposity. Otherwise WNL</li> <hr> <li><strong>Abdomen</strong>: Excess adiposity. Otherwise, WNL.</li></ul> </div> </div> <div class="navigation"><div class="question">What body mass measurement should you review or perform with Ms. Jones?</div> <div class="continue">[[Body mass index]] </div> <div class="continue">[[Bioelectric impedance analysis]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Do you mind if we talk about your weight gain</div><p>The initial direction to talk about weight gain without first offering concern caused Ms. Jones to put up a few barriers, resulting in her not wanting to talk about her weight and her skepticism of the suggestions about caffeine and sugar contributing to her problems. While weight gain is an important assessment to consider in this encounter, it can be explored while collecting the patient's history. Weight gain can be the result of:</p><ul><li>Illness</li><li>Moving less because of pain</li><li>Depression</li><li>Change in social circumstances causing a change in dietary habits</li><li>Other factors</li></ul><p>For patients who have gained a significant amount of weight since their last visit, collecting an accurate history prior to an assessment is valuable. <em>"Can we explore any life changes when you noticed your sleep problems?"</em> was a better first choice in this situation.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What is the best way to continue the conversation now that Ms. Jones appears skeptical?</div> <div class="response"><strong>You chose:</strong> Keep on topic about caffeine and sugary drinks</div><p>This choice is not ideal, but it did have some good points, like addressing Ms. Jones' caffeine and sugar intake. Reducing both is ideal for her. In this exchange, she has even agreed that she make a small change, like reducing her sugary beverage intake. Using this moment to build some rapport would have been a better option. The choice of <em>"Acknowledge her skepticism and ask her thoughts"</em> would have been better in this situation. Following that choice revealed valuable information about Ms. Jones' history.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p> An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - A2a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Do you mind if we talk about your weight gain?</div><p>The initial direction to talk about weight gain without first offering concern caused Ms. Jones to put up a few barriers, resulting in her not wanting to talk about her weight and her skepticism of the suggestions about caffeine and sugar contributing to her problems. While weight gain is an important assessment to consider in this encounter, it can be explored while collecting the patient's history. Weight gain can be the result of:<p><ul><li>Illness</li><li>Moving less because of pain</li><li>Depression</li><li>Change in social circumstances causing a change in dietary habits</li><li>Other factors</li></ul><p>For patients who have gained a significant amount of weight since their last visit, collecting an accurate history prior to an assessment is valuable. <em>"Can we explore any life changes when you noticed your sleep problems?"</em> was a better first choice in this situation.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What is the best way to continue the conversation now that Ms. Jones appears skeptical?</div> <div class="response"><strong>You chose:</strong> Change the topic to address her lack of breakfast</div><p>Fasting every day is definitely known to have ill effects. Lack of breakfast is a good topic to explore, given the myriad of studies on the topic of breakfast and weight loss, however, there has yet to be a consensus on this topic. This may not also be the time to start suggesting diet patterns to Ms. Jones. The choice of <em>"Acknowledge her skepticism and ask her thoughts"</em> would have been better in this situation to build more rapport and gather information. Following that choice revealed valuable information about Ms. Jones' history.</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong><p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - A3a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary D</div> <div class="container"> <div class="inner"> <div class="evaluation_points full">You have received full points for this encounter!</div> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Can we explore any life changes when you noticed your sleep problems?</div><p>Excellent! You chose the best way to initiate the patient interview, exploring life changes around when Ms. Jones noticed her sleep problems. Key interactions from this patient-centered choice are noted below:</p><ul><li>Gathering a history (synthesizing previous with current relevant history)</li><li>Demonstrating patient-centered interview skills (patient non-verbal cues, social determinant of health, active listening)</li></ul><p>You have identified pertinent history for Ms. Jones' presenting situation, including:</p><ul><li>Health of mother and father</li><li>Family history of hypertension (controlled with medications)</li><li>Recent life stressors of death and serious illness in the family</li><li>Ms. Jones has a good support system to cope with stress</li></ul> </div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Ms. Jones seems to be getting emotional, how should you proceed at this point in the conversation?</div> <div class="response"><strong>You chose:</strong> Acknowledge her emotion</div><p>Great job. This encounter demonstrated patient-centered interview skills. The dialogue revealed attentiveness to the patient and careful attention to both verbal and non-verbal cues through active listening. As a result, pertinent information about Ms. Jones' sleep problem and family history was revealed.</p></div> <div class="summary">You have all the necessary information needed to move forward with the encounter.</div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - B1a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Can we explore any life changes when you noticed your sleep problems?</div><p>Excellent! You chose the best way to initiate the patient interview, exploring life changes around when Ms. Jones noticed her sleep problems. Key interactions from this patient-centered choice are noted below:</p><ul><li>Gathering a history (synthesizing previous with current relevant history)</li><li>Demonstrating patient-centered interview skills (patient non-verbal cues, social determinant of health, active listening)</li></ul><p>You have identified pertinent history for Ms. Jones' presenting situation, including:</p><ul><li>Health of mother and father</li><li>Family history of hypertension (controlled with medications)</li><li>Recent life stressors of death and serious illness in the family</li><li>Ms. Jones has a good support system to cope with stress</li></ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Ms. Jones seems to be getting emotional, how should you proceed at this point in the conversation?</div> <div class="response"><strong>You chose:</strong> Quickly segue to the physical</div><p>While nice patient-centered interactions were used in this dialogue, the decision to move on quickly from the interview resulted in valuable information being missed in the collection of Ms. Jones' history. The choice of <em>"Acknowledge her emotion"</em> during the interview would have resulted in building more rapport with Ms. Jones and creating more open lines of communication.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div></div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - B2a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Can we explore any life changes when you noticed your sleep problems?</div><p>Excellent! You chose the best way to initiate the patient interview, exploring life changes around when Ms. Jones noticed her sleep problems. Key interactions from this patient-centered choice are noted below:</p><ul><li>Gathering a history (synthesizing previous with current relevant history)</li><li>Demonstrating patient-centered interview skills (patient non-verbal cues, social determinant of health, active listening)</li></ul><p>You have identified pertinent history for Ms. Jones' presenting situation, including:</p><ul><li>Health of mother and father</li><li>Family history of hypertension (controlled with medications)</li><li>Recent life stressors of death and serious illness in the family</li><li>Ms. Jones has a good support system to cope with stress</li></ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Ms. Jones seems to be getting emotional, how should you proceed at this point in the conversation?</div> <div class="response"><strong>You chose:</strong> Continue reviewing history</div><p>This was an okay choice, as Ms. Jones' history does need to be reviewed. Patient-centered technique was used here by encouraging Ms. Jones, however, the encouraging effort seems to dismiss her emotions. The choice of <em>"Acknowledge her emotion"</em> during the interview would have resulted in building more rapport with Ms. Jones and creating more open lines of communication.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div></div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - B3a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Sleep problems can range from pulmonary and renal disease to sleep apnea</div><p>Detailing sleep-related problems is a great start and a few broad differential diagnoses have formed in this dialogue. However, this is best left out of the conversation with Ms. Jones to avoid stressing her with details before results from an evaluation. Had you chosen <em>"Can we explore any life changes when you noticed your sleep problems?"</em>, you would have gathered helpful information about Ms. Jones' history, included below.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Appearing distressed about the possible causes of her lack of sleep, what is the best way to proceed with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Use medical terms to explain common reasons for sleep disruption</div><p>The medical information presented here is correct, but it is early to be discussing possibly diagnoses. Had you chosen either <em>"Start reviewing her recent history"</em> or <em>"Inquire about her thoughts on the chief concern"</em>, helpful information about Ms. Jones' history would have been revealed.</p> </div> <div class="summary"><strong> Regarding other possible choices: </strong> <p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - C1a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Sleep problems can range from pulmonary and renal disease to sleep apnea</div><p>Detailing sleep-related problems is a great start and a few broad differential diagnoses have formed in this dialogue. However, this is best left out of the conversation with Ms. Jones to avoid unnecessary stress. Had you chosen <em>"Can we explore any life changes when you noticed your sleep problems?"</em>, you would have gathered helpful information about Ms. Jones' history.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Appearing distressed about the possible causes of her lack of sleep, what is the best way to proceed with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Inquire about her thoughts on the chief concern</div><p>Good recovery from the last choice. This encounter was successfully completed with history elements being revealed about Ms. Jones' presenting situation. This was illustrated by the patient-centered questioning used when inquiring about Ms. Jones' thoughts about her chief concern. Another good recovery choice would have been to <em>"Start reviewing her history"</em></p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - C2a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>History Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> Knowing that weight discussions are sensitive for some patients, choose the best question or statement to initiate the next part of the discussion.</div> <div class="response"><strong>You chose:</strong> Sleep problems can range from pulmonary and renal disease to sleep apnea</div><p>Detailing sleep-related problems is a great start and a few broad differential diagnoses have formed in this dialogue. However, this is best left out of the conversation with Ms. Jones to avoid unnecessary stress. Had you chosen <em>"Can we explore any life changes when you noticed your sleep problems?"</em>, you would have gathered helpful information about Ms. Jones' history.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Appearing distressed about the possible causes of her lack of sleep, what is the best way to proceed with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Start reviewing her recent history</div><p>Good recovery from the last choice of providing too much medical detail. The overall encounter was successfully completed with history elements being revealed about Ms. Jones' presenting situation. The dialogue showed attentiveness to Ms. Jones' non-verbal cues about being sad about the loss of her dad. Although it seems Ms. Jones has a strong support system, this would have been an important cue to miss. Another good recovery choice would have been to <em>"Inquire about her thoughts on the chief concern"</em></p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>An accurate and complete clinical encounter would have included reviewing and collecting more of Ms. Jones' recent history and using patient-centered interview techniques. This approach would have collected the following information:</p><ul><li>A family history of both parents being overweight/obese</li><li>Family history of hypertension (controlled with medications)</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Ms. Jones has a good support system to cope with stress</li><li>Sleep-related signs leading to a tentative diagnosis of sleep apnea</li></ul></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Evaluation]]</div> </div> </div> <div class="footer"> <p class="small">You are here: History - Summary - C3a</p> <div class="chapter"><strong>Ch 1 |</strong> History</div> <div class="progress chapter1"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Body mass index</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="patient-dialogue"> <p> <em>[Getting fidgety sitting on the exam table.]</em> Is it time to get off this table yet?</p> </div> <div class="provider-dialogue"> <p> I can tell you are ready to be done. We are very close. <em>[Taking a quick glance at the computer]</em> I am checking to make sure your BMI was calculated and I will need one additional measurement to finish up. BMI, or body mass index, can tell me if you are susceptible to any weight-related health risks. Medically, any BMI over 30 is diagnosed as obese. Over that BMI, you have higher risks for developing heart disease, diabetes, high cholesterol, and high blood pressure. Your BMI is 38.6. </p> </div> <div class="patient-dialogue"> <p> Wow, that is extremely high. Both my parents have struggled with their weight and my mom is still on medication for high blood pressure. I would really like to avoid that. What can I do? </p> </div> <div class="provider-dialogue"> <p>Well, we will want to monitor your blood pressure and I will learn more about your health after some blood tests. Then we can discuss together ways to lower your BMI.</p> </div> </div> </div> <div class="navigation"><div class="question">What additional body mass measurement can help you measure Ms. Jones' health risks?</div> <div class="continue">[[Skinfold thickness]] </div> <div class="continue">[[Waist to hip ratio]] </div> <div class="continue">[[Waist circumference]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Question - A</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Skinfold thickness</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p><em>[Opens the door and motions to the nurse]</em> I am going to step out for a minute while the nurse takes a few measurements with the skinfold caliper.</p> </div> <div class="patient-dialogue"> <p> A trainer did that once at the gym. It measures body fat, right?</p> </div> <div class="provider-dialogue"> <p>It does. We can assess you for certain health risks with that information. I will be right back.</p> </div> <div class="patient-dialogue"> <p> Sounds good. <em>[She is left waiting only a minute or two]</em></p> </div> <div class="nurse-dialogue"> <p><em>[Entering the room]</em> Hi, Ms. Jones. I'm here to take measurements at your bicep, tricep, below your shoulder blade and right above your hip. Please let me know if you are ever uncomfortable.</p> </div> <div class="note"><em>[The nurse has a difficult time locating Ms. Jones' ilium and the limitation of the caliper is apparent. Nonetheless, the nurse records a skinfold total of 100 mm, translating to 37.2%]</em> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Physical Exam Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - A2</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Waist to hip ratio</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I would like to get some measurements for your waist-to-hip ratio.</p> </div> <div class="patient-dialogue"> <p> What's that for?</p> </div> <div class="provider-dialogue"> <p>This will calculate central body fat and will give me information important for assessing certain health risks.</p> </div> <div class="patient-dialogue"> <p> Really, like what?</p> </div> <div class="provider-dialogue"> <p>For example, a waist to hip ratio measurement will predict heart disease better than measuring your weight.</p> </div> <div class="patient-dialogue"> <p> Alright.</p> </div> <div class="note"><em>[It takes a little longer than expected finding Ms. Jones' hip bone, but eventually a measurement of 41 inches for waist and 35 inches for hips is recorded. The ratio is determined to be 1.17.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Physical Exam Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion -A3</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Waist circumference</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I am going to take a very quick waist and neck measurement and then we are done.</p> </div> <div class="patient-dialogue"> <p> Just tell me what to do.</p> </div> <div class="provider-dialogue"> <p>If you'll just hold this tape measure in front of you on your abdomen, just above your hips, I'll take the two ends around behind you. <em>[Measures waist]</em> Okay, you're at 41 inches.</p> </div> <div class="patient-dialogue"> <p> That was quick. Do you do this with all of your patients?</p> </div> <div class="provider-dialogue"> <p>Yes, during annual visits it is very routine. Let's get that neck measurement and you are all done. <em>[Now measuring]</em> Alright, 17 inches. </p> </div> <div class="patient-dialogue"> <p> What does all this mean?</p> </div> <div class="provider-dialogue"> <p>In addition to the health risks I mentioned with BMI, waist circumference is better at predicting heart disease. 35 inches is the cutpoint and you are at 41 inches. For the neck measurement, that may tell me more about your sleep problems. A neck circumference over 16 inches means greater risk for sleep apnea, which might be responsible for your sleep problems. I want to be thorough and rule out other potential causes for sleep problems, though. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Physical Exam Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - A1</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Bioelectric impedance analysis</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="patient-dialogue"> <p> <em>[Getting fidgety sitting on the exam table.]</em> I'm about ready to get off this table.</p> </div> <div class="provider-dialogue"> <p>Good timing, because we need to take just a few more measurements and I need you standing.</p> </div> <div class="patient-dialogue"> <p> Thank goodness.</p> </div> <div class="provider-dialogue"> <p><em>[Removing a scale from the cabinet]</em> I want to measure your body mass using this scale here. It sends an electric signal through your body, giving an estimate of your body mass. Have you had a lot of water today?</p> </div> <div class="patient-dialogue"> <p> The usual amount, I guess. </p> </div> <div class="provider-dialogue"> <p>Okay, let's get a few readings from this scale. This unit is pretty old and it can vary. <em>[Scale records the 38% and 40% body fat]</em></p> </div> </div> </div> <div class="navigation"><div class="question">How do you think you should complete this exam after taking a re-calibrated BIA measurement?</div> <div class="continue">[[Finish physical exam and continue with the appointment]] </div> <div class="continue">[[Gather BMI and waist circumference]] </div> <div class="continue">[[Calibrate the scale and repeat]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Question - B</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Dual-energy x-ray absorptiometry</div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p>We are actually going to walk down to one of our research rooms. We have a brand new machine that I'm excited to use called DXA, or Dual-Energy X-ray Absorptiometry. It can accurately measure your body mass.</p></div> <div class="patient-dialogue"><p> Sounds neat.</p></div> <div class="provider-dialogue"><p><em>[entering room]</em> Okay, I need you to lay on this table, underneath the scanner.</p></div> <div class="patient-dialogue"><p> I'm pretty sure I won't fit under that machine. <em>[she cocks her head at you, eyes open wide]</em></p></div> <div class="provider-dialogue"><p>Hmmmm, I guess we can't use this measurement.</p></div> <div class="note"><em>[The walk back to the room is awkward.]</em><br/></div> </div> <div class="navigation"><div class="question">Ms Jones' body mass still needs to be evaluated. What approach should you take walking back to the exam room?</div> [[Apologize and offer alternative measurements]] [[Offer the pool for a hydrostatic measurement]] </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Question - C</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Finish physical exam and continue with the appointment</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="note"><em>[The exam was continued which was otherwise normal.]</em></div> <div class="provider-dialogue"> <p>Okay, Ms. Jones, we are all done with the exam. There are a few things I would like to explore further.</p> </div> <div class="patient-dialogue"> <p> Does anything jump out at you about my sleep problems?</p> </div> <div class="provider-dialogue"> <p>There is nothing definite so far. Other than your elevated body mass that we discussed earlier, I didn't find anything out of the ordinary in your physical exam. There are tests that could potentially give some answers about your sleep problems. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Physical Exam Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - B1</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Gather BMI and waist circumference</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>This scale is pretty old. I'd like to try another type of measurement. The computer automatically calculated your BMI to be 38.6, but I would also like to get your waist circumference.</p> </div> <div class="patient-dialogue"> <p> Okay, why do you need those?</p> </div> <div class="provider-dialogue"> <p>Calculating your body mass will give me important information for assessing certain health risks. </p> </div> <div class="patient-dialogue"> <p> Oh really? Like what?</p> </div> <div class="provider-dialogue"> <p>A waist circumference can better predict heart disease than simply your weight. </p> </div> <div class="note"><em>[The tape measurer is held in front of Ms. Jones' abdomen, just above her hips, and a measurement of 41 inches is recorded.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Physical Exam Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - B2</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Calibrate the scale and repeat</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Let me calibrate this scale and we will try again in just a minute.</p> </div> <div class="note"><em>[Ms. Jones sighs]</em></div> <div class="provider-dialogue"> <p>We've got it ready to go.</p> </div> <div class="note"><em>[Ms. Jones steps on the scale and two new measurements are recorded, both 36% body fat.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Physical Exam Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - B3</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Apologize and offer alternative measurements</div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p> I am so sorry, Ms. Jones. I just glanced at the machine earlier. It really didn't look so small from the doorway. There are plenty other measurements we can use.</p></div> <div class="patient-dialogue"><p> Oh, it's okay. I was tired of that exam room anyway. This has been a nice little field trip. The blow to my ego is only minor.</p></div> <div class="note"><em>[you senses Ms. Jones' sarcasm.]</em></div> <div class="provider-dialogue"><p><em>[Now returning to the clinic room]</em> I sincerely apologize for that. These other measurements are very standard. One is a body mass index measurement, calculating your body mass using your height and weight measurements. The other is a waist measurement. It is very important we take these to assess certain health risks. </p></div> <div class="patient-dialogue"><p> Really, like what? </p></div> <div class="provider-dialogue"><p>For example, waist circumference predicts heart disease better than measuring your weight and height.</p></div> <div class="patient-dialogue"><p> Oh man, I'm getting a little tired of all this talk about my weight.</p></div> <div class="provider-dialogue"><p>I understand, but it's an important part of the physical. I use these measurements with all my patients.</p></div> <div class="patient-dialogue"><p> Oh, alright. But, don't think this is going to change anything.</p></div> <div class="provider-dialogue"><p>Okay, now, if you'll just hold this tape measure in front of you on your abdomen, just above your hips, I'll take two ends around behind you.</p></div> <div class="note">[You record 41 inches.]</div> </div> <div class="navigation"> <div class="continue">[[Physical Exam Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - C2</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Offer the pool for a hydrostatic measurement</div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p>Being a research hospital, this is just one of many of our machines we can use to calculate your body fat percentage. We also have a pool for a hydrostatic measurement. It is very accurate and pretty neat. </p></div> <div class="patient-dialogue"><p> I didn't really come today prepared to take a dip in a pool. Why do you need to do all of this again?</p></div> <div class="provider-dialogue"><p>Calculating your body mass is an important measurement for your physical today. It alerts me for potential health risks. There are other measurements I can take, though. Let's get back to the room and just take some measurements.</p></div> <div class="patient-dialogue"><p> Let's do that. I definitely don't have all day to be poolside. [Her giggling is a little forced.]</p></div> <div class="note">[you takes a mental note of her nervous laughter.]</div> </div> <div class="navigation"> <div class="continue">[[Physical Exam Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Discussion - C1</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice">Physical Exam Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question">Your <u>first choice</u> for assessing overweight/obesity: </div><div class="response">DEXA</div> DEXA machines have a limited scanning area and not the best choice for quick assessment. The correct answer would have been BMI, <em>"Body Mass Index"</em>. A better choice would have been <em>"Body mass index"</em>. <strong>BMI</strong> is still the major recommended standard used to: <ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul> Ms. Jones' BMI is 38.6, putting her at higher risk for developing heart disease, diabetes, and high cholesterol and blood pressure.<br/></div> <div class="feedback neutral"> <div class="question">Your <u>second choice</u> for assessing overweight/obesity: </div><div class="response">Offer the pool for a hydrostatic measurement</div> While a hydrostatic measurement is indeed a very accurate measurement for body fat percentage, it is not efficient or practical. The best answer to get back on track would have been to <em>"Apologize and offer other measurements"</em>, although initially choosing the DEXA machine for an obese patient would be pretty difficult to recover from. In fact, the selection to <em>"Use an authoritative approach"</em> resulted in Ms. Jones walking out of the appointment! <br/> After calculating BMI, obesity treatment guidelines recommend a <strong>waist circumference</strong> measurement at annual visits and more often in patients who are overweight or obese. It is easy to complete, as well as a reliable indicator for heart disease. (Jensen et al., 2013). </div> <div class="summary"> <h4>Measurement Summary Moving Forward</h4> you now has Ms. Jones' BMI calculated (38.6kg/m2) and determines her body mass diagnosis:<br/> <table style="width: 100%; text-align: left;"><tbody><tr><th style="width: 33%;">BMI (kg/m2)</th><th style="width: 33%;">Category</th><th style="width: 33%;">ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table><p class="gray-border"><strong>Diagnosis:</strong> Obesity E66.9</p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006): <ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul> With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.<br/> At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </div> </div> <div class="navigation"> <div class="stop">For usability testers, please stop here to answer a few questions about your experience so far.</div> <strong>OR</strong> For more information about the guidelines, see:<br/> Body Mass Measurement Guidelines</br> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - C1a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice">Physical Exam Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question">Your <u>first choice</u> for assessing overweight/obesity: </div><div class="response">DEXA</div> While DEXA machines provide reliable body mass measurements, they also have a limited scanning areas and not the best choice for quick assessment. The correct answer among these choices would have been BMI, A better choice would have been <em>"Body mass index"</em>. <strong>BMI</strong> is still the major recommended standard used to: <ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul> Ms. Jones' BMI is 38.6, putting her at higher risk for developing heart disease, diabetes, and high cholesterol and blood pressure.<br/></div> <div class="feedback correct"> <div class="question">Your <u>second choice</u> for assessing overweight/obesity: </div><div class="response">Apologize and offer alternative measurements</div> Good recovery. You chose the most useful option to help you recover from the poor decision to use the DEXA machine that left Ms. Jones feeling very uncomfortable. Obesity treatment guidelines also recommend a <strong>waist circumference</strong> measurement at annual visits and more often in patients who are overweight or obese. It is easy to complete, as well as a reliable indicator for heart disease. (Jensen et al., 2013). </div> <div class="summary"> <h4>Measurement Summary Moving Forward</h4> you now has Ms. Jones' BMI calculated (38.6kg/m2) and determines her body mass diagnosis:<br/> <table style="width: 100%; text-align: left;"><tbody><tr><th style="width: 33%;">BMI (kg/m2)</th><th style="width: 33%;">Category</th><th style="width: 33%;">ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006): <ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul> With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.<br/> At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </div> </div> <div class="navigation"> <div class="stop">For usability testers, please stop here to answer a few questions about your experience so far.</div> <strong>OR</strong> For more information about the guidelines, see:<br/> Body Mass Measurement Guidelines</br> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - C2a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Physical Exam Summary F</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What body mass measurement should you review or perform with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Bioelectric impedance analysis</div><p>BIA can be a very valuable tool, depending on the condition of the instrument and the time required to maintain it. In this case, the instrument has known problems and turns out to be an unreliable measurement tool. A better choice would have been <em>"Body mass index"</em>. <strong>BMI</strong> is still the major recommended standard used to:</p><ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul> Ms. Jones' BMI is 38.6, putting her at higher risk for developing heart disease, diabetes, and high cholesterol and blood pressure.</div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How do you think you should complete this exam after taking a re-calibrated BIA measurement?</div> <div class="response"><strong>You chose:</strong> Calibrate the Scale and Repeat</div><p>Since most providers do not have the luxury of time in their appointments with patients, spending precious moments calibrating the scale may not be a good use of valuable time with Ms. Jones. A better choice would have been to <em>"Take a different body mass measurement"</em>. Obesity treatment guidelines also recommend a <strong>waist circumference</strong> measurement at annual visits and more often in patients who are overweight or obese. It is easy to complete, as well as a reliable indicator for heart disease. (Jensen et al., 2013).</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong> Skinfold thickness and waist-to-hip ratio: These measurements can be valuable tools for measuring central adiposity, but there are limitations using these measurements for those with a BMI of 35 or higher (Hu et al., 2014). </div> <div class="summary"><h4>Measurement Summary</h4> Ms. Jones' BMI was calculated (38.6kg/m2) and her body mass diagnosis determined from the following:<table style="width: 60%;"><tbody><tr><th>BMI (kg/m2)</th><th>Category</th><th>ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table><p><strong>Diagnosis:</strong> Obesity E66.9</p><p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006):</p><ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul><p>With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.</p><p>At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </p><div class="more">[[View the Obesity Treatment Algorithm]]</div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - B3a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Physical Exam Summary E</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What body mass measurement should you review or perform with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Bioelectric impedance analysis</div><p>BIA can be a very valuable tool, depending on the condition of the instrument and the time required to maintain it. In this case, the instrument has known problems and turns out to be an unreliable measurement tool. A better choice would have been <em>"Body mass index"</em>. <strong>BMI</strong> is still the major recommended standard used to:</p><ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul>Ms. Jones' BMI is 38.6, putting her at higher risk for developing heart disease, diabetes, and high cholesterol and blood pressure.</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How do you think you should complete this exam after taking a re-calibrated BIA measurement?</div> <div class="response"><strong>You chose:</strong> Gather BMI and Waist Circumference</div><p>Fantastic clinical decision! Ms. Jones' BMI was confirmed and <strong>waist circumference</strong> was measured. Obesity treatment guidelines also recommend this measurement at annual visits and more often in patients who are overweight or obese (Jensen et al., 2013).</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong> Skinfold thickness and waist-to-hip ratio: These measurements can be valuable tools for measuring central adiposity, but there are limitations using these measurements for those with a BMI of 35 or higher (Hu et al., 2014). </div> <div class="summary"><h4>Measurement Summary</h4> Ms. Jones' BMI was calculated (38.6kg/m2) and her body mass diagnosis determined from the following:<table style="width: 60%;"><tbody><tr><th>BMI (kg/m2)</th><th>Category</th><th>ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table><p><strong>Diagnosis:</strong> Obesity E66.9</p><p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006):</p><ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul><p>With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.</p><p>At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </p><div class="more">[[View the Obesity Treatment Algorithm]]</div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - B2a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Physical Exam Summary D</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What body mass measurement should you review or perform with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Bioelectric impedance analysis</div><p>BIA can be a very valuable tool, depending on the condition of the instrument and the time required to maintain it. In this case, the instrument has known problems and turns out to be an unreliable measurement tool. A better choice would have been <em>"Body mass index"</em>. <strong>BMI</strong> is still the major recommended standard used to:</p><ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul><p>Ms. Jones' BMI is 38.6, putting her at higher risk for developing heart disease, diabetes, and high cholesterol and blood pressure. </p><p>See the table below for BMI categories and classes.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How do you think you should complete this exam after taking a re-calibrated BIA measurement?</div> <div class="response"><strong>You chose:</strong> Finish physical exam and continue</div><p>A better choice here would have been <em>"Take a different body mass measurement"</em>. Obesity treatment guidelines also recommend a <strong>waist circumference</strong> measurement at annual visits and more often in patients who are overweight or obese. This would have been a great additional measurement for Ms. Jones. It is easy to complete, as well as a reliable indicator for heart disease. (Jensen et al., 2013). </p></div> <div class="summary"><strong>Regarding other possible choices: </strong> Skinfold thickness and waist-to-hip ratio: These measurements can be valuable tools for measuring central adiposity, but there are limitations using these measurements for those with a BMI of 35 or higher (Hu et al., 2014). </div> <div class="summary"><h4>Measurement Summary</h4> Ms. Jones' BMI was calculated (38.6kg/m2) and her body mass diagnosis determined from the following:<table style="width: 60%;"><tbody><tr><th>BMI (kg/m2)</th><th>Category</th><th>ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table> <p><strong>Diagnosis:</strong> Obesity E66.9<p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006):</p><ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul><p>With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.</p><p>At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </p><div class="more">[[View the Obesity Treatment Algorithm]]</div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - B1a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Physical Exam Summary B</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What body mass measurement should you review or perform with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Body mass index</div><p>Excellent choice! <strong>BMI</strong> is still the major recommended standard used to:</p><ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul><p>See the table below for BMI categories and classes.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What additional body mass measurement can help you measure Ms. Jones' health risks?</div> <div class="response"><strong>You chose:</strong> Skinfold thickness</div><p>While skinfold measurements can be a valuable tool, there are limitations using the measurement for those with a BMI of 35 or higher (Hu et al., 2014). A better measurement, in this case, would have been <em>"waist circumference"</em>. Obesity treatment guidelines recommend this measurement at annual visits and more often in patients who are overweight or obese (Jensen et al., 2013).</p></div> <div class="summary"><h4>Measurement Summary</h4> Ms. Jones' BMI was calculated (38.6kg/m2) and her body mass diagnosis determined from the following:<table style="width: 60%;"><tbody><tr><th>BMI (kg/m2)</th><th>Category</th><th>ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table><p><strong>Diagnosis:</strong> Obesity E66.9</p><p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006):</p><ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul> <p>With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.</p><p>At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </p><div class="more">[[View the Obesity Treatment Algorithm]]</div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - A2a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Physical Exam Summary A</div> <div class="container"> <div class="inner"> <div class="evaluation_points full">You have received full points for this encounter!</div> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What body mass measurement should you review or perform with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Body mass index</div><p>Excellent choice! <strong>BMI</strong> is still the major recommended standard used to:</p><ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul><p>*See the table below for BMI categories and classes.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What additional body mass measurement can help you measure Ms. Jones' health risks?</div> <div class="response"><strong>You chose:</strong> Waist Circumference</div><p>Fantastic clinical decision! Obesity treatment guidelines recommend a <strong>waist circumference</strong> measurement at annual visits and more often in patients who are overweight or obese (Jensen et al., 2013).</p><p>With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease. It should be noted that central adiposity can be assumed for patients over a BMI of 30kg/m2. However, a baseline waist measurement is also helpful for tracking patient progress.</p><p>A neck measurement of 17 inches was also obtained. A neck measurement of over 16 inches in women (over 17 inches in men) may suggest sleep apnea/reduced sleep (Shlisky et al., 2012). </p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Bioelectric impedance analysis: This measurement is able to estimate the composition of body fat in patients, since fat "impedes" the electric signal of a BIA device. BIA can be a very valuable tool. Some devices are more accurate than others and BMI remains the standard measurement. Skinfold thickness and waist-to-hip ratio: These measurements can be valuable tools as well, but there are limitations using these measurements for those with a BMI of 35 or higher (Hu et al., 2014).</p></div> <div class="summary"><h4>Measurement Summary</h4> Ms. Jones' BMI was calculated (38.6kg/m2) and her body mass diagnosis determined from the following:<table style="width: 60%;"><tbody><tr><th>BMI (kg/m2)</th><th>Category</th><th>ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table><p><strong>Diagnosis:</strong> Obesity E66.9</p><p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006):</p><ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul><p>At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </p><div class="more">[[View the Obesity Treatment Algorithm]]</div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - A1a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice objective"><strong>III.</strong>Diagnostic Tests and Screening</div>[[Diagnostic Tests and Screening Objectives]] <div class="container"> <div class="inner"> <div class="results"><p>History and physical exam are now complete and you have briefly discussed the diagnosis of Class II Obesity with Ms. Jones, especially her higher risk for many health problems related to her elevated weight. Additional assessments may be necessary to obtain a comprehensive medical evaluation.</p><p><h4>Medical and Family History Summary</h4></p><ul><li>Intermittently elevated blood pressure</li><li>Medications: Women's multivitamin, IUD</li><li>A family history of both parents being overweight/obese</li><li>Mother-cervical cancer</li><li>Father-pancreatic cancer, died of a stroke</li><li>Good support system to cope with stress (socializes with caring family and friends often)</li></ul><p><h4>Physical Summary</h4></p><ul><li>Obesity diagnosis E66.9</li><li>Class II Obesity</li><li>Waist circumference: 41 inches (high risk for CVD)</li></ul></div> </div> <div class="navigation"><div class="question">What medical assessments should be considered at this point based on her body mass diagnosis and other findings?</div> <div class="continue"> [[Order labs and refer to a sleep specialist]] </div> <div class="continue">[[Evaluate for Anxiety Disorder]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Order labs and refer to a sleep specialist</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I am going to suggest we do some tests to get a broader view of your general health. How does that sound to you? </p> </div> <div class="patient-dialogue"> <p> Okay. You think that'll give more information about my sleep problems?</p> </div> <div class="provider-dialogue"> <p>I'm actually going to send you to a sleep specialist to get some more specifics about your sleep problem. With your neck circumference being 17 inches, your problems could be from sleep apnea.</p> </div> <div class="patient-dialogue"> <p>Sleep specialist? That sounds great! And what about these other tests? What type of information do you want to get? </div> <div class="note">Before answering Ms. Jones' questions about the tests, you talk with her about what she should expect when she goes to the appointment with the sleep specialist.</div> </div> </div> <div class="navigation"><div class="question">In addition to a basic metabolic panel, what tests should you order for Ms. Jones' work-up for weight-related comorbidities?</div> <div class="continue">[[Thyroid HbA1C Lipids Liver VitD]] </div> <div class="continue">[[Basic Metabolic Panel Only]] </div> <div class="continue">[[Thyroid Test Only]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Question - A</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice objective"><strong>IV.</strong> Lifestyle Screening and Assessment</div>[[Lifestyle Screening and Assessment Chapter Objectives]] <div class="container"> <div class="inner short"> <div class="summary"><p>Quick recap: Ms. Jones has presented for a physical and has been diagnosed with moderately severe (Class II) obesity with central adiposity. In a few encounters, Ms. Jones gets very uncomfortable discussing her weight, but she does seem open to discussing her diet. She was referred to a sleep specialist for probable sleep apnea (due to a neck circumference over 16 inches and her sleepless symptoms). The lab results for common obesity-related comorbidities will be available in the next few days.</p></div> </div> <div class="navigation"><div class="question">To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="continue">[[Stress coping and diet]] </div> <div class="continue">[[Sleep interventions]] </div> <div class="continue">[[Exercise goals]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Diagnostic Tests and Screening Summary B</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What medical assessments should be considered at this point based on her body mass diagnosis and other findings?</div> <div class="response"><strong>You chose:</strong> Order labs and refer to a sleep specialist</div><p>Great choice! A sleep specialist will perform a polysomnography, or sleep study, which is an ideal evaluation for sleep apnea. Weight loss is an important treatment for this condition. Symptoms for sleep apnea include:</p><ul><li>daytime sleepiness</li><li>unrefreshing sleep</li><li>fatigue</li><li>snoring</li></ul><p>Sleep apnea also has an association with the following:</p><ul><li>cardiovascular diseases</li><li>type 2 diabetes</li><li>metabolic abnormalities</li><li>cognitive impairment</li><li>deterioration of the quality of life and working capacity</li><li>increased mortality</li></ul><p>Patients with symptoms of sleep apnea are often referred to a specialist. The choice also referenced you ordering labs. The following eight diseases/conditions are most likely to co-occur with obesity. They include both conditions caused by the fat mass and metabolic changes.</p><ul><li>Cardiovascular Disease *overweight and obese women are also at a higher risk for ischemic stroke (Rexrode et al., 2016)</li><li>Type 2 Diabetes Mellitus</li><li>Hypertension</li><li>Dyslipidemia</li><li>Sleep apnea</li><li>Osteoarthritis and other physical functioning problems</li><li>Gall bladder disease</li><li>Cancer: Breast, Colon, and others</em></li></ul> </div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> In addition to a basic metabolic panel, what tests should you order for Ms. Jones' work-up for weight-related comorbidities?</div> <div class="response"><strong>You chose:</strong> Basic Metabolic Panel Only</div><p>A basic metabolic panel is a very common order for an overview of Ms. Jones' health, and typical for a physical exam. However, more tests may be needed at this time. The choice to do labs for thyroid, HbA1C, lipid profile, liver function, and vitamin D in addition to the metabolic panel would have been the best decision. These are a few laboratory tests that can be used to test for common comorbidities associated with obesity, such as diabetes, dyslipidemia, and NAFLD (non-alcoholic fatty liver disease). Vitamin D deficiencies are relatively common in patients with obesity. Supplementation is indicated for vitamin D levels below the normal range. </p><div class="more">[[View Lab Tests for Common Comorbid Conditions]]</div></div> <div class="summary"><strong>Regarding other possible choices: </strong><p> Evaluate for Anxiety Disorder: Many clinics have a form, like the PHQ (Kurt et al., 2001) to screen for mental health problems upon patient check-in. Ms. Jones had not self-reported any signs or symptoms of mood or anxiety disorders on the mental health evaluation form. It should be noted that the odds of having a mood or anxiety disorder are increased approximately 25% with obesity (Simon et al., 2006). These comorbidities need to be recognized and treated in conjunction with weight management. Hormonal changes to consider: Some hormonal conditions known to cause weight gain include hypogonadism, low testosterone, polycystic ovary syndrome, growth hormone imbalance and Cushing's disease (Mechanick et al., 2013).</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Summary - A1a</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Diagnostic Tests and Screening Summary C</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What medical assessments should be considered at this point based on her body mass diagnosis and other findings?</div> <div class="response"><strong>You chose:</strong> Refer to a sleep specialist and order labs</div><p>Great choice! A sleep specialist will perform a polysomnography, or sleep study, which is an ideal evaluation for sleep apnea. Weight loss is an important treatment for this condition. Symptoms for sleep apnea include:</p><ul><li>daytime sleepiness</li><li>unrefreshing sleep</li><li>fatigue</li><li>snoring</li></ul><p>Sleep apnea also has an association with the following:</p><ul><li>cardiovascular diseases</li><li>type 2 diabetes</li><li>metabolic abnormalities</li><li>cognitive impairment</li><li>deterioration of the quality of life and working capacity</li><li>increased mortality</li></ul>Patients with symptoms of sleep apnea are often referred to a specialist. The choice also referenced you ordering labs. The following eight diseases/conditions are most likely to co-occur with obesity. They include both conditions caused by the fat mass and metabolic changes.<ul> <li>Cardiovascular Disease *overweight and obese women are also at a higher risk for ischemic stroke (Rexrode et al., 2016)</li><li>Type 2 Diabetes Mellitus</li><li>Hypertension</li><li>Dyslipidemia</li> <li>Sleep apnea</li><li>Osteoarthritis and other physical functioning problems</li><li>Gall bladder disease</li><li>Cancer: Breast, Colon, and others</em></li></ul></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> In addition to a basic metabolic panel, what tests should you order for Ms. Jones' work-up for weight-related comorbidities?</div> <div class="response"><strong>You chose:</strong> Thyroid Test Only</div><p> Thyroid function is an important lab or order, but this dialogue choice fails to address some potential health risks for comorbidities or conditions associated with Ms. Jones' obesity. The choice to do labs for thyroid, HbA1C, lipid profile, liver function, and vitamin D, in addition to the metabolic panel, would have been the best decision. Those are a few laboratory tests that can be used to test for common comorbidities associated with obesity, such as diabetes, dyslipidemia, and NAFLD (non-alcoholic fatty liver disease). Vitamin D deficiencies are relatively common in patients with obesity. Supplementation is indicated for vitamin D levels below the normal range. </p><div class="more">[[View Lab Tests for Common Comorbid Conditions]]</div></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Evaluate for Anxiety Disorder: Many clinics have a form, like the PHQ (Kurt et al., 2001) to screen for mental health problems upon patient check-in. Ms. Jones had not self-reported any signs or symptoms of mood or anxiety disorders on the mental health evaluation form. It should be noted that the odds of having a mood or anxiety disorder are increased approximately 25% with obesity (Simon et al., 2006). These comorbidities need to be recognized and treated in conjunction with weight management. Hormonal changes to consider: Some hormonal conditions known to cause weight gain include hypogonadism, low testosterone, polycystic ovary syndrome, growth hormone imbalance and Cushing's disease (Mechanick et al., 2013).</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation Summary - A3a</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Polysomnography</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I would like to also refer you to the sleep clinic, in order to get a better idea of what is going on in your sleep. Will you be able to commit one evening to do that?</p> </div> <div class="patient-dialogue"> <p> Definitely, if we can get to the bottom of my problems. What will they do there?</p> </div> <div class="provider-dialogue"> <p>You will stay there the whole night and they will collect various data while you sleep, like your brain waves, oxygen levels, breathing patterns, etc. This will give us a great idea what is going on with your sleep.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Diagnostic Tests and Screening Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Discussion - B1</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Hormonal changes</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>We will be looking at a lot of blood tests today. I also want to order a few more tests. </p> </div> <div class="patient-dialogue"> <p> Might as well.</p> </div> <div class="provider-dialogue"> <p>I know you don't want to talk about your weight, but since you have gained a certain percentage since your last visit, I'd like to rule out some conditions that may cause weight gain. </p> </div> <div class="patient-dialogue"> <p> What condition can cause weight gain?</p> </div> <div class="provider-dialogue"> <p> There are a variety of hormonal imbalances that can cause weight gain.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Diagnostic Tests and Screening Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Discussion - B2</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Diagnostic Tests and Screening Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What medical assessments should be considered at this point based on her body mass diagnosis and other findings?</div> <div class="response"><strong>You chose:</strong> Evaluate for Anxiety Disorder</div><p>The odds of having a mood or anxiety disorder are increased approximately 25% with obesity (Simon et al., 2006). These comorbidities need to be recognized and treated in conjunction with weight management. Ms. Jones had not self-reported any signs or symptoms of mood or anxiety disorders on the mental health evaluation form. Many clinics have a form, like the PHQ (Kurt et al., 2001) to screen for mental health problems upon patient check-in. A better choice here would have been <em>"Test for additional comorbidities"</em>. The following eight diseases/conditions are most likely to co-occur with obesity. They include both conditions caused by fat mass and metabolic changes.</p><ul><li>Cardiovascular Disease</li><li>Type 2 Diabetes Mellitus</li><li>Hypertension</li><li>Dyslipidemia</li><li>Sleep apnea</li><li>Osteoarthritis and other physical functioning problems</li><li>Gall bladder disease</li><li>Cancer: Breast, Colon, and others</li></ul><div class="more">[[View Lab Tests for Common Comorbid Conditions]]</div></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What tests do you think you should request next?</div> <div class="response"><strong>You chose:</strong> Polysomnography</div><p>Great choice! A polysomnography, or sleep study, is an ideal evaluation for sleep apnea. Ms. Jones' neck circumference is 17 inches, suggesting sleep apnea. Weight loss is an important treatment for this condition. Symptoms for sleep apnea include:</p><ul><li>daytime sleepiness</li><li>unrefreshing sleep</li><li>fatigue</li><li>snoring</li></ul><p>Sleep apnea also has an association with the following:</p><ul><li>cardiovascular diseases</li><li>type 2 diabetes</li><li>metabolic abnormalities</li><li>cognitive impairment</li><li>deterioration of the quality of life and working capacity</li><li>increased mortality</li></ul><p>Patients with symptoms of sleep apnea are often referred to a specialist.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Summary - B1a</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Diagnostic Tests and Screening Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> What medical assessments should be considered at this point based on her body mass diagnosis and other findings?</div> <div class="response"><strong>You chose:</strong> Evaluate for Anxiety Disorder</div> <p>The odds of having a mood or anxiety disorder are increased approximately 25% with obesity (Simon et al., 2006). These comorbidities need to be recognized and treated in conjunction with weight management. Ms. Jones had not self-reported any signs or symptoms of mood or anxiety disorders on the mental health evaluation form. Many clinics have a form, like the PHQ (Kurt et al., 2001), to screen for mental health problems upon patient check-in.</p><p>A better choice here would have been <em>"Test for additional comorbidities"</em>. The following eight diseases/conditions are most likely to co-occur with obesity. They include both conditions caused by the fat mass and metabolic changes.</p><ul><li>Cardiovascular Disease</li><li>Type 2 Diabetes Mellitus</li><li>Hypertension</li><li>Dyslipidemia</li><li>Sleep apnea</li><li>Osteoarthritis and other physical functioning problems</li><li>Gall bladder disease</li><li>Cancer: Breast, Colon, and others</li></ul><div class="more">[[View Lab Tests for Common Comorbid Conditions]]</div></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What tests do you think you should request next?</div> <div class="response"><strong>You chose:</strong> Hormonal changes</div><p>This is a good choice for this particular path. Hormonal conditions can be ruled out on an as needed basis. Some hormonal conditions known to cause weight gain include hypogonadism, low testosterone, polycystic ovary syndrome, growth hormone imbalance and Cushing's disease (Mechanick et al., 2013). Even though this lab could be useful, for Ms. Jones' current problems, an even better choice for the second evaluation would have been to refer her to a sleep study, <em>"Polysomnography"</em>.</p><p>Polysomnographies are an ideal evaluation for sleep apnea. Ms. Jones' neck circumference is 17 inches, suggesting sleep apnea along with her signs of symptoms revealed in her interview. Weight loss is an important treatment for this condition. Symptoms for sleep apnea include:</p><ul><li>daytime sleepiness</li><li>unrefreshing sleep</li><li>fatigue</li><li>snoring</li></ul><p>Sleep apnea also has an association with the following:</p><ul><li>cardiovascular diseases</li><li>type 2 diabetes</li><li>metabolic abnormalities</li><li>cognitive impairment</li><li>deterioration of the quality of life and working capacity</li><li>increased mortality</li></ul><p>Patients with symptoms of sleep apnea are often referred to a specialist.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Summary - B2a</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Evaluate for Anxiety Disorder</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="note"><em>[Upon checking the computer, no positive screen for any psychiatric disorders are found.]</em></div> <div class="provider-dialogue"> <p>I viewed your record earlier and it is all updated with the current information you filled out when you arrived. Just wanted to double check that we haven't missed anything.</p> </div> <div class="patient-dialogue"> <p> Good. I spent a lot of time on those forms!</p> </div> <div class="provider-dialogue"> <p>It's all here. I think we have everything we need to get your blood drawn. We are going to do an overall evaluation of your health and it will include things like your cholesterol and blood sugar.</p> </div> </div> </div> <div class="navigation"><div class="question">What tests do you think you should request next?</div> <div class="continue">[[Polysomnography]] </div> <div class="continue">[[Hormonal changes]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Question - B</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> No other labs</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="note">Ms. Jones' last question to you was, "And what about these other tests? What type of information do you want to get?"</div> <div class="provider-dialogue"> <p> Once we see the results of these thyroid tests, I’ll see if I have any further recommendations for lab work.</p> </div> <div class="patient-dialogue"> <p> Okay. Do you think my sleep problems could be because my thyroid isn’t working like it should?</p> </div> <div class="provider-dialogue"> <p> At this point, I'm ruling out an enlargement of your thyroid due to the neck measurement we got earlier. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Diagnostic Tests and Screening Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Discussion - A3</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Stress coping and diet</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>You mentioned earlier that you were really stressed about the passing of your dad, but you were starting to feel better. What changes have you been making to feel that way?</p> </div> <div class="patient-dialogue"> <p> I think time has helped me heal. But, I am also much closer with my sister these days. We meet a lot for dinner during the week, especially since this all happened. It's been the best thing for us.</p> </div> <div class="provider-dialogue"> <p>Good, I'm glad to hear you have that. What does a typical evening look like for you?</p> </div> <div class="patient-dialogue"> <p> We usually go out to eat or go to each other's house for a wine and cheese hour. She has been my best friend through all of this.</p> </div> <div class="provider-dialogue"> <p>I can tell this is an important tradition you have started. <em>[A quick glance at the diet assessment Ms Jones completed]</em> When you do cook at home, I see you prepare foods for yourself, like chicken, fish, beans. All very healthy foods.</p> </div> <div class="patient-dialogue"> <p> I try to cook them when I have time, but usually I just grab what I can if I'm not out with my sister. I do eat fast food a lot. Burgers and fries are just too convenient. </p> </div> </div> </div> <div class="navigation"><div class="question">In an effort to start eliciting ideas from Ms. Jones to start thinking about how she could alter her diet, you could say:</div> <div class="continue">[[I urge you to avoid eating out]] </div> <div class="continue">[[Tell me more about cooking at home]] </div> <div class="continue">[[I can offer much better alternatives]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - B</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Sleep interventions</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Okay, Ms. Jones. We have ordered your labs, you have completed all the paperwork, and we are well on our way. Can I ask you some more questions?</p> </div> <div class="patient-dialogue"> <p> Of course.</p> </div> <div class="provider-dialogue"> <p>Before we get the results from your sleep study, I just want to gauge your interest in keeping a sleep diary. You would keep it for a week or two to keep track of any problem sleep patterns and contributing factors, like drinking caffeine. </p> </div> <div class="patient-dialogue"> <p> I might be able to do that.</p> </div> <div class="provider-dialogue"> <p>Excellent.</p> </div> </div> </div> <div class="navigation"><div class="question">Next, you want to begin some diet and exercise interventions. How should the conversation with Ms. Jones continue, using patient-centered interviewing skills?</div> <div class="continue">[[Tell me about your diet and exercise]]</div> <div class="continue">[[Do you eat well and are you active]] </div> <div class="continue">[[What are you doing about your recent weight gain]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - A</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Exercise goals</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Exercise is an important part of a weight management plan which is important for many aspects of your health, including treating sleep problems. Can we talk about that?</p> </div> <div class="patient-dialogue"> <p> Sure.</p> </div> <div class="provider-dialogue"> <p>You've told me that you walk some at work. Is this right?</p> </div> <div class="patient-dialogue"> <p> Yes, sometimes I really just need to get outside and take a break from looking at the computer screen, and co-workers join me at times so I get to socialize a little bit, as well. We walk for about 15-30 minutes. It's a pretty good way to get a break.</p> </div> <div class="provider-dialogue"> <p>: I'm glad you are walking regularly -- that’s a great start! However, it‘s recommended that you get two and a half hours of moderate-intensity activity per week, or 75 minutes of intense aerobic activity. It's also important to be doing strength training for at least two days a week to maintain muscle tone that helps burn more calories at rest. Adding more intense cardio and strength training will help with weight loss.</p> </div> <div class="patient-dialogue"> <p> But I get winded just walking to the parking deck everyday!</p> </div> </div> </div> <div class="navigation"><div class="question">How could you continue this conversation to get more feedback from Ms. Jones about making exercise goals?</div> <div class="continue">[[See what changes she is willing to make to increase activity]] </div> <div class="continue">[[Show her a physical activity plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - C</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Tell me more about cooking at home</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Tell me more about cooking at home.</p> </div> <div class="patient-dialogue"> <p> Oh, I love to cook. My mom taught me everything I know. I do notice a difference when I'm not eating out so much. I'm not sure if it is because I am less busy and less stressed or eating healthier foods at home. I definitely feel better when I'm not so busy. I will be honest, I do love a good burger, though!</p> </div> <div class="provider-dialogue"> <p> Being less stressed and eating a healthy diet will both contribute to your overall health. Is lack of time the most challenging part about eating those healthier foods at home?</p> </div> <div class="patient-dialogue"> <p> No, I also just have food cravings! I start wanting something sweet or greasy and once I get the idea in my head, it's hard not to go ahead and eat something I shouldn't. </p> </div> <div class="provider-dialogue"> <p> Food cravings can feel very powerful! Can I make some suggestions? </p> </div> <div class="patient-dialogue"> <p> Sure.</p> </div> <div class="provider-dialogue"> <p> To fight off any food cravings, try drinking water, eating lots of vegetables, and not skipping meals. If you do get a craving, taking deep breaths or distracting yourself by doing something else can help them go away. If you can, try delaying a half hour before reaching for junk or fast food.</p> </div> <div class="patient-dialogue"> <p> I'll definitely try that. I probably need to take a look at my schedule, too. Seems like if I just slow down a bit, that would help in several areas of my health. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - B1</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> I urge you to avoid eating out</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Ms. Jones, I urge you to avoid eating out. Foods in restaurants tend to have bigger portions and are often loaded with salt and fat. These could lead to problems with your heart, your blood pressure, and put you at risk for diabetes.</p> </div> <div class="patient-dialogue"> <p> I tried bringing my lunch, but I'm always rushing around in the morning and never have time to pack anything, so I end up getting something from the cafeteria or a drive-thru.</p> </div> <div class="provider-dialogue"> <p>Is lack of time the most challenging part about changing your diet so you can lose weight and then maintain a healthy weight?</p> </div> <div class="patient-dialogue"> <p> No, I also have food cravings! I start wanting something sweet or greasy and once I get the idea in my head, it's hard not to go ahead and eat something I shouldn't. </p> </div> <div class="provider-dialogue"> <p> Food cravings can feel very powerful! Avoiding hunger pains is also important. Try drinking water, eating lots of vegetables, and not skipping meals. If you do get a craving, taking deep breaths or distracting yourself by doing something else can help them go away. If you can, try delaying a half hour before reaching for a candy bar or heading to the drive-thru.</p> </div> <div class="patient-dialogue"> <p> Sounds so easy. I can definitely give those a try. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - B2</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> I can offer much better alternatives</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> I know that eating out is convenient, but I can offer better alternatives to fast food and some healthier choices when cooking at home, as well. </p> </div> <div class="patient-dialogue"> <p> Like what? </p> </div> <div class="provider-dialogue"> <p>I can provide you with some websites for fast and easy recipes.</p> </div> <div class="patient-dialogue"> <p> That sounds good. I can check that out maybe.</p> </div> <div class="provider-dialogue"> <p>Great. Making small changes like that will be great for your diet.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - B3</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> See what changes she is willing to make to increase activity</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="note">Ms. Jones has just complained about getting winded and that the recommended level of exercise seems high.</div> <div class="provider-dialogue"> <p>I understand that it would be difficult to just start doing that much exercise all at once. But you could start slowly by adding just a little more exercise each week and then build up. Let's talk about how much of an increase you think you could make at this time.</p> </div> <div class="patient-dialogue"> <p> I could probably add some more days that I walk. I walk with a lady at work a few times a week and enjoy it. She only works a few days, though. I don't mind walking by myself on the other days. It's just not something I thought to do without her.</p> </div> <div class="provider-dialogue"> <p>That's great. It sounds like you already have a route and enjoy that activity. Adding a walk on a couple more days per week is a great start. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - C1</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Show her a physical activity plan</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> You don't need to run a marathon, but I would like to set you up on an activity plan. I have an example of one right here.</p> </div> <div class="patient-dialogue"> <p> Oh, come on. I definitely don't have time to add anything to my plate.</p> </div> <div class="provider-dialogue"> <p>You are already walking for 30 minutes per week. Will adding another hour or two really be that difficult?</p> </div> <div class="patient-dialogue"> <p> Yes, it will be. I just don't have time for that.</p> </div> <div class="provider-dialogue"> <p>You really need to make this a priority, Ms. Jones.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - C2</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Diet</strong> </p></div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p>I'm glad you are willing to consider adding that into your routine. On a scale of one to ten (ten being willing to change), where are you on considering eating out less? </p></div> <div class="patient-dialogue"><p> I'd say a five. </p></div> <div class="provider-dialogue"><p>Eating out is important for keeping up with your sister. Why not lower? </p></div> <div class="patient-dialogue"><p> I mean, I know it can't be good for my health or my wallet to eat out so much, so that's why I said a five. I would be willing to try, I guess, but I'm not so sure I could keep it up. </p></div> <div class="provider-dialogue"><p>I hear that you are willing to give it a try. That's a great attitude moving forward. </p></div> </div> <div class="navigation"> <div class="continue">Lifestyle Summary A</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - A1</p> </div>

<div class="yourchoice"><strong>You Chose:</strong> Physical activity goals</div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p>I'm glad you are willing to consider adding that into your routine. I see on your form that you walk some at work and I see that you walk for 15 minutes, a few times a week. That's it? </p></div> <div class="patient-dialogue"><p> Um, yeah. I'm really busy. </p></div> <div class="provider-dialogue"><p>Can you fit in another 15 minutes? It is recommended that you get two and a half hours of moderate-intensity, or 75 minutes of intense aerobic activity per week. You should also be doing muscle-strengthening of all muscle groups, two or more days a week. </p></div> <div class="patient-dialogue"><p> Doc, I get winded just walking to the parking deck every day! I just came to get medicine to help me sleep and you're signing me up for a marathon.</p></div> </div> <div class="navigation"> <div class="continue">Lifestyle Summary B</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - A2</p> </div>

<div class="yourchoice"><strong>You Chose:</strong> Stress</div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p>[glancing at Ms. Jones' mental health assessment] Things are looking good, stress-wise, even though you have been through a lot lately. You are finding a way to cope with the loss of your dad and that is great.</p></div> <div class="patient-dialogue"><p> Yes, but I don't really feel great. Mentally, I feel okay, but I feel like I'm just being run down.</p></div> <div class="provider-dialogue"><p>Tell me again, how you are getting by with your stress.</p></div> <div class="patient-dialogue"><p> I have gotten a lot closer with my sister and we either go out to dinner or we hang out and have a cheese and wine hour. It has been a lifesaver, being there for each other.</p></div> <div class="provider-dialogue"><p>Sounds like she's an important support for you. It might be helpful, in terms of weight management, to separate the support she gives you and the support that the food may be giving you. What do you think about changing the environment when you meet?</p></div> <div class="patient-dialogue"><p> I hadn't looked at it that way. I'm sure we can try to meet in other places. Come to think of it, Dad used to talk about wanting to have a garden, but he never got around to it. I have wanted to start something like that to honor him, but didn't know where we could fit it into our schedules. We could just do it when we meet up. Why didn't I think about that before?!</p></div> </div> <div class="navigation"> <div class="continue">Lifestyle Summary C</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Discussion - A3</p> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary D</div> <div class="container"> <div class="inner"> <div class="evaluation_points full">You have received full points for this encounter!</div> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Stress coping and diet</div><p>Excellent decision! Patient-centered questioning was used to get Ms. Jones talking about her current stress levels, which seem to be under control. Using open-ended questions, the diet assessment was used to begin a brief intervention about Ms. Jones' food habits.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> In an effort to start eliciting ideas from Ms. Jones to start thinking about how she could alter her diet, you could say:</div> <div class="response"><strong>You chose:</strong> Tell me more about cooking at home</div><p>Great job. Ms. Jones is an excellent candidate for lifestyle modification, particularly with her diet. Open-ended questions were used effectively to elicit useful feedback to further the process of Ms. Jones accepting any change. When talking about her cravings, the "Four Ds" are used in the dialogue, which are steps that have been described for dealing with drug withdrawal. They may be also be helpful for patients who struggle with food cravings by helping them cope with the tension of a strong craving until it may diminish:</p><p> The 4 Ds to Cope With a Craving</p><ol><li>Deep breaths: Breathe slowly and deeply</li><li>Drink water: This may help create a feeling of fullness</li><li>Distract: Do something else and move away from any food cues</li><li>Delay: At least 3 minutes to a half hour</li></ol><p>Had physical activity changes been discussed, you would have also learned that she already walks with a lady at work a few times a week and enjoys it. This could lead to positive change in terms of health outcomes and increased exercise.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Sleep interventions: Brief interventions like a sleep diary may be helpful, however Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity. Exercise Goals: A little more interviewing with Ms. Jones about her current activity and open-ended questions to guide her to facilitate her own goals would be ideal over setting goals so soon.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - B1a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Stress coping and diet</div><p>Excellent decision! Patient-centered questioning was used to get Ms. Jones talking about her current stress levels, which seem to be under control. Using open-ended questions, the diet assessment was used to begin a brief intervention about Ms. Jones' food habits.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> In an effort to start eliciting ideas from Ms. Jones to start thinking about how she could alter her diet, you could say:</div> <div class="response"><strong>You chose:</strong> I urge you to avoid eating out</div><p>A more directive approach was used here and it is not effective with all patients. Continuing with open-ended questions and reflective listening, such as found in the selection, <em>"Tell me more about cooking at home"</em>, would have led Ms. Jones to come up with her own ways to introduce healthier lifestyle options.</p><p>Had physical activity changes been discussed, the dialogue would have revealed that she already walks with a lady at work a few times a week and enjoys it. This could lead to positive change in terms of health outcomes and increased exercise.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Sleep interventions: Brief interventions like a sleep diary may be helpful, however Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity. Exercise Goals: A little more interviewing with Ms. Jones about her current activity and open-ended questions to guide her to facilitate her own goals would be ideal over setting goals so soon.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - B2a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Stress coping and diet</div><p>Excellent decision! Patient-centered questioning was used to get Ms. Jones talking about her current stress levels, which seem to be under control. Using open-ended questions, the diet assessment was used to begin a brief intervention about Ms. Jones' food habits.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> In an effort to start eliciting ideas from Ms. Jones to start thinking about how she could alter her diet, you could say:</div> <div class="response"><strong>You chose:</strong> I can offer much better alternatives</div><p>Alternatives to unhealthy habits are a great way to get patients to start thinking about how they can make changes to their diet. However, offering up alternatives without any input from Ms. Jones may not be effective. Continuing with open-ended questions and reflective listening, such as found in the selection, <em>"Tell me more about cooking at home"</em>, would have led Ms. Jones to come up with her own ways to introduce healthier lifestyle options.</p><p>Had physical activity changes been discussed, the dialogue would have revealed that Ms. Jones already walks with a lady at work a few times a week and enjoys it. This could lead to positive change in terms of health outcomes and increased exercise.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Sleep interventions: Brief interventions like a sleep diary may be helpful, however Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity. Exercise Goals: A little more interviewing with Ms. Jones about her current activity and open-ended questions to guide her to facilitate her own goals would be ideal over setting goals so soon.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - B3a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary A</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Sleep interventions</div><p>Since Ms. Jones has agreed to see a sleep specialist, the interview time may be better spent talking about diet. Brief interventions like a sleep diary may be helpful, however, Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity. A better first choice would have been to address Ms. Jones' <em>Stress coping and diet</em>. In that choice, some of her food habits are revealed, which will be very helpful in setting goals and establishing a weight-loss treatment plan.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Next, you want to begin some diet and exercise interventions. How should the conversation with Ms. Jones continue, using patient-centered interviewing skills? </div> <div class="response"><strong>You chose:</strong> Tell me about your diet and exercise</div><p>Excellent! Ms. Jones is an excellent candidate for lifestyle modification, particularly with her diet. Open-ended questions and reflective listening are effectively used here to elicit useful feedback to further the process of Ms. Jones accepting any change.</p><p>Had physical activity changes been discussed, the dialogue would have revealed that Ms. Jones already walks with a lady at work a few times a week and enjoys it. This could lead to positive change in terms of health outcomes and increased exercise.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Exercise Goals: A little more interviewing with Ms. Jones about her current activity and open-ended questions to guide her to facilitate her own goals would be ideal over setting goals so soon.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - A1a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Sleep interventions</div><p>Since Ms. Jones has agreed to see a sleep specialist, the interview time may be better spent talking about diet. Brief interventions like a sleep diary may be helpful, however, Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity. A better first choice would have been to address Ms. Jones' <em>"Stress coping and diet"</em>. In that choice, some of her food habits are revealed, which will be very helpful in setting goals and establishing a weight-loss treatment plan.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Next, you want to begin some diet and exercise interventions. How should the conversation with Ms. Jones continue, using patient-centered interviewing skills? </div> <div class="response"><strong>You chose:</strong> Do you eat well and are you active?</div><p>Ms. Jones is an excellent candidate for lifestyle modification, particularly with her diet, so asking about her diet and exercise is important. However, the use of close-ended questioning does not get very much information from Ms. Jones. More information would have been revealed in the choice <em>"Tell me about your diet and exercise"</em>. In that encounter, the use of effective open-ended questions and reflective listening elicits useful feedback to further the process of Ms. Jones accepting any change.</p><p>Had physical activity changes been discussed, the dialogue would have revealed that she already walks with a lady at work a few times a week and enjoys it. This could lead to positive change in terms of health outcomes and increased exercise.</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Exercise Goals: A little more interviewing with Ms. Jones about her current activity and open-ended questions to guide her to facilitate her own goals would be ideal over setting goals so soon.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - A2a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Sleep interventions</div><p>Since Ms. Jones has agreed to see a sleep specialist, the interview time may be better spent talking about diet. Brief interventions like a sleep diary may be helpful, however Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity. A better first choice would have been to address Ms. Jones' <em>"Stress coping and diet"</em>. In that choice, some of her food habits are revealed, which will be very helpful in setting goals and establishing a weight-loss treatment plan.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Next, you want to begin some diet and exercise interventions. How should the conversation with Ms. Jones continue, using patient-centered interviewing skills? </div> <div class="response"><strong>You chose:</strong> What are you doing about your recent weight gain</div><p>Ms. Jones has already expressed her discomfort talking about her weight. This choice jumps abruptly and insensitively from starting the conversation to developing a plan. A better choice here would have been <em>"Tell me about your diet and exercise"</em>. In that encounter, the use of effective open-ended questions and reflective listening elicits useful feedback to further the process of Ms. Jones accepting any change. Had exercise goals been discussed, the dialogue would have revealed that she already walks with a lady at work a few times a week and enjoys it. This could lead to positive change in terms of health outcomes and increased exercise.</p></div> <div class="summary"><strong><p>Regarding other possible choices: </strong> </p><p>Exercise Goals: A little more interviewing with Ms. Jones about her current activity and open-ended questions to guide her to facilitate her own goals would be ideal over setting goals so soon.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - A3a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Exercise goals</div><p>Exercise goals are a very important aspect of Ms. Jones' treatment, however, this response jumps to goals and skipped the conversation where goals should be made. The best choice here would have been to discuss Ms. Jones' <em>"Stress coping and diet"</em>. Open-ended questions and reflective listening are suggested here to elicit useful feedback to further the process of Ms. Jones accepting any change.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> How could you continue this conversation to get more feedback from Ms. Jones about making exercise goals?</div> <div class="response"><strong>You chose:</strong> See what changes she is willing to make to increase activity</div><p>Great decision and recovery. You chose a more patient-centered approach in this conversation. The dialogue was affirming and Ms. Jones' cues were read very well. By the end of the conversation, Ms. Jones was already setting some of her own exercise goals.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Sleep interventions: Brief interventions like a sleep diary may be helpful, however Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - C1a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Lifestyle Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> To continue the interview, eliciting from Ms. Jones what kind of changes she is willing to make, what topic do you think is best for you to initiate?</div> <div class="response"><strong>You chose:</strong> Exercise goals</div><p>Exercise goals are a very important aspect of Ms. Jones' treatment, however, this response jumps to goals and skipped the conversation where goals should be made. The best choice here would have been to discuss Ms. Jones' <em>"Stress coping and diet"</em>. Open-ended questions and reflective listening are suggested here to elicit useful feedback to further the process of Ms. Jones accepting any change.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> How could you continue this conversation to get more feedback from Ms. Jones about making exercise goals?</div> <div class="response"><strong>You chose:</strong> Show her a physical activity plan</div><p>The dialogue continues to try to elicit change from Ms. Jones in adopting goals that she was never really a part of developing. The tone of this dialogue is not very affirming and is very directive. None of these skills are effective in obtaining a positive conversation about Ms. Jones modifying her current lifestyle to move forward with her treatment. A better choice, where this positive outcome plays out, would have been to choose <em>"See what changes she is willing to make to increase activity."</em> There you would have learned that she already walks with a lady at work a few times a week and enjoys it.</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Sleep interventions: Brief interventions like a sleep diary may be helpful, however Ms. Jones is at a point with her weight where her inadequate sleep and her obesity need to be TREATED simultaneously. Treating together interrupts the cycle of possible sleep apnea contributing to obesity.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[V Counseling and Education]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Summary - C2a</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice objective"><strong>V.</strong> Counseling and Education</div>[[Counseling and Education Chapter Objectives]] <div class="container"> <div class="inner"> <div class="results"><p>Throughout the encounter with Ms. Jones, a few unhealthy eating patterns have been identified, as well as a personal barrier to weight loss. Ms. Jones suggests that she is willing to make a few changes, with both her diet and physical activity, including:</p><ul><li>Substituting her unhealthy foods with healthier items</li><li>Walking more at work during the week</li></ul></div> </div> <div class="navigation"><div class="question">In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="continue">[[Get her to focus on losing excess weight]] </div> <div class="continue">[[Set dietary goals for Ms. Jones]] </div> <div class="continue">[[Empower her with more information about making slow changes]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Empower her with more information about making slow changes</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I'm so glad you are willing to make some changes as we move forward. I would like to work together with you toward your health goal. </p> </div> <div class="patient-dialogue"> <p> Okay. I just want to feel good again and get a good night's sleep. I'm excited to try to make some changes to my diet, but what if I don't see any changes to my weight?</p> </div> <div class="provider-dialogue"> <p>I'm glad you are excited to make some changes and your concern is valid. It is not very easy to change habits, but it may not be as hard as you think if you see it as a slow process. I've seen patients, with similar problems, make small changes that really make an impact. </p> </div> <div class="patient-dialogue"> <p>I have made changes in the past, but I've never lost a ton of weight or anything. What about your other patients like me. How much weight did they lose? </p> </div> <div class="provider-dialogue"> <p>The weight varied. Only about a 5% reduction is necessary to start seeing the benefits, though. So, for you that would be around 11 pounds. </p> </div> <div class="patient-dialogue"> <p> Oh, wow. I was thinking it would need to be more. That sounds like something I can do.</p> </div> </div> </div> <div class="navigation"><div class="question">Ms. Jones continues to be open to change. What question will you ask Ms. Jones or what action will be taken to keep her moving forward with brainstorming some goals?</div> <div class="continue">[[On a scale of one to ten how ready are you to start]] </div> <div class="continue">[[Get her to brainstorm goals and set a follow up appointment to solidify]] </div> <div class="continue">[[What steps are you willing to take right now]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Question - A</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Get her to focus on losing excess weight</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>The doctor at the sleep clinic should be able to better assist you with your sleep problems. Part of your treatment could include losing some excess weight. </p> </div> <div class="patient-dialogue"> <p> How is that going to help me sleep better? </p> </div> <div class="provider-dialogue"> <p>There is a possibility that your excess weight is contributing to your sleep problems and, in turn, not getting enough sleep can lead to weight gain. We need to break that cycle. And to do that, you need to make some changes in your dietary patterns.</p> </div> <div class="patient-dialogue"> <p> I've done so many weight loss programs, but I never maintain what I lose. </p> </div> <div class="provider-dialogue"> <p>I am hoping to suggest some changes to help you keep off the weight. </p> </div> <div class="patient-dialogue"> <p> I might be a lost cause. </p> </div> </div> </div> <div class="navigation"><div class="question">Ms. Jones is getting discouraged, how can you try to get her back on track?</div> <div class="continue">[[Tell her about dietary changes she should make]] </div> <div class="continue">[[Ask if there is anything she liked about the programs in the past]] </div> <div class="continue">[[Change the topic]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Question - B</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Set dietary goals for Ms. Jones</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Okay, Ms. Jones. We should set some goals to help you start feeling better, including some dietary changes. That is the first choice to treat the underlying contributing factors to your weight gain and subsequent sleep problems. </p> </div> <div class="patient-dialogue"> <p> You can't just give me a pill or something to sleep better? </p> </div> <div class="provider-dialogue"> <p> There are definitely medications to help you sleep, but we need to cut out your sleep problems at the source. </p> </div> <div class="patient-dialogue"> <p> I don't get it. I feel like I've been this weight, on and off, most of my life and I have never had sleep problems before. </p> </div> <div class="provider-dialogue"> <p> As we get older, sometimes unhealthy eating habits and weight gain start to “catch up” with us. I strongly recommend losing 5-10% of your body weight over the next 3-6 months. You will see a difference, I assure you! You can do this, Ms. Jones.</p> </div> <div class="patient-dialogue"> <p> Hmmm. I don't know about that. </p> </div> </div> </div> <div class="navigation"><div class="question">Ms. Jones is not showing interest in losing weight. How can you try to get her motivated?</div> <div class="continue">[[Discuss her previous weight loss]] </div> <div class="continue">[[Educate her on the risks of obesity with tough love]] </div> <div class="continue">[[Use her parents as examples of where her health is leading]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Question - C</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> What steps are you willing to take right now</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>So, this looks like something you can do. What steps are you willing to take right now toward that 11 pound goal? </p> </div> <div class="patient-dialogue"> <p> Well, I know that means I have to start cutting out calories. I can start eating more meat and veggies, instead of cheese fries and bread. I'm definitely not going to stop hanging out with my sister, but there are always better options.</p> </div> <div class="provider-dialogue"> <p>That sounds like a great start. Anything else? </p> </div> <div class="patient-dialogue"> <p> Sometimes we have cheese and wine at the house. I usually make the platter, so I'll just substitute some hummus and veggies and only have the wine a few nights per week. </p> </div> <div class="provider-dialogue"> <p>It sounds like you know great alternatives. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - A1</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> On a scale of one to ten, how ready are you to start?</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>So, this looks like something you can do. On a scale of one to ten, with ten being very ready, how ready are you to start? </p> </div> <div class="patient-dialogue"> <p> I'd say a nine. </p> </div> <div class="provider-dialogue"> <p>Why not lower? </p> </div> <div class="patient-dialogue"> <p> You told me about all these risks earlier, so I'm ready to get started! </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - A2</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Get her to brainstorm goals and set a follow up appointment to solidify</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>So, this looks like something you can do. Are you ready to brainstorm some goals? </p> </div> <div class="patient-dialogue"> <p> Yes, I'm ready to start. </p> </div> <div class="provider-dialogue"> <p>I am going to recommend that you lose 5-10% of your body weight over the next 3-6 months. Together, lets come up with some ideas that could help you get there. </p> </div> <div class="patient-dialogue"> <p> I know I should probably restrict my calories. I know I eat a lot of food. I can also start to exercise a little bit more. I'll see what I can come up with.</p> </div> <div class="provider-dialogue"> <p>Restricting calories and more exercise is a great start. How about you come back next week and we can discuss your plans in more detail? </p> </div> <div class="patient-dialogue"> <p>Okay. I'm pretty excited that you are helping me with this.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - A3</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Ask if there is anything she liked about the programs in the past</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> You are certainly not a lost cause, Ms. Jones. What I am suggesting will include a few simple changes. What did you like about those programs you mentioned in the past?</p> </div> <div class="patient-dialogue"> <p> I've done a few online diets and things I've read about in magazines. I liked the recipes they offered and the grocery lists that came with the eating plan. I guess I liked the convenience of it. </p> </div> <div class="provider-dialogue"> <p> So you lost some weight with that approach? </p> </div> <div class="patient-dialogue"> <p> Yes, I did. I just couldn't keep it off.</p> </div> <div class="provider-dialogue"> <p> But, you have a particular diet that you liked to follow?</p> </div> <div class="patient-dialogue"> <p> Oh yeah! I have some pretty good recipes that are super easy. </p> </div> <div class="provider-dialogue"> <p> How about we just start there? And then we can meet again to see how it is working.</p> </div> <div class="patient-dialogue"> <p> Oh, okay. I definitely don't mind breaking out that old folder of recipes I collected. I just have to find it!</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - B1</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Tell her about dietary changes she should make</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> You are certainly not a lost cause, Ms. Jones. I really think you will do well with the recommended dietary changes.</p> </div> <div class="patient-dialogue"> <p> There is so much out there, though. And nothing has ever worked for me in the long run. </p> </div> <div class="provider-dialogue"> <p>So, we have a few options here. You need to make at least some of these changes, like reducing carbohydrates and saturated fat intake. You need to eliminate trans and saturated fats.</p> </div> <div class="patient-dialogue"> <p> That's all the best stuff!</p> </div> <div class="provider-dialogue"> <p> Well, you can eat healthy fats to replace the less healthy fats.</p> </div> <div class="patient-dialogue"> <p> It still sounds pretty boring. I need some spice in my life. I love good food!</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - B2</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Change the topic</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> You're not a lost cause, Ms. Jones. Tell me this, how would you like to be off your medication?</p> </div> <div class="patient-dialogue"> <p> It would be great! I don't like having all these health issues.</p> </div> <div class="provider-dialogue"> <p>So you would have that as motivation. This can actually happen. </p> </div> <div class="patient-dialogue"> <p> I just have so much going on. Making changes is not something I am comfortable with right now, okay?</p> </div> <div class="provider-dialogue"> <p>I understand. Making changes can be stressful with a lot going on. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - B3</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Discuss her previous weight loss</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="patient-dialogue"> <p> Usually, I just put myself on one of those diets I read out of a magazine or online. I just followed it.</p> </div> <div class="provider-dialogue"> <p> And then what happened?</p> </div> <div class="patient-dialogue"> <p> Other priorities took over my diet. Life got too busy.</p> </div> <div class="provider-dialogue"> <p> Looking back on it now, do you think there is anything from that healthy eating plan you could use now and commit to for a long term change, even with your busy schedule? </p> </div> <div class="patient-dialogue"> <p> I'm not sure. When you're busy, you still have to eat. Grabbing fast food is better than being hungry.</p> </div> <div class="provider-dialogue"> <p> Sounds like you need a solution that doesn't take much time, but that is healthier. What if we just looked at the options you choose when you eat fast food? Can we start there?</p> </div> <div class="patient-dialogue"> <p> Sure. I can do that.</p> </div> <div class="note">An example of a popular calorie tracker app is shown to Ms. Jones, showing the calories in her typical fast food meals. Next, she is shown how the high calorie fast food compares with relatively healthier options at the same fast food restaurant. She is excited to download a similar app to her phone.</div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - C1</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Educate her on the risks of obesity with tough love</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> I know this can be a touchy subject, but I’d like to be very direct with you if that’s alright, Ms. Jones. Your risks of heart disease, diabetes, and cancer are pretty high if we do not address this soon. Any of those could create much more difficult symptoms to manage that could be with you the rest of your life.</p> </div> <div class="patient-dialogue"> <p> My life is so crazy, it is so hard to focus on this. I just can't handle so many changes all at once. I am still grieving over my dad's death, and work, and keeping up with family stuff. It is just so much for me to take in. It's so overwhelming.</p> </div> <div class="provider-dialogue"> <p> I definitely understand that, Ms. Jones, which is why I recommend starting with minor changes right now. Do you think that small changes to your diet with healthier choices would be possible? </p> </div> <div class="patient-dialogue"> <p> So, like, when I go out to eat, I would get the grilled chicken instead of a hamburger? Or I can still do my wine and cheese with my sister as long as I don’t eat or drink too much? Family time is so important to me and I would be much more willing to try adjusting my habits than just stopping them all together.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary H]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - C2</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Use her parents as examples of where her health is leading</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Ms. Jones, carrying excess weight increases your risk for heart disease, diabetes, and cancer. You might be at the same health risks as your parents. I am worried about your health.</p> </div> <div class="patient-dialogue"> <p> When my life isn't so crazy, I'll go on a diet.</p> </div> <div class="provider-dialogue"> <p> This needs to be a lifelong change, Ms. Jones. Your current habits are going to catch up to you.</p> </div> <div class="patient-dialogue"> <p> I'm really done talking about this right now. Can you prescribe me a sleeping pill or something so I can go?</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Counseling and Education Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Discussion - C3</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary A</div> <div class="container"> <div class="inner"> <div class="evaluation_points full">You have received full points for this encounter!</div> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Empower her with more information about making slow changes</div><p>Excellent decision. Starting a weight-loss treatment plan should not be delayed, especially if comorbid conditions are a focus of treatment. Weight loss is one of the most effective treatments for many comorbidities (Jensen et al., 2014). Even a 5% weight loss is associated with:</p><ul><li>Blood pressure reduction</li><li>Triglycerides reduced</li><li>LDL reduced</li><li>HDL increased</li></ul>(NHLBI, 2013)</div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Ms. Jones continues to be open to change. What question will you ask Ms. Jones or what action will be taken to keep her moving forward with brainstorming some goals?</div> <div class="response"><strong>You chose:</strong> What steps are you willing to take right now</div><p>Excellent. Because of the rapport building, and the continued use of patient-centered techniques, over the course of the appointment, Ms. Jones is already beginning to set her own goals (more on this in the next chapter). Using open-ended questioning, which move Ms. Jones toward her treatment plan, is an ideal choice here.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Get her to focus on losing excess weight: While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), the choice to empower Ms. Jones with knowledge was the best option at this point in the interview. Set dietary goals for Ms. Jones: Again, the timing is off for this option. Setting dietary goals FOR Ms. Jones is also not the goal here. You want to guide Ms. Jones to set her own dietary goals.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - A1a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary B</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Empower her with more information about making slow changes</div><p>Excellent decision. Starting a weight-loss treatment plan should not be delayed, especially if comorbid conditions are a focus of treatment. Weight loss is one of the most effective treatments for many comorbidities (Jensen et al., 2014). Even a 5% weight loss is associated with:</p><ul><li>Blood pressure reduction</li><li>Triglycerides reduced</li><li>LDL reduced</li><li>HDL increased</li></ul>(NHLBI, 2013)</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Ms. Jones continues to be open to change. What question will you ask Ms. Jones or what action will be taken to keep her moving forward with brainstorming some goals?</div> <div class="response"><strong>You chose:</strong> On a scale of one to ten, how ready are you to start</div><p>While the question itself is a great motivational technique to elicit feedback, Ms. Jones has already given several hints over the course of the appointment that she is ready to start. <em>"What steps are you willing to take right now"</em> would have been a better question to ask Ms. Jones, leading her toward her treatment plan and give you more insight for appropriate guidance.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Get her to focus on losing excess weight: While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), the choice to empower Ms. Jones with knowledge was the best option at this point in the interview. Set dietary goals for Ms. Jones: Again, the timing is off for this option. Setting dietary goals FOR Ms. Jones is also not the goal here. You want to guide Ms. Jones to set her own dietary goals.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - A2a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary C</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Empower her with more information about making slow changes</div><p>Excellent decision. Starting a weight-loss treatment plan should not be delayed, especially if comorbid conditions are a focus of treatment. Weight loss is one of the most effective treatments for many comorbidities (Jensen et al., 2014). Even a 5% weight loss is associated with:</p><ul><li>Blood pressure reduction</li><li>Triglycerides reduced</li><li>LDL reduced</li><li>HDL increased</li></ul>(NHLBI, 2013)</div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Ms. Jones continues to be open to change. What question will you ask Ms. Jones or what action will be taken to keep her moving forward with brainstorming some goals?</div> <div class="response"><strong>You chose:</strong> Get her to brainstorm goals and set a follow-up appointment to solidify</div><p>Brainstorming goals is a great way to get Ms. Jones to be an integral part of her own weight-loss treatment plan. In this interaction, the dialogue is successfully initiated by getting Ms. Jones to brainstorm some ways that she can begin to lose weight. Even though Ms. Jones is excited to start making plans, the momentum is stymied with a follow-up appointment. She could easily leave the appointment today with an initial plan to address the ideas presented.</p><p><em>"What steps are you willing to take right now"</em> would have been an even better question to ask Ms. Jones. Using an open-ended question has the potential to lead Ms. Jones toward her weight-loss treatment plan and give you good insight for appropriate guidance.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Get her to focus on losing excess weight: While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), the choice to empower Ms. Jones with knowledge was the best option at this point in the interview. Set dietary goals for Ms. Jones: Again, the timing is off for this option. Setting dietary goals FOR Ms. Jones is also not the goal here. You want to guide Ms. Jones to set her own dietary goals.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - A3a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary D</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Get her to focus on losing excess weight</div><p>While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), a better choice at this point in the appointment would be to <em>"Empower her with information about health risks associated with elevated body mass"</em>. Using patient-centered techniques to bring up the risks to Ms. Jones could have elicited a more positive response from her.</p><p>Providers can use evaluation and classification of patient fat mass to guide treatment and track patient progress in weight management plans. An understanding of all the comorbidities potentially associated with excess weight can serve as a guide to providing patients a comprehensive medical evaluation and early treatment, including vigorous weight management.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Ms. Jones is getting discouraged, how can you try to get her back on track?</div> <div class="response"><strong>You chose:</strong> Ask if there is anything she liked about the programs in the past</div><p>Great choice to turn it around! Even though Ms. Jones got discouraged from the previous interaction, you picked up on the fact that Ms. Jones had success with diets in the past. Expanding on that, using patient centered techniques, allowed Ms. Jones to feel more in control and confident about moving forward with a treatment plan.</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Set dietary goals for Ms. Jones: The timing is off for this option of making goals, which will come later in the interview. Setting dietary goals FOR Ms. Jones is also not the goal here. You want to guide Ms. Jones to set her own dietary goals.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - B1a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary E</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Get her to focus on losing excess weight</div><p>While discussing losing excess weight and dietary options is a good option (and a big focus of the next chapter), a better choice at this point in the appointment would be to <em>"Empower her with information about health risks associated with elevated body mass"</em> was the best choice for this encounter. Using patient-centered techniques to bring up the risks to Ms. Jones could have elicited a more positive response from her.</p><p>Providers can use evaluation and classification of patient fat mass to guide treatment and track patient progress in weight management plans. An understanding of all the comorbidities potentially associated with excess weight can serve as a guide to providing patients a comprehensive medical evaluation and early treatment, including vigorous weight management.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> Ms. Jones is getting discouraged, how can you try to get her back on track?</div> <div class="response"><strong>You chose:</strong> Tell her about dietary changes she should make</div><p>An opportunity was missed here. In the first dialogue you chose in this chapter, Ms. Jones mentioned she had previously used a weight program, however unsuccessfully. Choosing <em>"Ask if there is anything she liked about the programs in the past"</em> was the better choice for this encounter. Had the dialogue expanded on those programs, using patient centered techniques, Ms. Jones could have provided her successes and failures. This would have been great information for you to use as they move forward with Ms. Jones' treatment plan.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Set dietary goals for Ms. Jones: The timing is off for this option of making goals, which will come later in the interview. Setting dietary goals FOR Ms. Jones is also not the goal here. You want to guide Ms. Jones to set her own dietary goals.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - B2a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary F</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Get her to focus on losing excess weight</div><p>While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), a better choice at this point in the appointment would be to <em>"Empower her with information about health risks associated with elevated body mass"</em> was the best choice for this encounter. Using patient-centered techniques to bring up the risks to Ms. Jones could have elicited a more positive response from her.</p><p>Providers can use evaluation and classification of patient fat mass to guide treatment and track patient progress in weight management plans. An understanding of all the comorbidities potentially associated with excess weight can serve as a guide to providing patients a comprehensive medical evaluation and early treatment, including vigorous weight management.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> Ms. Jones is getting discouraged, how can you try to get her back on track?</div> <div class="response"><strong>You chose:</strong> Change the topic</div><p>An opportunity was missed here. In the first dialogue you chose in this chapter, Ms. Jones mentioned she had previously used a weight program, however unsuccessfully. Choosing <em>"Ask if there is anything she liked about the programs in the past"</em> was the better choice for this encounter. Had the dialogue expanded on those programs, using patient centered techniques, Ms. Jones could have provided her successes and failures. This would have been great information to use as you move forward with Ms. Jones' treatment plan.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Set dietary goals for Ms. Jones: The timing is off for this option of making goals, which will come later in the interview. Setting dietary goals FOR Ms. Jones is also not the goal here. You want to guide Ms. Jones to set her own dietary goals.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - B3a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Set dietary goals for Ms. Jones</div><p>While setting goals is integral (and a big focus of the next chapter), a better choice at this point in the appointment would be to <em>"Empower her with information about health risks associated with elevated body mass"</em> was the best choice for this encounter. Using patient-centered techniques to bring up the risks to Ms. Jones could have elicited a more positive response from her.</p><p>Providers can use evaluation and classification of patient fat mass to guide treatment and track patient progress in weight management plans. An understanding of all the comorbidities potentially associated with excess weight can serve as a guide to providing patients a comprehensive medical evaluation and early treatment, including vigorous weight management.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> Ms. Jones is not showing interest in losing weight. How can you try to get her motivated?</div> <div class="response"><strong>You chose:</strong> Discuss her previous weight loss</div><p>This is a great choice. Expanding on the success and failures of previous weight loss attempts would give you information that would be very useful in Ms. Jones' treatment. In this encounter, you also introduces an app to help her make healthier decisions at popular fast food restaurants.</p> </div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Get her to focus on losing excess weight: While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), the choice to empower Ms. Jones with knowledge was the best option at this point in the interview.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - C1a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Set dietary goals for Ms. Jones</div><p>While setting goals is integral (and a big focus of the next chapter), a better choice at this point in the appointment would be to <em>"Empower her with information about health risks associated with elevated body mass"</em> was the best choice for this encounter. Using patient-centered techniques to bring up the risks to Ms. Jones could have elicited a more positive response from her.</p><p>Providers can use evaluation and classification of patient fat mass to guide treatment and track patient progress in weight management plans. An understanding of all the comorbidities potentially associated with excess weight can serve as a guide to providing patients a comprehensive medical evaluation and early treatment, including vigorous weight management.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> Ms. Jones is not showing interest in losing weight. How can you try to get her motivated?</div> <div class="response"><strong>You chose:</strong> Educate her on the risks of obesity with tough love</div><p>Educating Ms. Jones about her current health risks is on point, but the interview seems a bit backwards in this encounter. Ms. Jones seems receptive to the facts about losing modest amounts of weight to see the health benefits. Perhaps starting off with the risks of obesity, using patient-centered techniques, Ms. Jones would have been in a more positive frame of mind to start thinking about dietary goals.</p><p>A better choice here would be to <em>"Discuss her previous weight loss"</em>. Expanding on the success and failures of previous weight loss attempts would give you information that would be very useful in Ms. Jones' treatment.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Get her to focus on losing excess weight: While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), the choice to empower Ms. Jones with knowledge was the best option at this point in the interview.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - C2a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Counseling and Education Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> In an effort to keep moving forward, eliciting Ms. Jones to take ownership of making positive goals, what should you focus on next?</div> <div class="response"><strong>You chose:</strong> Set dietary goals for Ms. Jones</div><p>While setting goals is integral (and a big focus of the next chapter), a better choice at this point in the appointment would be to <em>"Empower her with information about health risks associated with elevated body mass"</em>. Using patient-centered techniques to bring up the risks to Ms. Jones could have elicited a more positive response from her.</p><p>Providers can use evaluation and classification of patient fat mass to guide treatment and track patient progress in weight management plans. An understanding of all the comorbidities potentially associated with excess weight can serve as a guide to providing patients a comprehensive medical evaluation and early treatment, including vigorous weight management.</p></div> <div class="feedback incorrect"> <div class="question"><strong>Question 2:</strong> Ms. Jones is not showing interest in losing weight. How can you try to get her motivated?</div> <div class="response"><strong>You chose:</strong> Use her parents as examples of where her health is leading</div><p> Patients should certainly be educated about diseases that are most likely correlated with obesity, but scare tactics should be avoided. Also, in this interaction, you chose an emotionally charged and personal issue, resulting in Ms. Jones shutting down completely.</p><p>A better choice here would be to <em>"Discuss her previous weight loss"</em>. Expanding on the success and failures of previous weight loss attempts would give you information that would be very useful in Ms. Jones' treatment.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p> Get her to focus on losing excess weight: While discussing losing excess weight and dietary options is very good (and a big focus of the next chapter), the choice to empower Ms. Jones with knowledge was the best option at this point in the interview.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[VI Treatment Plans]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Counseling - Summary - C3a</p> <div class="chapter"><strong>Ch 5 |</strong> Counseling and Education</div> <div class="progress chapter5"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice objective"><strong>VI.</strong> Treatment Plans</div>[[Treatment Chapter Objectives]] <div class="container"> <div class="inner"> <div class="results"><p>So far in this encounter, the clinical protocol steps for patient weight management have included:</p><ul><li>History Gathering</li><li>Medical Evaluation</li><li>Lifestyle Screening</li><li>Brief Counseling</li></ul><p>Ms. Jones came in today presenting with sleep problems and has been tentatively diagnosed with sleep apnea and referred to a sleep specialist for confirmation. She will leave your office today with a weight-loss treatment plan to hopefully address the underlying causes of her sleep problems, as well as reduce her risk for several comorbid conditions.</p><p>In previous chapters, Ms. Jones was receptive to many dietary changes and even proposed a few herself. She was also receptive to walking a little more at work. By the end of the appointment, you want Ms. Jones to leave with a comprehensive plan with a high success rate for sustained weight loss.</p></div></div> <div class="navigation"><div class="question">How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="continue">[[Focus on more exercise]] </div> <div class="continue">[[Prescribe exercise and diet for weight loss]] </div> <div class="continue">[[Recommend she read up on evidence based diets]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Prescribe exercise and diet for weight loss</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>What I am going to do is prescribe these changes we have discussed with your exercise and diet. When you come back for a follow-up, we will see how it is working. And we may adjust accordingly. How does that sound to you?</p> </div> <div class="patient-dialogue"> <p> I've never heard of diet or exercise being prescribed before. Sounds good.</p> </div> <div class="provider-dialogue"> <p>From our conversations, you are going to increase your walking at work and it may be easier for you to restrict certain foods, as opposed to following a specific diet or limiting your calorie intake. Am I correct?</p> </div> <div class="patient-dialogue"> <p> Definitely. I think I will keep my daily and social schedule the same, but I can easily cut out foods or substitute for a healthier option in every situation, I believe. And increasing my walking at work should be easy to implement. It is something I enjoy! </p> </div> <div class="provider-dialogue"> <p>Excellent! This is a wonderful start, Ms. Jones.</p> </div> </div> </div> <div class="navigation"><div class="question">What other options, available to Ms. Jones, can you suggest along with the diet/exercise prescription?</div> <div class="continue">[[Behavioral supports]] </div> <div class="continue">[[The DASH diet]] </div> <div class="continue">[[A higher intensity exercise program]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Question - B</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Focus on more exercise</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>In addition to writing down your dietary goals, I want to focus on your exercise goals as well. </p> </div> <div class="patient-dialogue"> <p> Of course. I think what we talked about earlier will work. Walking more at work is really going to fit into my schedule right now. </p> </div> <div class="provider-dialogue"> <p> That’s great, but I think you will need to do a little more to succeed. I want you to start thinking of ways you can start fitting in some interval and strength training. We will focus on that during your follow-up.</p> </div> <div class="patient-dialogue"> <p> I've never been that active, though. I've always been able to lose weight by focusing more on my diet.</p> </div> <div class="provider-dialogue"> <p> Focusing on your diet will definitely help lose some weight, but exercise produces an increase in weight loss. It is recommended that you get 200-300 minutes of physical activity per week for greater weight loss. </p> </div> </div> </div> <div class="navigation"><div class="question">What other options, available to Ms. Jones, can you suggest along with more exercise?</div> <div class="continue">[[A food diary]] </div> <div class="continue">[[Family support]] </div> <div class="continue">[[Regular health monitoring]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Question - A</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Recommend she read up on evidence-based diets</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Before you go, I would like you to recommend that you read up on a few diets that are supported by research and see if you can find any new recipes. I would recommend the Mediterranean Diet, DASH diet, and low carb diets for you. Read about them and see which one you like and we'll talk about it next time.</p> </div> <div class="patient-dialogue"> <p> I already have some diet plans that I have enjoyed following in the past. </p> </div> <div class="provider-dialogue"> <p>If you bring a copy of those diet plans, I could look them over at your next appointment. We can talk about it some more then.</p> </div> <div class="note"><em>[Ms. Jones is almost done with her appointment and you will not see her for another month or so.]</em> </div> </div> </div> <div class="navigation"><div class="question">What other options, available to Ms. Jones, should you suggest along with the diet books?</div> <div class="continue">[[Physical activity plans]] </div> <div class="continue">[[Online support]] </div> <div class="continue">[[Your direct office phone number]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Question - C</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Behavioral supports</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>With your diet and exercise in place, how do you feel about having someone to help or guide you along the way?</p> </div> <div class="patient-dialogue"> <p> That would be nice. How are you going to do that?</p> </div> <div class="provider-dialogue"> <p>I can set you up here in the clinic to help you tailor your eating plan as you progress toward your weight-loss goals. Would you like to meet with our clinic nutritionist? </p> </div> <div class="patient-dialogue"> <p> That would be good. I can definitely find time in my schedule to get some recipe ideas. </p> </div> <div class="provider-dialogue"> <p>When you check out, we'll get you on the appointment schedule to meet with the nutritionist. I want to provide as much support as possible. I send a lot of my patients to a weight-loss support group that is run by a licensed clinical social worker specializing in weight loss. This can be part of your weight-loss plan and you would meet with the group every week for 6 months. It is a big commitment, but the rate of success is much higher than without it. </p> </div> <div class="patient-dialogue"> <p> That actually sounds great. I've never had help before. I'm feeling really good about this now!</p> </div> <div class="note"><em>[Ms. Jones is given several info booklets as well as a print out of everything that was discussed about her goals, including diet and exercise prescriptions. She leaves very motivated to make some changes.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary D]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - B1</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> The DASH diet</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>With your blood pressure being slightly elevated today, you might like this plan called "The DASH Diet". It will keep your salt intake low and will hopefully help improve your blood pressure. </p> </div> <div class="patient-dialogue"> <p> I think I may have heard about that diet. </p> </div> <div class="provider-dialogue"> <p>It helps prevent and treat hypertension and can be combined with your other goals to help you lose weight. According to your eating assessment, you already eat a decent amount of fruits and vegetables, lean meat, and grains. It would just cut out some red meats and added sugar.</p> </div> <div class="patient-dialogue"> <p> Great. Sounds like what we have talked about already. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary E]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - B2</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> A higher intensity exercise program</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I also want to write down a few of your exercise goals. I know you mentioned earlier that you could walk at work. How would you feel about increasing the intensity?</p> </div> <div class="patient-dialogue"> <p> Oh, I don't know about that. I get winded just walking a flight of stairs. I'm comfortable with increasing my walking for now. </p> </div> <div class="provider-dialogue"> <p>I would like to hear about you running next time you come in.</p> </div> <div class="patient-dialogue"> <p> You definitely won't hear that. I hate running!</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary F]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - B3</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary D</div> <div class="container"> <div class="inner"> <div class="evaluation_points full">You have received full points for this encounter!</div> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Prescribe exercise and diet for weight loss</div><p>This is an excellent choice! Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul><p>For Ms. Jones, she has agreed to substituting lower calorie options when she eats out. She also thinks reducing her sugary drinks would not be difficult.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, can you suggest along with the diet/exercise prescription?</div> <div class="response"><strong>You chose:</strong> Behavioral supports</div><p>Yes! In addition to prescribing dietary change, behavioral supports are <strong>absolutely</strong> necessary for a comprehensive lifestyle intervention.</p><p>Behavioral supports include the brief motivational interventions provided in your practice as well as referrals. Outside referrals may be to a trained interventionist, such as:</p><ul><li> A registered dietitian</li><li>A counselor</li><li> A medical or commercial weight-loss program</li></ul> Behavioral support is best if it is:</li><ul><li>In-person</li><li>High-intensity</li><li>Long term (at least 6 months)</li><li>Individual or group sessions</li></ul></ul><p>As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. Programs are found all over the United States.</p><p>Physical activity is the third necessary component of a lifestyle intervention. Recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Focus on more exercise: Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015). Recommend she ready up on evidence-based diets: Recommending books could never hurt, but personalizing her goals, that Ms. Jones is likely to adhere, with weight-loss prescription is a much better choice.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - B1a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Case Review</div> <div class="container"> <div class="inner"> <div class="ehr"> <div class="header patientimg"></div> <div class="content"><p>This case with Ms. Jones highlights the importance of assessing patients for overweight and obesity using body mass measurements. Also highlighted are the important techniques used when counseling patients on health improvements that they can obtain through weight loss.</p><p>Specific clinical protocol steps used in the case include:</p><ul><li>Assessing body mass</li><li>Medical evaluation</li><li>Lifestyle screening and assessment</li><li>Brief counseling</li><li>Treatment</li></ul></div></div> <div class="results followup"><p><strong>Follow-Up with Ms. Jones</strong></p><p>Lab results:</p><ul><li>Blood glucose: <strong>100 mg/dL</strong> [normal range: 65-110 mg/dL]</li><li>A1C: <strong>5.6%</strong> [normal range: 4-5.6%]</li><li>LDL: <strong>145 mg/dL </strong>[normal range: 85-125 mg/dL]</li><li>Triglycerides: <strong>180 mg/dL</strong> [normal range: 50-150 mg/dL]</li><li>Total cholesterol: <strong>216 mg/dL (5.59 mmol/L)</strong> [normal range: 3-5.5 mmol/L]</li><li>HDL: <strong>35 mg/dL </strong>[normal range: 40-80 mg/dL]</li></ul><p>There is no indication to be on a statin after evaluating CVD risk. On a phone call to Ms. Jones, the significance of her lab results were discussed and an emphasis made on the importance of following the dietary changes for weight loss and improved health. Ms. Jones also confirmed that she had made her appointment with the nutritionist, clinical social worker, and sleep specialist. It was also mentioned that the nutritionist would have recommendations for her elevated cholesterol along with losing weight.</p> </div> <div class="results followup"><p><strong>2-Month Follow-Up</strong></p><ul><li>Sleep study diagnosis: Obstructive sleep apnea (Ms. Jones has been wearing a CPAP for 5 weeks and feels well-rested).</li><li>Weight: Ms. Jones has lost 12 pounds since her appointment. She made the diet changes she was prescribed, along with the physical activity changes and took advantage of the behavioral supports.</li></ul><p>Ms. Jones lends her success to switching out foods for healthier options. She still treats herself once in a while, however. She notes that she isn't losing weight as fast as she did initially. She is congratulated on her success and reminded her of the many, small, permanent changes over time that will make a difference over a lifetime. She is asked if she is ready for a new plan to discuss the next set of changes required for continued weight loss. Ms. Jones is very receptive given her success so far. She is also encouraged to keep up-to-date with her sleep specialist and continuing her group sessions.</p><p>It is very important to note that treating those who are overweight are equally as important as treating those who are obese. In addition, it should be stressed that treatment for overweight/obesity should not be delayed when treating related comorbidities.</p></div></div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue"> [[View References]] </div> <div class="continue">[[Finish and Take Survey]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Case Review</p> <div class="chapter"><strong>Ch 7 |</strong> Summary</div> <div class="progress chapter7"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary E</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Prescribe exercise and diet for weight loss</div><p>This is an excellent choice! Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, can you suggest along with the diet/exercise prescription?</div> <div class="response"><strong>You chose:</strong> The DASH diet</div><p>The DASH diet (Dietary Approaches to Stop Hypertension) is a great plan for those trying to prevent or treat hypertension. A similar diet has already been prescribed with input from Ms. Jones. <em>"Behavioral supports"</em> would have been a better choice for this brief encounter.</p><p>In addition to prescribing dietary change, behavioral supports and sufficient physical activity are necessary for a comprehensive lifestyle intervention.</p><p>Behavioral supports include the brief motivational interventions provided in your practice as well as referrals. Outside referrals may be to a trained interventionist, such as:</p><ul><li> A registered dietitian</li><li>A counselor</li><li> A medical or commercial weight-loss program</li></ul> <p>Behavioral support is best if it is:</p><ul><li>In-person</li><li>High-intensity</li><li>Long term (at least 6 months)</li><li>Individual or group sessions</li></ul><p>As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. Programs are found all over the United States.</p><p>For physical activity, recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Focus on more exercise: Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015). Recommend she ready up on evidence-based diets: Recommending books could never hurt, but personalizing her goals, that Ms. Jones is likely to adhere, with weight-loss prescription is a much better choice.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - B2a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary F</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Prescribe exercise and diet for weight loss</div><p>This is an excellent choice! Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li> </ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, can you suggest along with the diet/exercise prescription?</div> <div class="response"><strong>You chose:</strong> A higher intensity exercise program</div><p>High-intensity exercise programs are still an excellent choice. However, there was a better choice for Ms. Jones in this particular case. She does not seem ready to implement a high intensity program and has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p><p><em>"Behavioral supports"</em> would be the better choice here. Behavioral supports include the brief motivational interventions provided in your practice as well as referrals. Outside referrals may be to a trained interventionist, such as:</p><ul><li> A registered dietitian</li><li>A counselor</li><li> A medical or commercial weight-loss program</li></ul> <p>Behavioral support is best if it is:</p><ul><li>In-person</li><li>High-intensity</li><li>Long term (at least 6 months)</li><li>Individual or group sessions</li></ul><p>As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. Programs are found all over the United States.</p><p>For physical activity, recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p><p>In addition to dietary change, both behavioral support and physical activity are necessary for a comprehensive lifestyle intervention.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Focus on more exercise: Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015). Recommend she ready up on evidence-based diets: Recommending books could never hurt, but personalizing her goals, that Ms. Jones is likely to adhere, with weight-loss prescription is a much better choice.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - B3a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Physical activity plans</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Do you have any physical activity plans you like to follow? </p> </div> <div class="patient-dialogue"> <p> Not really. I just walk with my friend at work. I'm going to increase that, though.</p> </div> <div class="provider-dialogue"> <p> That sounds good! I will write that down in your goals. I'm glad to hear that you are open to increasing your activity levels.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary G]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - C1</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Online support</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Before you go, I want you to be supported as you work toward your goals. There are many online support groups that can hold you accountable. Are you aware of these?</p> </div> <div class="patient-dialogue"> <p> Oh yeah, I have a few diet apps on my phone that provide a community of folks you can talk to with your frustrations and stuff.</p> </div> <div class="provider-dialogue"> <p> Getting support is crucial for your success.</p> </div> <div class="note"><em>[Ms. Jones is given several info booklets as well as a print out of everything that was discussed about her goals. She leaves somewhat motivated to make some changes.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary H]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - C2</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Your office phone number</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>We have certainly talked about a lot today.</p> </div> <div class="patient-dialogue"> <p> Yes, we have!</p> </div> <div class="provider-dialogue"> <p>In case you have any questions about your goals, please call me in the office. I am here for you whenever you need me.</p> </div> <div class="note"><em>[Ms. Jones is given several info booklets as well as a print out of everything that was discussed about her goals. She leaves a little motivated to make some changes.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary I]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - C3</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary G</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Recommend she read up on evidence based diets</div><p>Recommending diet books could never hurt! But, in your brief encounter with Ms. Jones, the better choice would be to <em>"Prescribe a weight-loss diet"</em> that has been discussed with Ms. Jones. This creates a very personalized goal that she is more likely to adhere.</p><p>Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, should you suggest along with the diet books?</div> <div class="response"><strong>You chose:</strong> Physical activity plans</div><p>Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p><p>An ideal path for this encounter would have been behavioral supports, which is only mentioned as <em>"Online support"</em> as an option. While online support is good, there are also better options you could present. Behavioral supports include the brief motivational interventions provided in primary practice as well as referrals. Outside referrals may be to a trained interventionist, such as a registered dietitian or a counselor and/or a medical or commercial weight-loss program. Behavioral support is best if it is in-person, high-intensity, and long term (at least 6 months). It can be individual or group sessions. As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. They are found all over the United States.</p><p>For physical activity, recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p><p>In addition to dietary change, both behavioral support and physical activity are necessary for a comprehensive lifestyle intervention.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p> Focus on more exercise: Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - C1a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary H</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Recommend she read up on evidence based diets</div><p>Recommending diet books could never hurt! But, in your brief encounter with Ms. Jones, the better choice would be to <em>"Prescribe a weight-loss diet"</em> that has been discussed with Ms. Jones. This creates a very personalized goal that she is more likely to adhere.</p><p>Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, should you suggest along with the diet books?</div> <div class="response"><strong>You chose:</strong> Online support</div><p>Many people use online apps and supportive programs for weight loss. Support programs are integral in patient weight loss, so this choice was the best out of the 3 choices given for this particular branched path. As the provider, you are in a unique position to provide <em>intensive</em> support for patients, which would be ideal in this situation. Behavioral supports include the brief motivational interventions provided in your practice as well as referrals. Outside referrals may be to a trained interventionist, such as a registered dietitian or a counselor and/or a medical or commercial weight-loss program. Behavioral support is best if it is in-person, <em>high-intensity</em>, and long term (at least 6 months). It can be individual or group sessions. As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. They are found all over the United States.</p><p>In addition to dietary change, both behavioral support and physical activity are necessary for a comprehensive lifestyle intervention.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Focus on more exercise: Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - C2a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary I</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Recommend she read up on evidence based diets</div><p> Recommending diet books could never hurt! But, in your brief encounter with Ms. Jones, the better choice would be to prescribe the weight-loss diet that you have been discussing with Ms. Jones. This creates a very personalized goal that she is more likely to adhere to.</p><p>Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li> <li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, should you suggest along with the diet books?</div> <div class="response"><strong>You chose:</strong> Your office phone number</div><p>Many providers make themselves available during various hours. As you know, providers are insanely busy, but you are in a unique position to provide intensive support for patients in other ways. An ideal path for this choice would have been behavioral supports and is only presented as "Online support" as an option. While online support is good, there are also better options you could present. Behavioral supports include the brief motivational interventions provided in your practice as well as referrals. Outside referrals may be to a trained interventionist, such as a registered dietitian or a counselor and/or a medical or commercial weight-loss program. Behavioral support is best if it is in-person, high-intensity, and long term (at least 6 months). It can be individual or group sessions. As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. They are found all over the United States.</p><p>In addition to dietary change, both behavioral support and physical activity are necessary for a comprehensive lifestyle intervention.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong> <p>Focus on more exercise: Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - C3a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> A food diary</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I would like you to take this journal home with you and record all the foods you eat.</p> </div> <div class="patient-dialogue"> <p> Oh yes, I've done that before. I have an app for that now.</p> </div> <div class="provider-dialogue"> <p>And you like the app?</p> </div> <div class="patient-dialogue"> <p> When I use it, yes. It is pretty easy. I just haven't been motivated lately to lose weight. It has worked in the past.</p> </div> <div class="note"><em>[Ms. Jones is given several info booklets as well as a print out of everything that has been discussed about her goals, including diet and exercise prescriptions. She leaves somewhat motivated to make some changes.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - A1</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Family support</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>I know you are close with your family. Will they support you as you work toward your goals?</p> </div> <div class="patient-dialogue"> <p> Hmmm. I know they support me in many ways, but I'm not sure they will be 100% supportive of changing my eating habits. In the past, they made fun of what I was eating as opposed to being encouraging.</p> </div> <div class="provider-dialogue"> <p> Could you encourage them to eat healthier? Maybe you and your sister could cook together creating healthy meals?</p> </div> <div class="patient-dialogue"> <p> I could try, but my sister and the rest of my family can be really stubborn and set in their ways.</p> </div> <div class="provider-dialogue"> <p>Yes, sometimes that is the case, but maybe if you take this information with you and really help your family understand why this is important for your health than they would be a little more understanding.</p> </div> <div class="note"><em>[Ms. Jones is given several info booklets as well as a print out of everything that has been discussed about her goals, including diet and exercise prescriptions. She leaves somewhat motivated to make some changes.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion - A2</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Regular health monitoring</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p>Before you go, I want to make sure that you continue to make appointments so I can monitor you on your progress. I want to make sure you are on track toward your goals. How about I set you up here in the clinic to help you tailor your eating plan as you progress toward your weight-loss goals. We can definitely work around your schedule. Would you like to meet with our clinic nutritionist? </p> </div> <div class="patient-dialogue"> <p> They can help me lose weight? </p> </div> <div class="provider-dialogue"> <p>Our nutritionist is excellent and will educate you on what you need to be eating to obtain your health goals. I will also recommend weight-loss support group that is run by a licensed clinical social worker specializing in weight loss. That can be part of your weight-loss plan and you would meet with the group once a week for 6 months. The success rate is very high with this particular group. It is a commitment, what do you think?</p> </div> <div class="patient-dialogue"> <p> I guess I can't really make any excuses. This is important. I will make it work. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Treatment Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Discussion- A3</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary A</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Focus on more exercise</div><p>Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p><p>In this brief encounter with Ms. Jones, the better choice would be to <em>"Prescribe a weight-loss diet"</em> that has been the topic of discussion with Ms. Jones. This creates a very personalized goal that she is more likely to adhere.</p><p>Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul><p>For physical activity, recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p><p>Both diet and physical activity are necessary for a comprehensive lifestyle intervention. The third component is discussed below.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, can you suggest along with more exercise?</div> <div class="response"><strong>You chose:</strong> A food diary</div><p>Food diaries are excellent tools to monitor food intake and check progress. Instead of focusing on just a food diary for this encounter, a better choice would have been to take it one step further and offer behavioral supports for the proposed lifestyle changes in Ms. Jones' diet. This would have been seen in the option, <em>"Regular health monitoring"</em>.</p><p>Dietary changes, behavioral support and physical activity are paramount for success in patient weight-loss.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Recommend she ready up on evidence-based diets: Recommending books could never hurt, but personalizing her goals, that Ms. Jones is likely to adhere, with weight-loss prescription is a much better choice.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - A1a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary B</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Focus on more exercise</div><p>Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p><p>In this brief encounter with Ms. Jones, the better choice would be to <em>"Prescribe the weight-loss diet"</em> that has been the topic of discussion with Ms. Jones. This creates a very personalized goal that she is more likely to adhere to.</p><p>Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li> </ul><p>For physical activity, recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, can you suggest along with more exercise?</div> <div class="response"><strong>You chose:</strong> Family support</div><p>You are on the right track with this one, but not everyone will benefit from the support of close family or friends. The correct path for this encounter would have included a referral to behavioral supports, as seen in the option, <em>"Regular health monitoring"</em>. Behavioral supports include the brief motivational interventions provided in primary practices as well as referrals. Outside referrals may be to a trained interventionist, such as a registered dietitian or a counselor and/or a medical or commercial weight-loss program. Behavioral support is best if it is in-person, high-intensity, and long term (at least 6 months). It can be individual or group sessions. As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. They are found all over the United States.</p><p>Dietary changes, behavioral support and physical activity are paramount for success in patient weight-loss.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Recommend she ready up on evidence-based diets: Recommending books could never hurt, but personalizing her goals, that Ms. Jones is likely to adhere, with weight-loss prescription is a much better choice.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - A2a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Treatment Summary C</div> <div class="container"> <div class="inner"> <div class="feedback neutral"> <div class="question"><strong>Question 1:</strong> How could you start implementing this weight-loss plan with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Focus on more exercise</div><p>Ms. Jones has already agreed to increase her walking at work, which is a very good start for her. For those who are obese AND sedentary, walking at low intensity for even 30 minutes, five days a week, can result in significant weight loss (5 to 6%) and decreased abdominal obesity (4 to 5 cm) (Ross et al., 2015).</p><p>In this brief encounter with Ms. Jones, the better choice would be to <em>"Prescribe the weight-loss diet"</em> that has been the topic of discussion with Ms. Jones. This creates a very personalized goal that she is more likely to adhere to.</p><p>Comprehensive lifestyle interventions include prescribing a dietary change that achieves a reduced caloric or reduced carbohydrate intake. This can be achieved through:</p><ul><li> Specifying a lower number of calories</li><li> A calorie deficit to subtract from current intake</li><li> An evidence-based diet that emphasizes eating healthy foods and restricts certain types of foods, such as carbohydrates, depending on the patient.</li></ul><p>For physical activity, recommend increasing physical activity both in terms of increasing exercise and decreasing sedentary behavior throughout the day.</p></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> What other options, available to Ms. Jones, can you suggest along with more exercise?</div> <div class="response"><strong>You chose:</strong> Regular health monitoring</div><p>Typically, a provider will just monitor weight for those who are not ready to lose weight. Ms. Jones, however, is responding positively to accepting a weight-loss plan and you included a referral to behavioral supports. Behavioral supports include the brief motivational interventions provided in primary practices as well as referrals. Outside referrals may be to a trained interventionist, such as a registered dietitian or a counselor and/or a medical or commercial weight-loss program. Behavioral support is best if it is in-person, high-intensity, and long term (at least 6 months). It can be individual or group sessions. As a future physician, if you are not aware of where to refer your patients for behavioral supports, you can find a program through the CDC's National Diabetes Prevention Program. They are found all over the United States.</p><p>Dietary changes, behavioral support and physical activity are paramount for success in patient weight loss.</p></div> <div class="summary"><strong>Regarding other possible choices: </strong><p>Recommend she ready up on evidence-based diets: Recommending books could never hurt, but personalizing her goals, that Ms. Jones is likely to adhere, with weight-loss prescription is a much better choice.</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Prescribed Weight Loss Plan]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Treatment - Summary - A3a</p> <div class="chapter"><strong>Ch 6 |</strong> Treatment</div> <div class="progress chapter6"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">References</div> <div class="container"> <div class="inner"> <div class="references">Bradley DW, Murphy G, Snetselaar LG, et al.. The incremental value of medical nutrition therapy in weight management. Manag Care. 2013. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23373140 Accessed on: 2015-03-03. <br/> Farley AC, Hajek P. Aveyard P, Interventions for preventing weight gain after smoking cessation. Cochrane Database Syst Rev. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22258966 Accessed on: 2015-02-12. <br/> Ilanne-Parikka P , Eriksson JG. Lindstrom J, Effect of lifestyle intervention on the occurrence of metabolic syndrome and its components in the Finnish Diabetes Prevention Study. Diabetes Care . 2008; 31: 805-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18184907 Accessed on: 2015-02-02. <br/> Jensen M, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults . Journal of the American College of Cardiology. 2014. Available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee Accessed on: 2015-01-21. <br/> Jensen MD, Ryan DH, et al. 2013 Report on the Management of Overweight and Obesity in Adults: Full Panel Report Supplement. . 2013. Available at: http://jaccjacc.cardiosource.com/acc_documents/2013_FPR_S5_Obesity.pdf Accessed on: 2015-03-10. <br/> Mayo Clinic Staff. DASH diet: Healthy eating to lower your blood pressure. Mayo Clinic. 2013. Available at: http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456 <br/> Mechanick JI, Youdim A, Jones DB. et al., Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity. 2013. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23529939 Accessed on: 2014-10-13. <br/> Muir M. Archer-Heese G, Essentials of a bariatric patient handling program. The Online Journal of Issues in Nursing. 2009; 14: . Available at: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No1Jan09/Bariatric-Patient-Handling-Program-.html Accessed on: 2015-05-11. <br/> O'Hara P, Connett JE. Lee WW, Early and late weight gain following smoking cessation in the lung health study. American Journal of Epidemiology . 1998; 148: 821-830. Available at: http://aje.oxfordjournals.org/content/148/9/821.long Accessed on: 2015-02-11. <br/> Rexrode K, Rundek T. Body mass index and stroke in UK women. Neurology. September 2016:10.1212/WNL.0000000000003186. doi:10.1212/wnl.0000000000003186. <br/> Ross R, Hudson R, Stotz PJ, et al.. Effects of exercise amount and intensity on abdominal obesity and glucose tolerance in obese adults: A randomized trial. Annals of Internal Medicine. 2015; 162(5): 325-334. <br/> Shlisky JD, Hartman TJ, Kris-Etherton PM, Rogers CJ, Sharkey NA. Nickols-Richardson SM, Partial Sleep Deprivation and Energy Balance in Adults: An Emerging Issue for Consideration by Dietetics Practitioners. J Acad Nutr Diet. 2012; 112(11): 1785-97. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23102177 Accessed on: 2014-03-31. <br/> Simon GE, Von Korff M, Saunders K. et al., Association between obesity and psychiatric disorders in the US adult population. JAMA Psychiatry. 2006; 63(7): 824-830. Available at: http://archpsyc.jamanetwork.com/article.aspx?articleid=209790 Accessed on: 2015-03-16. <br/> Tremblay MS, LeBlanc AG, Janssen I, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. International Journal of Behavioral Nutrition.. 2011; 8: 98. Available at: http://www.ijbnpa.org/content/8/1/98 Accessed on: 2014-12-31. <br/> Vincent HK, Vincent KR . Lamb KM, Obesity and mobility disability in the older adult. Obesity Reviews . 2010; 11: 568-579. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20059707 Accessed on: 2015-05-11. <br/> Wannamethee SG , Sharper AG . Walker M, Overweight and obesity and weight change in middle aged men: impact on cardiovascular disease and diabetes . J Epidemiol Community Health. 2005; 59: 134-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15650145 Accessed on: 2015-02-02. <br/> WHO. BMI classification. Global Database on Body Mass Index. 2006. Available at: http://apps.who.int/bmi/ Accessed on: 2014-08-29. <br/> Kurt K, Spitzer RL,Williams JBW, Validity of a Brief Depression Severity Measure. JGIM: Journal of General Internal Medicine. 2001. 16, 606-613. Available at: http://onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.2001.016009606.x/full </div> </div> <div class="navigation"> <div class="question">Continue to:</div> <div class="return">[[Case Review]]</div> <div class="continue">[[Finish and Take Survey]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Case References</p> <div class="chapter"><strong>Ch 7 |</strong> Summary</div> <div class="progress chapter7"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Quiz</div> <div class="container"> <div class="inner"> <div class="results"> <h4>Use the skills you learned with this patient to answer the questions below.</h4><hr/> <strong>1. A patient has just been evaluated and diagnosed with obesity and central adiposity because of her BMI and waist measurement. Other tests have not yet been ordered, but what weight-related comorbidities may already be present or likely to develop at her current body mass and distribution of body fat? (Medical History available to view)</strong><br/> A. Hypertension<br/> B. Dyslipidemia<br/> C. Metabolic Syndrome<br/> D. Certain cancers<br/> <strong>2. Match each patient's BMI and health status to a recommended treatment level:</strong><br/> A. BMI 25, hypertension and type 2 diabetes mellitus Treatment: Calorie-restricted diet and increased physical activity <br/> B. BMI 26, otherwise healthy Treatment: Calorie-restricted diet, increased physical activity, and weight loss program or counseling with a trained interventionist <br/> C. BMI 29, dyslipidemia, atrial fibrillation Treatment: Calorie-restricted diet and increased physical activity <br/> D. BMI 31, otherwise healthy Treatment: Calorie-restricted diet, increased physical activity, and weight loss program or counseling with a trained interventionist <br/> <strong>3. Which of the following provider responses are likely to be effective in terms of patient motivation? (Choose all that apply)</strong><br/> A. I'm glad to hear you ask. That shows that even though you are discouraged, you have some confidence that you can make changes that will improve your health.<br/> B. Have you considered swimming? You might be able to do that since the water takes some stress off your joints.<br/> C. What activities do you find that you can still do on most days?<br/> D. I'd like to summarize: You have to eat a diet of fewer calories and get more physical activity in order to lose weight.<br/> <strong>4. The following can be concluded based on a patient's waist measurement: (Check all that apply)</strong><br/> A. A diagnosis of obesity<br/> B. A diagnosis of central adiposity<br/> C. Increased risk for heart disease<br/> D. Increased risk for type 2 diabetes<br/> </div> </div> <div class="navigation"> <div class="continue">[[Quiz Feedback]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Quiz</p> <div class="progress"><div class="inner casesummary"></div></div> </div>

<div class="yourchoice">Quiz Feedback</div> <div class="container"> <div class="inner"> <div class="results"> <strong>1. A patient has just been evaluated and diagnosed with obesity and central adiposity because of her BMI and waist measurement. Other tests have not yet been ordered, but what weight-related comorbidities may already be present or likely to develop at her current body mass and distribution of body fat? (Medical History available to view)</strong><br/> //YOU CHOSE: A. Hypertension//<br/> FEEDBACK: Correct! With a BMI in the obesity range and central adiposity, she is at risk for metabolic syndrome, including hypertension, especially since her blood pressure is elevated currently. The other answers are also correct. Dyslipidemia, metabolic syndrome, and certain cancers are all weight-related comorbidities associated with elevated BMI and waist circumference.<br/> //YOU CHOSE: B. Dyslipidemia//<br/> FEEDBACK: Correct! With a BMI in the obesity range and central adiposity, she is at risk for metabolic syndrome including dyslipidemia. The other answers are also correct. Hypertension, metabolic syndrome, and certain cancers are all weight-related comorbidities associated with elevated BMI and waist circumference.<br/> //YOU CHOSE: C. Metabolic Syndrome//<br/> FEEDBACK: Correct! With a BMI in the obesity range and central adiposity, she is at risk for metabolic syndrome. The other answers are also correct. Hypertension, dyslipidemia, and certain cancers are all weight-related comorbidities associated with elevated BMI and waist circumference.<br/> //YOU CHOSE: D. Certain cancers//<br/> FEEDBACK: Correct! Obesity is associated with a greater risk of developing certain cancers, like breast, cervical, colon, and thyroid. The other answers are also correct. Hypertension, dyslipidemia, and metabolic syndrome are all weight-related comorbidities associated with elevated BMI and waist circumference. <br/> --- <strong>2. Select the correct match of a patient's BMI and health status to a recommended treatment level:</strong><br/> //YOU CHOSE: A. BMI 25, hypertension and type 2 diabetes mellitus Treatment: Calorie-restricted diet and increased physical activity//<br/> FEEDBACK: Incorrect. Calorie-restricted diet, increased physical activity, and weight loss program or counseling with a trained interventionist is the recommendation for anyone with a BMI of 25 or over, who also has a weight-related comorbidity <br/> //YOU CHOSE: B. BMI 26, otherwise healthy Treatment: Calorie-restricted diet, increased physical activity, and weight loss program or counseling with a trained interventionist //<br/> FEEDBACK: Incorrect. Calorie-restricted diet and increased physical activity is the recommendation for anyone with a BMI of 25 to 27, who is otherwise healthy <br/> //YOU CHOSE: C. BMI 29, dyslipidemia, atrial fibrillation Treatment: Calorie-restricted diet and increased physical activity//<br/> FEEDBACK: Incorrect. Calorie-restricted diet, increased physical activity, and weight loss program or counseling with a trained interventionist is the recommendation for anyone with a BMI of 25 or over, who also has a weight-related comorbidity <br/> //YOU CHOSE: D. BMI 31, otherwise healthy Treatment: Calorie-restricted diet, increased physical activity, and weight loss program or counseling with a trained interventionist //<br/> FEEDBACK: Correct! This is the recommendation for anyone with a BMI of 27 or over, who is otherwise healthy <br/> --- <strong>3. Which of the following provider responses are likely to be effective in terms of patient motivation?</strong><br/> //YOU CHOSE: A. I'm glad to hear you ask. That shows that even though you are discouraged, you have some confidence that you can make changes that will improve your health.//<br/> FEEDBACK: Good choice. This doctor used reflective listening ("you are discouraged") and included an affirmation ("I'm glad to hear you ask...you've got some confidence") . Answer C is also a good choice. It uses an open-ended question. <br/> //YOU CHOSE: B. Have you considered swimming? You might be able to do that since the water takes some stress off your joints.//<br/> FEEDBACK: Incorrect. This comment is directive and not an open-ended question. <br/> //YOU CHOSE: C. What activities do you find that you can still do on most days?//<br/> FEEDBACK: This would be a good choice. This is an open-ended question. Answer A is also a good choice that uses reflective listening. <br/> //YOU CHOSE: D. I'd like to summarize: You have to eat a diet of fewer calories and get more physical activity in order to lose weight//<br/> FEEDBACK: Incorrect. This is a provider directed rather than patient elicited plan. When "summarizing" as a motivational technique, summarize the patients words and feelings, not your own. <br/> --- <strong>4. The following can NOT be concluded based on a patient's waist measurement: </strong><br/> //YOU CHOSE: A. A diagnosis of obesity//<br/> FEEDBACK: Correct! BMI is used to define overweight and obesity, and subsequently used to diagnose overweight or obesity. Someone with a high waist circumference (central adiposity) may not necessarily have a diagnosis for overweight or obesity. <br/> //YOU CHOSE: B. A diagnosis of central adiposity//<br/> FEEDBACK: Incorrect. The cut point for diagnosing a woman with central adiposity is a waist measurement of ≥ 34.5 inches (88 cm). <br/> //YOU CHOSE: C. Increased risk for heart disease//<br/> FEEDBACK: Incorrect. Elevated waist circumference (over 34.5 inches in women) is associated with an increased risk for heart disease. Also, waist measurements are twice as effective as BMI at predicting future coronary heart disease <br/> //YOU CHOSE: D. Increased risk for type 2 diabetes//<br/> FEEDBACK: Incorrect. Elevated waist circumference (over 34.5 inches in women) is associated with an increased risk for type 2 diabetes. <br/> </div> </div> <div class="navigation"> <div class="continue">[[Survey]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Quiz Feedback</p>

<div class="yourchoice"><strong>You Chose:</strong> Survey</div> <div class="container"> <div class="inner"> <div class="results"><ol><li>The cases achieved the learning objectives <ul><li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li></ul></li> <li>I understood the choices I was presented <ul><li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li></ul></li> <li>I enjoyed working through the cases <ul><li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li></ul></li> <li>The cases were a valuable learning experience <ul><li>N/A</li> <li>Strongly Disagree</li> <li>Disagree</li> <li>Neither Agree or Disagree</li> <li>Agree</li> <li>Strongly Agree</li></ul></li></ol> </div></div> </div> <div class="footer"> <div class="progress"><div class="inner casesummary"></div></div> </div>

<div class="yourchoice">Case Overview</div> <div class="container case"> <div class="inner"><div class="report"><h4 class="title">Case Overview</h4><div class="patient-overview"><div class="patientimg"></div> <div class="name">Miranda Jones</div> <div class="age">Age 35</div> <div class="occupation">Office worker</div> <div class="complaint">"I haven't been sleeping well lately."</div></div>In this clinical simulation, you will make choices as Ms. Jones' primary care provider and experience outcomes based on the choices you make. You will be challenged to: <ul><li>Develop a trusting relationship with Ms. Jones</li><li>Explore together her personal health habits that may be contributing to her overall health</li><li>Discuss some topics that may be sensitive for her, or perhaps even for yourself</li></ul> <strong>Case Backdrop:</strong> When working through the case of Miranda Jones, it is important to remember that this case is primarily about treating obesity. Some details that are extraneous to the primary objectives of the case are summarized rather than explored in details. There are four main sections of the patient interview: <ul><li>History</li><li>Evaluation</li><li>Diagnosis</li><li>Treatment</li></ul> <div class="continue">[[Meet Your Patient|I History]]</div> </div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Diagnostic Tests and Screening Summary A</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What medical assessments should be considered at this point based on her body mass diagnosis and other findings?</div> <div class="response"><strong>You chose:</strong> Order labs and refer to a sleep specialist</div><p>Great choice! A sleep specialist will perform a polysomnography, or sleep study, which is an ideal evaluation for sleep apnea. Weight loss is an important treatment for this condition. Symptoms for sleep apnea include:</p><ul><li>daytime sleepiness</li><li>unrefreshing sleep</li><li>fatigue</li><li>snoring</li></ul>Sleep apnea also has an association with the following:<ul><li>cardiovascular diseases</li><li>type 2 diabetes</li><li>metabolic abnormalities</li><li>cognitive impairment</li><li>deterioration of the quality of life and working capacity</li><li>increased mortality</li></ul>Patients with symptoms of sleep apnea are often referred to a specialist. The choice also referenced you ordering labs. The following eight diseases/conditions are most likely to co-occur with obesity. They include both conditions caused by the fat mass and metabolic changes.<ul><li>Cardiovascular Disease *overweight and obese women are also at a higher risk for ischemic stroke (Rexrode et al., 2016)</li><li>Type 2 Diabetes Mellitus</li><li>Hypertension</li><li>Dyslipidemia</li><li>Sleep apnea</li><li>Osteoarthritis and other physical functioning problems</li><li>Gall bladder disease</li><li>Cancer: Breast, Colon, and others</em></li></ul></div> <div class="feedback correct"> <div class="question"><strong>Question 2:</strong> In addition to a basic metabolic panel, what tests should you order for Ms. Jones' work-up for weight-related comorbidities?</div> <div class="response"><strong>You chose:</strong> Thyroid HbA1C Lipids Liver VitD </div><p>Excellent choice! HbA1C, lipid profiles, liver, and vitamin D are a few laboratory tests that can be used to test for common comorbidities associated with obesity, such as diabetes, dyslipidemia, and NAFLD (non-alcoholic fatty liver disease). Vitamin D deficiencies are relatively common in patients with obesity. Supplementation is indicated for vitamin D levels below the normal range.<p><div class="more">[[View Lab Tests for Common Comorbid Conditions]]</div></div> <div class="summary"><strong>Regarding other possible choices:</strong> <p>Evaluate for Anxiety Disorder: Many clinics have a form, like the PHQ (Kurt et al., 2001) to screen for mental health problems upon patient check-in. Ms. Jones had not self-reported any signs or symptoms of mood or anxiety disorders on the mental health evaluation form. It should be noted that the odds of having a mood or anxiety disorder are increased approximately 25% with obesity (Simon et al., 2006). These comorbidities need to be recognized and treated in conjunction with weight management. Hormonal changes to consider: Some hormonal conditions known to cause weight gain include hypogonadism, low testosterone, polycystic ovary syndrome, growth hormone imbalance and Cushing's disease (Mechanick et al., 2013).</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Summary - A1a</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Sleep interventions</div> <div class="container"> <div class="inner"> <div class="provider-dialogue"><p>Okay, Ms. Jones. We have ordered your labs, you have completed all the paperwork, and we are well on our way. How are you on time? Can I ask you some more questions?</p></div> <div class="patient-dialogue"><p> Of course. What else would help?</p></div> <div class="provider-dialogue"><p>Before we get the results from your sleep study, I just want to gauge your interest in keeping a sleep diary.</p></div> <div class="patient-dialogue"><p> What good would a diary do?</p></div> <div class="provider-dialogue"><p>You would keep it for a week or two to keep track of any problem sleep patterns and contributing factors, like drinking caffeine. </p></div> <div class="patient-dialogue"><p> I might be able to do that.</p></div> <div class="provider-dialogue"><p>Excellent.</p></div> </div> <div class="navigation"> <div class="question">Next, you want begin some diet interventions. How would you like to begin this conversation?</div> [[Diet]] [[Physical activity]] [[Stress]] </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - A</p>

<div class="yourchoice"><strong>You Chose:</strong> Tell me about your diet and exercise</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Since the specialist is going to explore your sleep problems in depth, I would like to focus on how I can help. Tell me about your diet and exercise habits.</p> </div> <div class="patient-dialogue"> <p> Well, I do walk everyday at work. I really like doing that actually. Sometimes I really just need to get outside and take a break from looking at the computer screen. Sometimes, my co-workers come with me and I get to socialize a little bit which is nice. We walk for like 15-30 minutes I would say. It's a pretty good way to get a break. As for my diet, I know that I could be better. I snack and eat out a lot and I know that is not the best for you, it's just so easy and time efficient.</div> <div class="provider-dialogue"> <p> Sounds like you are getting some moderate exercise pretty consistently, and that’s great you have built that into your week. Tell me more about your snacking and eating out habits.</p> </div> <div class="patient-dialogue"> <p>After work, I'm just so tired, so I grab a burger and fries on the way home. And since my dad died, my sister has been coming over a lot, too. We end up chatting and snacking late at night with wine and cheese. I really look forward to that, but now that you've measured my waistline I see it's taken a big hit!</p> </div> <div class="provider-dialogue"> <p>Sounds like you and your sister are very supportive of each other and there’s no need to give up your wine and cheese hour, as long as you are drinking alcohol in moderation. <em>[They chat more about her drinking it is revealed that she only has a few glasses of wine per week]</em>. Are you interested in modifying your diet with healthier choices?</p> </div> <div class="patient-dialogue"> <p> It's not easy. I'm just so busy all the time.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - A1</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Do you eat well and are you active?</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Since the specialist is going to explore your sleep problems in depth, I would like to focus on how I can help. Do you eat well and are you active?</p> </div> <div class="patient-dialogue"> <p> Sometimes. I mean, I do my best.</p> </div> <div class="provider-dialogue"> <p>Do you get about two and a half hours of exercise per week, you think?</p> </div> <div class="patient-dialogue"> <p> I'm not sure of the exact number, but I get exercise everyday.</p> </div> <div class="provider-dialogue"> <p>That's great. Are you interested in losing weight?</p> </div> <div class="patient-dialogue"> <p> I don't like to talk about my weight so much, but I am interested in being healthier. I just don't feel like my old self.</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - A2</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> What are you doing about your recent weight gain?</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"> <p> Since the specialist is going to explore your sleep problems in depth, I would like to focus on how I can help. What are you doing about your recent weight gain?</p> </div> <div class="patient-dialogue"> <p> I haven't really focused on my weight gain so much. I'm really doing all I can to make it through this year in one piece, you know?</p> </div> <div class="provider-dialogue"> <p>You have had a rough year. Are you interested in feeling better?</p> </div> <div class="patient-dialogue"> <p> I am.</p> </div> <div class="provider-dialogue"> <p>I know you have put on some weight and that could be contributing to your sleep problems. I think you should consider maybe losing some weight. What do you think?</p> </div> <div class="patient-dialogue"> <p> How do you think my weight is contributing to my sleep problems?</p> </div> <div class="note"><em>[A litte more time is spent talking to Ms. Jones about her sleep problems again.]</em></div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Lifestyle Summary C]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - A3</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div> <div class="progress chapter4"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Classes of Medications That May Cause Weight Gain</div> <div class="container"> <div class="inner"> <div class="results">Entire classes of medications may cause weight gain or just some medications within the group. The amount of weight gained varies, but can be a significant contributor to excess weight. Classes of medications that include at least some medications that cause weight gain include the following: <ul><li>Diabetes medications</li><li>Psychotropic medications (Antipsychotics, Mood stabilizers, Antidepressants)</li><li>Contraceptives</li><li>Antihypertensives</li><li>Antiepileptics</li><li>Antiretroviral</li><li>Corticosteroids</li><li>Sedating antihistamines </li></ul>(Domecq et al., 2015)<br/> <strong>The Biology of Medication-Induced Weight Gain</strong><br/>Some medications used for treating various conditions predispose patients to gain weight (orexigenic). The biological mechanisms involved include the following:<ul><li>Decreased postprandial thermogenesis</li><li>Increase appetite through CNS effects on satiety</li><li>Increased fat deposition</li><li>Increased blood sugar and insulin resistance</li><li>Worsened dyslipidemia</li><li>Fluid retention</li><li>Lowered activity from sedative effects</li><li>Decreased exercise tolerance due to fatigue</li></ul></br> (Sharma et al., 2001; ADA et al., 2004; Ucok & Gaebel, 2008; Dal'Ava, 2012)</br> </div> </div> <div class="navigation"> <div class="continue">[Lifestyle Screening and Assessment]</div> </div> </div> <div class="footer"> <p class="small">You are here: Classes of Weight Gaining Medications</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice">AHA/ACA/TOS Body Mass Measurement Guidelines</div> <div class="container"> <div class="inner"> Guidelines are based on the BMI, and lower BMI cut points if there is a comorbidity: <ul><li>If BMI ≥ 25 kg/m<sup>2</sup>, that is, all overweight/obese patients, recommend a reduced-calorie diet and increased physical activity.</li><li>If BMI ≥ 27 kg/m<sup>2</sup> (or BMI ≥ 25 with failed past attempts at weight loss or a weight-related comorbidity), behavioral supports are indicated. These supports include weight-loss groups and counseling by a trained interventionist, such as a registered dietitian (Jensen et al., 2013).</li></ul> <strong>Guidelines for treatments to be applied as adjuncts to the above treatments:</strong> <ul> <li>When BMI is over 30, or when there is a weight-related comorbidity and BMI is over 27, the addition of pharmacotherapy (Jensen et al., 2013).</li> <li>When BMI is over 40 or when there is a weight-related comorbidity and BMI is over 35, referral for weight-loss surgery (Jensen et al., 2013).</li> <li>Very low-calorie diets, typically provided as pre-made meal replacements, are effective at producing fast and significant weight loss. But because of associated risks, should be medically managed and not be considered below BMI of 30 (Mullhollan et al., 2012).</li></ul> Additionally, consider referring patients who are morbidly obese or obese with significant comorbid conditions to a specialist in obesity medicine, a small but growing specialty. </div> <div class="navigation"><div class="question">Please click the back button at the top left of this screen to return to the summary page. <strong>OR</strong></div> </div> </div> <div class="footer"> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Prescribed Weight-Loss Plan</div> <div class="container"> <div class="inner"> <div class="ehr"> <div class="header patientimg"> <div class="patientname"></div> </div> <div class="content"> <p><strong>Date:</strong> June 14, 2016</p><p><strong>Goal:</strong> Lose 11 pounds by September 1, 2016 (~1 lb/week)</p><p> <h4>Physical Activity Agreements:</h4></p><p> <u>**</u>Walking</p> <p>__Dance/Aerobics</p> <p>__Bike riding</p> <p>__Flexibility/Yoga</p> <p>__Other</p><p> <strong>How long and how often:</p></strong><p>__<u>30</u>__minutes</p><p>__<u>5</u>__ times per week</p><p><h4>Dietary Agreements:</h4></p><ul><li><strong>Dietary goals:</strong> Substitute high fat and high carbohydrate fast meals and snacks with healthier options, like grilled chicken tenders and fruit instead of a cheeseburger and fries.</li><li><strong>Calorie intake:</strong> Not counting, but generally aim for 1500 kcal/day</li></ul><p><strong>Intensive Support Agreements:</strong></p><ul><li>Meet with the recommended weight-loss support group every week for 6 months. </li></ul> <p><h4>Long-term goals:</h4></p><ul><li><strong>Physical Activity Changes:</strong> Introduce muscle-strengthening exercises two times per week. </li><li><strong>Dietary Changes:</strong> When weight loss has reached a plateau, a new diet plan will be evaluated.</li><li><strong>Support Changes:</strong> Continue program support, up to one year.</li></ul></div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Case Review]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Prescribed Weight Loss Plan</p> <div class="chapter"><strong>Ch 7 |</strong> Summary</div> <div class="progress chapter7"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice">Case Instructions</div> <div class="container"> <div class="inner"> <div class="results">Welcome to <strong><i>Clinical Encounter: Obesity</i></strong>, a branched learning simulation to test your clinical skills in the assessment and treatment of a patient with obesity. <br/> Instructions for students in the usability test: <br/> <ol><li>View the following case overview, patient EHR and the patient/provider dialogue.</li> <li>You will be asked to make choices as a provider to apply best practices in patient-centered interviewing skills as well as appropriate clinical skills in the assessment and treatment of a patient with obesity. The selections are presented in this demo as red tabs for you to click.</li> <li>You will be given feedback after every two or three choices you make. A new chapter will begin after each feedback summary. </li> <li>If you ever need to "go backward", click the curved arrow in the upper left corner of the inline frame.</li></ol> </div> </div> <div class="navigation"> <div class="continue"[Case Overview]</div> </div> </div> <div class="footer"> <p class="small">You are here: Case Overview</p> </div>

<div class="yourchoice">For Usability Testers Only</div> <div class="container"> <div class="inner"> <div class="results"> <h4>Chapter Summaries</h4> You have now completed the History and Physical Exam Chapters. Normally, players would complete another four chapters to complete the simulation. Three chapters will be summed up here and then you will be directed to the Treatment Chapter, the last chapter, for the sake of time regarding usability testing. <br/> <h4>Evaluation Chapter:</h4> The focus of this chapter is on testing for comorbidities and the impact of smoking (cessation) and medications on weight gain. Classes of weight gaining medications are discussed in detail. you confirms that Ms. Jones has never smoked and she does not present any problems with her current medications. you also gathers enough information that results in a referral to a sleep specialist to confirm a diagnosis of sleep apnea.<br/> <h4>Lifestyle Screening and Assessment Chapter:</h4> This chapter gives more information about Ms. Jones' stress levels and changes to her diet over the past year. you uses open-ended questioning to elicit change from Ms. Jones in terms of her diet. She reacts with a few of her own ideas to incorporate healthier choices into her diet. You also learn that Ms. Jones already walks a few times a week and enjoys it.<br/> <h4>Counseling and Education Chapter:</h4> The risks associated with an elevated body mass are focused in this chapter, as well as information about using evaluation and classification of patient fat mass to guide treatment and track patient progress. </div> </div> <div class="navigation"> <div class="continue">[Treatment Chapter]</div> </div> </div> <div class="footer"> <div class="progress"><div class="inner chaptersummary"></div></div> </div>

<div class="yourchoice"><strong>You Chose:</strong> View Lab Tests for Common Comorbid Conditions</div> <div class="container"> <div class="inner"> <div class="results"><h4>Lab Tests for Common Comorbidities</h4><p>The following are laboratory tests for common comorbidities of obesity as well as conditions that cause weight gain:</p><ul><li>Glucose, HbA1c</li><li>BUN, creatinine, electrolytes</li><li>Liver profile</li><li>Lipid profile</li><li>C-reactive protein</li><li>Uric acid</li><li>CBC</li><li>TSH (hypothyroidism)</li><li>Urine, microalbumin</li><li>Pregnancy</li><li>Nutritional as indicated</li><li>Hormonal (as needed to rule out:)</li><ul><li>Hypogonadism</li><li>Low testosterone</li><li>Polycystic ovary syndrome (PCOS)</li><li>Growth hormone imbalance</li><li>Cushing's disease</li></ul></ul><p style="clear:both;">(Mechanick et al., 2013)</p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Lab Tests for Common Comorbid Conditions</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="stop">For usability testers, please stop here to answer a few questions about your experience so far.</div>

<div class="version">v 2.0</div> <div class="welcomeheader" id="obesity"></div> <div class="container"> <div class="inner"> <div class="welcomeimg patientbox"> <div class="patientimg"></div> <div class="patientinfo"> <strong>Miranda Jones</strong> <p>"I haven't been sleeping well lately."</p> <div class="continue">[[Begin Case|Case Overview]]</div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg pt5"></div> <div class="patientinfo"> <strong>Carol</strong> <p>"I always gain weight after my diets."</p> <div class="continue fakebutton"> <div>Coming Soon</div> </div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg pt6"></div> <div class="patientinfo"> <strong>Dr. Golden</strong> <p>"I want to be a better role model for my patients."</p> <div class="continue fakebutton"> <div>Coming Soon</div> </div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg pt7"></div> <div class="patientinfo"> <strong>Rebecca</strong> <p>"I eat a lot after a stressful day, but feel guilty about if afterward."</p> <div class="continue fakebutton"> <div>Coming Soon</div> </div> </div> </div>  <div class="welcomeimg patientbox inactive"> <div class="patientimg pt8"></div> <div class="patientinfo"> <strong>Dave</strong> <p>"I want to know more about weight-loss surgery."</p> <div class="continue fakebutton"> <div>Coming Soon</div> </div> </div> </div> <div class="info">[[Instructions]]</div> </div> </div> <style> tw-passage { background: #e1e1e1; background: -webkit-linear-gradient(left top, rgb(205, 221, 216), #e1e1e1); background: -o-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: -moz-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: linear-gradient(to bottom right, rgb(205, 221, 216), #e1e1e1); } </style>

<div class="yourchoice">Getting Started</div> <div class="container intro"> <div class="inner"> <div class="summary closebox"><div class="close">[[ |Welcome]]</div><h2 class="title">Instructions</h2><div class="summary"> <strong>Instructions:</strong> Move through this patient visit by choosing responses to questions at the bottom of each passage. Continue to the end of the case (Case Review). </div><div class="summary"><strong>Feedback on Mastery:</strong> You will complete typical steps of a patient encounter and receive feedback after each step: review case history, complete an evaluation, diagnosis, and brief intervention, and make a plan of care for your patient. Feedback on your choices will be color coded as follows: </div> <div class="feedback correct third start"><div class="response">Best Selection</div></div><div class="clear"></div><div class="feedback neutral third"><div class="response">Less Than Ideal Selection</div></div><div class="clear"></div><div class="feedback incorrect third end"><div class="response">Incorrect Selection</div></div> <div style="clear:both;"></div> <div class="return">[[Back|Welcome]]</div></div></div></div> <style> tw-passage { background: #e1e1e1; background: -webkit-linear-gradient(left top, rgb(205, 221, 216), #e1e1e1); background: -o-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: -moz-linear-gradient(bottom right, rgb(205, 221, 216), #e1e1e1); background: linear-gradient(to bottom right, rgb(205, 221, 216), #e1e1e1); } </style>

<div class="yourchoice"><strong>You Chose:</strong> Discuss Dietary Habits</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="provider-dialogue"><p>What does a typical evening look like for you?</p></div> <div class="patient-dialogue"><p> My sister and I usually go out to eat or go to each other's house for a wine and cheese hour. She is my best friend.</p></div> <div class="provider-dialogue"><p>I can tell this is an important tradition for you. When you do cook at home, I see you prepare foods for yourself, like chicken, fish, beans. All very healthy foods.</p></div> <div class="patient-dialogue"><p> I try to cook them when I have time, but usually I just grab what I can if I'm not out with my sister. I do eat fast food a lot. Burgers and fries are just too convenient. </p></div> <div class="provider-dialogue"><p>A lot of people struggle with that.</p></div> </div> </div> <div class="navigation"> <div class="question">In an effort to start eliciting ideas from Ms. Jones to start thinking about how she could alter her diet, you could say:</div> </div> </div> <div class="footer"> <p class="small">You are here: Lifestyle Screening - Question - B</p> <div class="chapter"><strong>Ch 4 |</strong> Lifestyle</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div> </div>

<div class="yourchoice">History Objectives</div> <div class="container intro"> <div class="inner"> <div class="summary"><strong>Meet Your Patient:</strong> Upon completion of this chapter, learners will be able to: <ol><li>Use patient-centered, motivational interviewing approach to:<ul><li>Establish rapport with a knowledgeable patient who has an obesity diagnosis</li><li>Focusing the patient interview to identify patient barriers to weight loss</li></ul></ol> </div> <div class="summary"><strong>Summary of Activity Objectives:</strong> The Miranda Jones case contains the following main objectives: <ol><li>Assess patients for overweight and obesity using body mass measurements, in order to determine appropriate treatment. </li><li>Recommend evidence-based behavior modifications regarding diet and physical activity for long-term weight management.</li><li>Use motivational counseling techniques tailored to meet individual weight-loss treatment needs.</li><li>Refer patients for high-intensity behavioral support for weight loss.</li></ol> <hr/>The Miranda Jones case contains the following Activity Knowledge Objectives: <ol><li>Define overweight, obesity, and central adiposity.</li><li>Calculate body mass index.</li>Describe the obesity algorithm for treating patients with overweight and obesity</li><li>List basic motivational interviewing techniques that are effective in weight management.</li></ol> </div> </div> <div class="navigation"><div class="question">Return to:</div> <div class="return">[[I History]]</div> </div> </div>

<div class="yourchoice">Physical Exam Chapter Objectives</div> <div class="container intro"> <div class="inner"> <div class="summary"><strong><p>Physical Exam Chapter Clinical Objectives:</strong> Upon completion of this chapter, learners will be able to:</p><ol><li>Assess patients for overweight and obesity using BMI and waist circumference.</li><li>Interpret BMI and waist circumference in terms of body mass diagnosis and severity.</li><li>Use a patient-centered, motivational interviewing approach to:</li><ul><li>Use interpretation of body mass assessments to select category of treatment.</li></ul></ol> </div> <div class="summary"><strong>Summary of Activity Objectives:</strong> <p>The Miranda Jones case contains the following main objectives:</p><ol><li>Assess patients for overweight and obesity using body mass measurements, in order to determine appropriate treatment. </li><li>Recommend evidence-based behavior modifications regarding diet and physical activity for long-term weight management.</li><li>Use motivational counseling techniques tailored to meet individual weight-loss treatment needs.</li><li>Refer patients for high-intensity behavioral support for weight loss.</li></ol> <hr/><p>The Miranda Jones case contains the following Activity Knowledge Objectives:</p><ol><li>Define overweight, obesity, and central adiposity.</li><li>Calculate body mass index.</li>Describe the obesity algorithm for treating patients with overweight and obesity</li><li>List basic motivational interviewing techniques that are effective in weight management.</li></ol> </div> </div> <div class="navigation"><div class="question">Return to:</div> <div class="return">[[II Physical Exam]]</div> </div> </div>

<div class="yourchoice">Diagnostic Tests and Screening Objectives</div> <div class="container intro"> <div class="inner"> <div class="summary"><p><strong>Diagnostic Tests and Screening:</p><p></strong> Upon completion of this chapter, learners will be able to:</p><ol><li>Use body mass assessment to determine all the weight-related comorbidities for which a patient with excess body mass has increased risk.</li><li>Counsel patients on health improvements that they can obtain through weight loss.</li></ol> </div> <div class="summary"><p><strong>Summary of Activity Objectives:</strong></p> <p>The Miranda Jones case contains the following main objectives:</p><ol><li>Assess patients for overweight and obesity using body mass measurements, in order to determine appropriate treatment. </li><li>Recommend evidence-based behavior modifications regarding diet and physical activity for long-term weight management.</li><li>Use motivational counseling techniques tailored to meet individual weight-loss treatment needs.</li><li>Refer patients for high-intensity behavioral support for weight loss.</li></ol> <hr/><p>The Miranda Jones case contains the following Activity Knowledge Objectives:</p><ol><li>Define overweight, obesity, and central adiposity.</li><li>Calculate body mass index.</li>Describe the obesity algorithm for treating patients with overweight and obesity</li><li>List basic motivational interviewing techniques that are effective in weight management.</li></ol> </div> </div> <div class="navigation"><div class="question">Return to:</div> <div class="return">[[III Diagnostic Tests and Screening]]</div> </div> </div>

<div class="yourchoice">Lifestyle Screening and Assessment Chapter Objectives</div> <div class="container intro"> <div class="inner"> <div class="summary"><strong><p>Lifestyle Screening and Assessment Chapter:</strong> Upon completion of this chapter, learners will be able to:</p><ol><li>Use a patient-centered, motivational interviewing approach to:</li><ul><li>Focus the patient interview to identify patient barriers to weight loss.</li>Evoke patient understanding of stressful factors in their lives and awareness of stress-related lifestyle changes (involving diet).</li><li>Identify patient strengths in past health changes.</li></ul></ol> </div> <div class="summary"><strong>Summary of Activity Objectives:</strong> <p>The Miranda Jones case contains the following main objectives:</p><ol><li>Assess patients for overweight and obesity using body mass measurements, in order to determine appropriate treatment. </li><li>Recommend evidence-based behavior modifications regarding diet and physical activity for long-term weight management.</li><li>Use motivational counseling techniques tailored to meet individual weight-loss treatment needs.</li><li>Refer patients for high-intensity behavioral support for weight loss.</li></ol> <hr/><p>The Miranda Jones case contains the following Activity Knowledge Objectives:</p><ol><li>Define overweight, obesity, and central adiposity.</li><li>Calculate body mass index.</li>Describe the obesity algorithm for treating patients with overweight and obesity</li><li>List basic motivational interviewing techniques that are effective in weight management.</li> </div> </div> <div class="navigation"><div class="question">Return to:</div> <div class="return">[[IV Lifestyle Screening and Assessment Chapter]]</div> </div> </div>

<div class="yourchoice">Counseling and Education Chapter Objectives</div> <div class="container intro"> <div class="inner"> <div class="summary"><p><strong>Counseling and Education Chapter:</strong> Upon completion of this chapter, learners will be able to:</p><ol><li>Counsel patients on health improvements that they can obtain through weight loss.</li><li><p>Use a patient-centered, motivational interviewing approach to:</p><ul><li>Focus the patient interview to identify patient barriers to weight loss.</li><li>Identify patient strengths in past health changes.</li><li>Work with the patient to develop a weight-loss goal.</li></ul></ol> </div> <div class="summary"><p><strong>Summary of Activity Objectives:</strong> The Miranda Jones case contains the following main objectives:</p><ol><li>Assess patients for overweight and obesity using body mass measurements, in order to determine appropriate treatment. </li><li>Recommend evidence-based behavior modifications regarding diet and physical activity for long-term weight management.</li><li>Use motivational counseling techniques tailored to meet individual weight-loss treatment needs.</li><li>Refer patients for high-intensity behavioral support for weight loss.</li></ol> <hr/><p>The Miranda Jones case contains the following Activity Knowledge Objectives:</p><ol><li>Define overweight, obesity, and central adiposity.</li><li>Calculate body mass index.</li>Describe the obesity algorithm for treating patients with overweight and obesity</li><li>List basic motivational interviewing techniques that are effective in weight management.</li> </div> </div> <div class="navigation"><div class="question">Return to:</div> <div class="return">[[V Counseling and Education]]</div> </div> </div>

<div class="yourchoice">Treatment Chapter Objectives</div> <div class="container intro"> <div class="inner"> <div class="summary"><p><strong>Treatment Chapter:</strong> Upon completion of this chapter, learners will be able to:</p><ol><li>Recommend lifestyle changes in order for patients to achieve weight loss.</li><li>Use a patient-centered, motivational interviewing approach to:</li><ul><li>Work with the patient to develop and individualized weight-loss plan</li></ul></ol> </div> <div class="summary"><p><strong>Summary of Activity Objectives:</strong> The Miranda Jones case contains the following main objectives:</p><ol><li>Assess patients for overweight and obesity using body mass measurements, in order to determine appropriate treatment. </li><li>Recommend evidence-based behavior modifications regarding diet and physical activity for long-term weight management.</li><li>Use motivational counseling techniques tailored to meet individual weight-loss treatment needs.</li><li>Refer patients for high-intensity behavioral support for weight loss.</li></ol> <hr/><p>The Miranda Jones case contains the following Activity Knowledge Objectives:</p><ol><li>Define overweight, obesity, and central adiposity.</li><li>Calculate body mass index.</li>Describe the obesity algorithm for treating patients with overweight and obesity</li><li>List basic motivational interviewing techniques that are effective in weight management.</li></ol> </div> </div> <div class="navigation"><div class="question">Return to:</div> <div class="return">[[VI Treatment Plans]]</div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Obesity Treatment Algorithm</div> <div class="container"> <div class="inner"> <div class="results"> <p><h4>AHA/ACA/TOS Body Mass Measurement Guidelines</h4></p> <p>Guidelines are based on the BMI, and lower BMI cut points if there is a comorbidity: </p><ul><li>If BMI ≥ 25 kg/m<sup>2</sup> (that is, all overweight/obese patients), recommend a reduced-calorie diet and increased physical activity.</li><li>If BMI ≥ 27 kg/m<sup>2</sup> (or BMI ≥ 25 with failed past attempts at weight loss or a weight-related comorbidity), behavioral supports are indicated. These supports include weight-loss groups and counseling by a trained interventionist, such as a registered dietitian (Jensen et al., 2013).</li></ul><p><strong>Guidelines for treatments to be applied as adjuncts to the above treatments:</strong></p><ul><li>When BMI is over 30, or when there is a weight-related comorbidity and BMI is over 27, the addition of pharmacotherapy (Jensen et al., 2013).</li><li>When BMI is over 40 or when there is a weight-related comorbidity and BMI is over 35, referral for weight-loss surgery (Jensen et al., 2013).</li><li>Very low-calorie diets, typically provided as pre-made meal replacements, are effective at producing fast and significant weight loss. But because of associated risks, should be medically managed and not be considered below BMI of 30 (Mullhollan et al., 2012).</li></ul><p>Additionally, consider referring patients who are morbidly obese or obese with significant comorbid conditions to a specialist in obesity medicine, a small but growing specialty. </p></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Obesity Treatment Algorithm</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Physical Exam Summary C</div> <div class="container"> <div class="inner"> <div class="feedback correct"> <div class="question"><strong>Question 1:</strong> What body mass measurement should you review or perform with Ms. Jones?</div> <div class="response"><strong>You chose:</strong> Body mass index</div><p>Excellent choice! <strong>BMI</strong> is still the major recommended standard used to:</p><ul><li>Measure body mass and determine excess weight and treatment.</li><li>Perform a quick calculation based on patient data routinely obtained - weight (kg) divided by height (m<sup>2</sup>). </li></ul><p>See the table below for BMI categories and classes.</p></div> <div class="feedback neutral"> <div class="question"><strong>Question 2:</strong> What additional body mass measurement can help you measure Ms. Jones' health risks?</div> <div class="response"><strong>You chose:</strong> Waist to Hip Ratio</div><p>While waist to hip measurements can be a valuable tool, there are limitations using the measurement for those with a BMI of 35 or higher (Hu et al., 2014). A better measurement, in this case, would have been <strong><em>"waist circumference"</em></strong>. Obesity treatment guidelines recommend this measurement at annual visits and more often in patients who are overweight or obese (Jensen et al., 2013).</p></div> <div class="summary"><h4>Measurement Summary</h4> Ms. Jones' BMI was calculated (38.6kg/m2) and her body mass diagnosis determined from the following:<table style="width: 60%;"><tbody><tr><th>BMI (kg/m2)</th><th>Category</th><th>ICD 10</th></tr><tr><td>Below 18.5</td><td>Underweight</td><td>R63.6</td></tr><tr><td>18.5–24.9</td><td>Normal</td><td></td></tr><tr><td>25.0–29.9</td><td>Overweight</td><td>E66.3</td></tr><tr><td>30.0 and Above</td><td>Obesity</td><td>E66.9</td></tr></tbody></table></td></tr></table><p><strong>Diagnosis:</strong> Obesity E66.9</p><p>The severity of obesity can also be determined, using the International Classification of Adult Weight (WHO, 2006):</p><ul><li>Class I Obesity: BMI 30 - 34.9</li><li><b>Class II Obesity:</b> BMI 35 - 39.9 (severe)</li><li>Class III Obesity: <u>></u>BMI 40 (morbid)</li></ul><p>With a <strong>waist circumference</strong> of 41 inches, Ms. Jones is above the cut point of 35 inches for women at greater risk for heart disease.</p><p>At this class of obesity and above, along with significant weight-related comorbidities, a patient is considered for bariatric surgery. </p><div class="more">[[View the Obesity Treatment Algorithm]]</div></div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[III Diagnostic Tests and Screening]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam - Summary - A3a</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="container completed"> <div class="inner"> <div class="summary">You have completed the case of Miranda Jones. <br/> <br/>  <strong>When finished: <a href="http://www.impactobesity.com/ceobesitymiranda" target="_blank">Be Sure to Complete the Survey</a></strong> <div class="return">[[Retake The Experience|Welcome]]</div> </div> </div> </div>

<div class="yourchoice objective"><strong>II.</strong> Evaluation</div> <div class="container"> <div class="inner"> <div class="summary"><p>Ms. Jones' medical and family history has been collected and you are now moving on to the evaluation section of the appointment. The following chapters are associated with Ms. Jones' evaluation.</p> <p>II. Physical Exam</p> <p>III. Diagnostic Tests</p> <p>IV. Lifestyle Screening</p> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[II Physical Exam]] </div> </div> </div> <div class="footer"> <p class="small">You are here: Physical Exam</p> <div class="chapter"><strong>Ch 2 |</strong> Physical Exam</div> <div class="progress chapter2"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong>Basic Metabolic Panel</div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="note">Ms. Jones' last question to you was, "And what about these other tests? What type of information do you want to get?"</div> <div class="provider-dialogue"> <p> I’m going to check your thyroid function to make sure that isn’t contributing to your weight gain, and get a basic metabolic panel to check a few other things, including your blood sugar levels and electrolytes. </p> </div> <div class="patient-dialogue"> <p> My blood sugar level? Do you think I have diabetes? </p> </div> <div class="provider-dialogue"> <p> The blood sugar level is just one component of the test, but your BMI does put you at a higher risk for developing diabetes and a condition we call pre-diabetes, which basically means you’re borderline. </p> </div> <div class="patient-dialogue"> <p> That’s kind of scary.</p> </div> <div class="provider-dialogue"> <p> Have you eaten anything today before your visit?</p> </div> <div class="patient-dialogue"> <p> I grabbed a quick sandwich on my way here since I wasn’t sure how long I’d have to wait. Why? </p> </div> <div class="provider-dialogue"> <p> In that case, I'll check your Hb A1C which doesn't need to be fasting, so you don't need to schedule another appointment. It will also give us a better picture of how your blood sugars are doing over the last few months rather than where it's at right now. </p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Diagnostic Tests and Screening Summary B]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Discussion - A2</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

<div class="yourchoice"><strong>You Chose:</strong> Thyroid HbA1C Lipids Liver VitD </div> <div class="container"> <div class="inner"> <div class="dialogue-container"> <div class="note">Ms. Jones' last question to you was, "And what about these other tests? What type of information do you want to get?"</div> <div class="provider-dialogue"> <p> The tests are pretty routine, but I suggest we look at several things, like your blood sugar, thyroid, liver function, cholesterol, and I'll check your vitamin D as well. At your current BMI, these levels can be higher or lower than normal.</p> </div> <div class="patient-dialogue"> <p>I see. What if my levels are higher or lower than they should be?</p> </div> <div class="provider-dialogue"> <p>We will definitely cross that bridge when we see the results, but there are treatment options available. Weight loss also improves some of these conditions and can reduce the risk if not already present. </p> </div> <div class="patient-dialogue"> <p> And when do we get the results back? I can go ahead and jump the gun on this by getting my act together! I've been wanting to focus on my health more, but haven't really had anything to spark that fire. Maybe this is what I needed.</p> </div> <div class="provider-dialogue"> <p>They should be back in the next few days. That's great to hear that you want to focus on your health, Ms. Jones!</p> </div> </div> </div> <div class="navigation"><div class="question">Continue to:</div> <div class="continue">[[Diagnostic Tests and Screening Summary A]]</div> </div> </div> <div class="footer"> <p class="small">You are here: Evaluation - Discussion - A1</p> <div class="chapter"><strong>Ch 3 |</strong> Evaluation</div> <div class="progress chapter3"> <div class="inner"></div> <div class="chaptermark1"></div> <div class="chaptermark2"></div> <div class="chaptermark3"></div> </div> </div>

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