Holistic Assessment By General Practitioner

URN:QUT19418 | PATIENT: BRENNAN,
Michael
You are the practice RN at a suburban medical clinic.
Mr. Michael Brennan 52yrs is attending his General Practice surgery
for his regular six-monthly check-up. He presents today with
complaints of fatigue, difficulty losing weight and no motivation. He
denies any polyuria, polydipsia, polyphagia or blurred vision. He
notes a marked decrease in his energy levels, particularly in the
afternoons. He is tearful and states that he is not taking his
antidepressants. He states that every time he tries to cut down on his
eating, he has symptoms of shakiness, diaphoresis, and increased
hunger. He does not follow any specific diet and has been fearful of
hypoglycaemia that he often eats extra snacks.

Caring for a patient with Diabetes, Obesity and Mental Illness
Setting the scene
Michael’s holistic assessment by the General Practitioner
(GP) today indicates:
Physical:
 52-year-old male
 Weight 140kg (up from 135kg six months ago)
 Height 176 cm
 BP 160/70; HR 88
 Temp 37.7
 BGL: 9.0mmol
 Pain in his knees and ankles (rated as 4/10 on pain
scale) – patient states this makes it difficult to do any
exercise
 Laboratory testing indicated that chemistries, Blood
Urea Nitrogen, creatinine, liver function tests, thyroid
function tests and urine microalbumin are all normal
 GlycatedHaemoglobin (HBA1c) was 7% for one year
but is now 9%
 LDL: 2.2mmol/L
 HDL: 1.6mmol/L
Previous history:
 9-year history of diabetes
 Obesity
 Depression
 Hypertension
 Arthritis
Surgical history:
 Trans-urethral resection prostrate
 Cholecystectomy
Medications:
Nurofen, Metformin, Coversyl, Atorvastatin, he is to commence Sertraline today.
Social:
Michael lives on his own in a small unit after his wife left him five years ago. He has
learned some cooking skills and prepares most of his meals although takeaways are an
easy option for him during his work day as a taxi driver. He has good family support from
one daughter, one son and two grandchildren who live close. Michael has little social
engagement other than his children and often chooses not to leave the house. He has lost
contact with most of his mates since his divorce.
Epidemiology / pathophysiology of disease processes
The National Health Priority Areas of Diabetes Mellitus, Obesity and Mental Health were
established with the aim of improving health outcomes in these areas. Review your
modules, references and extended reading regarding these National Priority areas.
NSB334 Summer 2019 Page 2 of 9

Diabetes is a chronic condition marked by high levels of glucose in the blood caused by
either the inability to produce insulin or by the body not being able to use insulin
effectively. The main types of diabetes are Type 1, Type 2 or Gestational. In 2014-2015
approximately 1.2 million people (6% of Australian adults) had diabetes, based on self-
reported data. This is a growing issue with increasing hospitalisations due to diabetes and
one in ten Australian deaths having diabetes as an underlying and/or associated death.
In 2011-2012, almost 2 in 3 (63%) of Australian adults are overweight or obese. Obesity is
a major risk factor for cardiovascular disease, Type 2 diabetes, some musculoskeletal
conditions and some cancers, while making the management of and controlling of chronic
disorders difficult.
Mental health and behavioural disorders describe a wide spectrum of disorders which
can vary in both severity and duration. The most common disorders are depression,
anxiety and substance use disorders and are important drivers of disability and
morbidity. There is also an association between diagnosis of mental health disorders
and a physical disorder with 1 in 8 (12%) of people with a 12-month mental disorder also
reporting a physical condition and 1 in 20 (5%) reporting two or more physical
conditions.
There is a clear bidirectional association between diabetes and mental illness. Statistics
show that Australians with diabetes have a higher prevalence of poor mental health than
those without diabetes. People with diabetes are more than twice as likely to have
mental or behavioural problems as those without diabetes.
Workbook Questions
Use the Clinical Reasoning Cycle to review the nursing priorities in relation to the care of
Michael.
1. a. The international classification of obesity and overweight is the body mass index (BMI),
identify what Michael’s BMI is and his classification for his body weight and obesity. Use a
reputable web site to find this information. (0.5 marks)
For adults, the normal BMI ranges between 18.5 and 24.9 and BMI of 25.0 and above are
considered to be overweight (WHO, 2020). The patient in the case study, Michael, has BMI of
45.2 which is considered obese.
b. Waist circumference and body shape or fat distribution is another assessment consideration
for Michael. Identify three (3) associated disease risks for Michael.
(1.5 marks)
An improver waist circumference forms a risk factor for the diseases developed as a result of
obesity. At BMIs greater than or equal to 35, waist circumference has slightly adds prognostic
power of disease risk beyond that of BMI(Nhlbi.nih.gov, 2020). Therefore, these factors
increases the risk of the following diseases-
 Cardiometabolic disease characterised by insulin resistance, hypertension, impaired
glucose tolerance, dyslipidemia and central adiposity (Tran et al., 2018).
 Cardiovascular diseases (CVD).
 Musculoskeletal problems associated with locomotor disability and joint pain like
osteoarthritis (OA).
c. Having high levels of visceral fat is a health risk. Explain, justifying with relevant
pathophysiology why this is so.
(2 marks)
NSB334 Summer 2019 Page 3 of 9