Kelly Neuman, age 55, returns for his follow up appointment one month later.  From the health history and physical examination, you note the following findings:

 

History and Physical Examination

Mr. Neuman reports that he has been trying to follow your recommendations from your last appointment.  He reaffirms that he is very interested in losing weight and has started taking the stairs up to his apartment instead of using the elevator although he continues to get short of breath with this.  He denies dizziness or other problems with climbing stairs.  He comments that he wants to lose the weight because his class reunion is coming up and believes that he has turned into a “fat, bald guy”.  He would also like to maybe start playing basketball with some co-workers but he states “right now, there is no way that I can keep up”.  He has not yet explored joining a health club or weight loss groups but he might like to work with a personal trainer and do some weight lifting.  He demonstrates verbally that he understands the activity recommendations provided.  He continues to eat fast food for lunch and/or supper 4 times per week as this is “most convenient” but he reports that he has been cooking recommended meals every morning for breakfast and 3-4 suppers per week.  For lunch, he packs a sandwich, fruit, and some kind of snack.  He identifies the food pyramid and states the correct recommended servings from each category.  Mr. Neuman admits to being concerned about his hypertension and thinks he should perhaps be on medications to control this.  He acknowledges health risks that accompany hypertension and ways to reduce this.  He also admits that he has been considering a job change; the project causing him extensive stress last month just seems to be getting worse.  He continues to lack contact with his previous friends but has been out twice to a movie with a neighbor.  He has been sleeping “a little better”:  about 5-6 hours per night.

 

Weight 292 lbs.

BP 177/82, pulse 80, respirations 14

Alert and oriented

Heart sounds within normal limits, regular

Lungs are clear bilaterally

Abdomen is rounded, bowel sounds present in all four quadrants, no tenderness on palpation

No edema is noted in extremities

Strength and mobility appear within normal limits