Weight Management Strategies: Focused SOAP Note

Weight Management Strategies for Sedentary Professionals: A Case Study Approach


Certain patient groups may have specific concerns related to their unique demographics. Conditions pertaining to men’s or women’s health, older adults, college students, LGBTQ individuals, athletes, those with distinct cultural beliefs, or individuals undergoing palliative or end-of-life care all fall within this category. It’s important to note that individuals may identify with more than one of these categories.

This assignment focuses on practicing the assessment, diagnosis, and treatment of disorders observed in special population patients.

To Prepare:

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  • Review this week’s Learning Resources, emphasizing preventative health and the assessment, diagnosis, and treatment of special populations.
  • Review the case study provided by your Instructor. Consider the health history needed and the physical exams and diagnostic tests appropriate for gathering information about the patient’s condition. Reflect on how results would contribute to making a diagnosis.
  • Identify three to five potential conditions for consideration in a differential diagnosis.
  • Reflect on clinical guidelines supporting the diagnosis.
  • Develop a preventative health treatment plan, including health promotion and patient education strategies for special populations.


Use the Focused SOAP Note Template to address the following:


  • Summarize details provided about the patient’s personal and medical history.


  • Detail observations from the physical assessment, including relevant positive and negative findings. Describe the presence of any morbidities or psychosocial issues.


  • Explain your differential diagnoses, providing a minimum of three. List them from highest to lowest priority, and include CPT and ICD-10 codes for each diagnosis. Identify your primary diagnosis and justify it.


  • Explain your plan for diagnostics and the primary diagnosis. Outline treatment and management, encompassing pharmacologic and non-pharmacologic approaches, alternative therapies, and follow-up parameters. Provide a rationale for this treatment plan.

Reflection notes:

  • Describe any “aha!” moments you experienced while analyzing this case.




Focused SOAP Note Template


Patient Information:

Initials Mr. E, Age- 42 years, Sex- male, Race- Hispanic


CC (chief complaint): Mr. E. comes to the clinic with a plan of embarking on a rigorous exercise program with the ultimate goal of losing weight.


Location: N/A

Onset: N/A

Character: N/A

Associated signs and symptoms: N/A

Timing: N/A

Exacerbating/relieving factors: N/A

Severity: N/A

Current Medications: No current medications.

Allergies: No known food or drug allergies.

PMHx: The patient’s immunization history is in line with the immunization schedule. His last immunization was a tetanus shot which he was given in November 20th 2021.

Soc & Substance Hx: The patient is a tax accountant. He is a single man who has never been married and lives in a condominium. He denies substance and alcohol use. He has not been physically active for the past 10 years.  He is responsible for all his grocery shopping and meal preparation. Has gained a lot of weight due to his nature of work that requires him to sit all day behind his desk.

Fam Hx: His parents are alive. The grandparents died from natural causes of death. He has one sibling aged 36 years who is alive and healthy.

Surgical Hx: Has no prior surgical procedures

Mental Hx: Has had no diagnosis for mental health illnesses like anxiety or depression.  Has no ideation for suicide or homicide.

Violence Hx: Has no concerns over his personal, home, community or sexual safety.

Reproductive Hx: He is not dating and is not sexually active.


GENERAL: Has too much weight gain. No fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: No burning on urination.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not sexually active. Has no penile discharge

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.



Physical exam:

Vitals: BP 128/80, Temperature 37 Degrees Celsius, R.R 18, Weight 190 pounds, Height 5’3

General: Too much weight gain

Diagnostic results:

Body mass index calculator- a body mass index of between 25 and 30 indicates that a person is overweight.


Differential Diagnoses:

Over weight

Overweight is a condition characterized by a body mass index of or more than 25kg/m2.


Obesity is defined as having a body mass index of 30kg/m2 or more (Fruh, 2017).


Based on the patient’s medical and social history, the patient is overweight. He has been gaining a lot of weight which has been linked to his nature of work that entails sitting on his desk for many hours. The primary reason why he visited the hospital was to have a medical checkup first before embarking on a rigorous exercise program. He aims to lose 30 pounds by working out at the gym.

Both overweight and obesity are health conditions that can easily be managed with a combination of medications and behavior modifications. The Food and Drug Agency recommends Orlistat for the management of obesity (Qi, 2018).

Non-pharmacological interventions that can be used to manage the patient’s weight besides exercise and activity would involve healthy feeding patterns. Diet-related changes would include cutting calories, consuming more plant-based foods like fruits, whole grains, and vegetables, and lean sources of proteins.

Besides diet-related interventions, the patient should embark on physical activity. The checkup should provide vital information about his overall health and the status of his body organs. Due to staying for so long without engaging in physical exercise, he should begin with low-intensity exercises going up. According to Healthy People 2020, physical exercise lowers an individual’s risk of early deaths, stroke, coronary heart disease, high blood pressure, type 2 diabetes, and depression among others (U.S Department of Health and Human Services, n.d.).

It would be important to educate the patient concerning the need to adhere to a physical exercise schedule and healthy feeding patterns to minimize the chances of relapse. Physical exercise would require that individuals demonstrate discipline to achieve the desired body outcomes. Based on his nature of work, he should engage in physical activity and controlled feeding patterns that align with the body’s utilization of energy.

The patient’s age is 42 years and therefore if his weight is uncontrolled could expose him to chronic diseases in old age which besides resulting in a cost-related burden will also lead to poor quality of life.


The patient has an opportunity to improve his health outcomes while at the same time minimizing the risks of developing chronic illnesses. He however needs to adhere to a physical exercise routine that he wants to embark on to achieve consistent results. Working with patients showed how patients can be responsible for their health-related decisions to ensure they achieve positive health outcomes over time.


Fruh S. M. (2017). Obesity: Risk factors, complications, and strategies for sustainable long-term weight management. Journal of the American Association of Nurse Practitioners29(S1), S3–S14. https://doi.org/10.1002/2327-6924.12510

Qi, X. (2018). Review of the clinical effect of orlistat. In IOP Conference Series: Materials Science and Engineering (Vol. 301, No. 1, p. 012063). IOP Publishing.

U.S Department of Health and Human Services. (n.d.). Physical activity. Physical Activity | Healthy People 2020. Retrieved January 27, 2022, from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/objectives