Medicine Grand RoundsClinical Vignette

Jack Naggar, MDPGY-2

March 5, 2013

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Mr. I is a 48 year-old gentleman who presents to primary care clinic to discuss weight loss

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• He finds that it is difficult to maintain a healthy diet and exercise regimen as he works long hours (often working the night shift) as a taxi cab driver, and has the majority of his meals at Indian buffets• For exercise he enjoys going on walks with his wife, but has not done so recently because of the cold weather• His mood is good, though he reports that working the night shift can be draining

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:• Obesity• Diabetes Mellitus type II – diagnosed in 2008• Non-alcoholic fatty liver disease• Hyperlidemia• Chronic atypical chest discomfort – workup to date un-revealing• Gastro-esophageal reflux disease

•Past Surgical History:• None

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Social History:– Born in Bangladesh, emigrated to US in 2000– Currently employed as Taxi cab driver – work schedule is erratic– Lives with wife and 2 children– No history of drugs, tobacco, alcohol use

• Family History:– Father – Tuberculosis– Brother – asthma

• Allergies: – No Known Drug Allergies

• Medications:– Aspirin 81mg daily– Metformin 1000mg twice daily– Glimepiride 2mg daily– Simvastatin 20mg twice daily– Omeprazole 40mg daily

Additional History

Physical Examination

•General: Well-appearing, sitting upright in no acute distress•Vital Signs: list T:98 BP:126/80 HR:79 RR:12 O2 sat: 98% RA•Weight: 83kg BMI: 33•Physical exam remarkable for

• Acanthosis nigricans on bilateral axilla• Hepatomegaly

•Remainder of Physical Exam was normalUNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC: Within normal limits•Basic Metabolic panel: Glucose 102 (70-99)

•Remainder of basic was within normal limits•Hepatic panel: AST 46 (11-39) ALT 58 (11-35)

•Remainder of hepatic panel was within normal limits

•Other Laboratory Data•LDL 71 (<100) HDL 42 (30-64) Cholesterol 142 (<200) Triglycerides 143 (55-320)•Hemoglobin A1C: 7.2% (<5.7%)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•Abdominal Ultrasound: Diffusely increased echotexture of liver parenchyma consistent with fatty infiltration versus hepatocellular disease

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Obesity with multiple systemic complications– Diabetes Mellitus type II– Non-alcoholic fatty liver disease– Hyperlipidemia– Gastroesophageal reflux disease

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• He was referred to diabetic nurse educator for diabetic teaching

• He was referred to nutritionist regarding healthy diet

• Options regarding healthy eating while at work were discussed

• He was continued on all current outpatient medications

• Referral for weight loss surgery will be considered at the next visit

Clinic Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS