Question

JJ is a 50 y.o. woman who works as an accountant. She presents to her family physician with elevated blood pressure and obesity. JJ has struggled with her weight since childhood and indicates that her weight problems worsened 5 years ago when she returned to work as an accountant.

PMH

No history of any obesity co-morbidities

Admits to snoring at night, but denies waking up in the middle of the night or falling asleep during daytime activities

FH

+ for overweight and obesity

One brother is overweight

Father and sister normal weight

Mother is obese, hypertensive, Type 2 DM diagnosed at age of 60

SH

No history of smoking

Denies consumption of alcohol

Married with three children - ages 20, 15, and 10

Sedentary lifestyle

Review of Systems

Skin: No history of rashes or unusual skin pigmentation

HEENT: Normal

Neurologic: No headaches, tremors, seizures, or depression

Endocrine: Normal menstrual cycle, denies abnormal heat or cold intolerance Cardiovascular: Normal rate and rhythm, No orthopnea or dyspnea.

Joints: No swelling, heat, or redness

Physical Examination Vital Signs

Temperature: 98.6 degrees F.

Heart rate: 80 BPM

Blood pressure: 145/90 mm Hg

Height: 5 '5 "

Current Weight: 220 pounds

BMI: 36.6

Waist circumference: 40 inches

Weight history:

Lowest adult weight was 150 # at age of 25 (the year She married). Following the birth of her third child JJ lost 30 # and managed to maintain a weight around 170 # until she returned to work as an accountant 5 years ago. Her current weight of 220 pounds most that she has weighed. |

Exam:

Obese women

Non-palpable thyroid.

No edema.

No wounds

Laboratory Data

Patient's Fasting Values                        Normal Values

Glucose: 122 mg/dL                                 Less than 100 mg/dL

Potassium: 3.9 mEq/L                              3.5-5.0 mEq/L

Sodium: 140 mEq/L                                 135-145 mEq/L

Cholesterol: 236 mg/dL                            Desirable < 200 mg/dL

Triglycerides: 179 mg/dL                          Desirable < 150 mg/dL

HDL: 39 mg/dL                                         Desirable for female > 50 mg/dL

LDL: 153 mg/dL                                        Desirable < 130 mg/dL

Medical Diagnosis: Metabolic Syndrome

ATP III Clinical Identification of Metabolic Syndrome

(Diagnosis of metabolic syndrome is made when individual exhibits a minimum of three of the five risk factors)

Risk Factor	Defining Level
Abdominal Obesity (waist circumference)	Men >102 cm (> 40 inches) Women < 88 cm (> 35 inches)
Triglycerides	> 150 mg/dL or equal
HDL Cholesterol	Men < 40 mg/dL Women < 50 mg/dL
Blood Pressure	> 130/85 mm Hg or equal
Fasting Glucose	> 100 mg/dL or equal

ATP III is Adult Treatment Panel III. Table taken from: Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C. Definition of metabolic syndrome. Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on scientific issues related to definition. Circulation. 109:433–8. 2004 (2).

JJ provides vague information on serving sizes particularly when she feels guilty about them. The following is what was extrapolated from her usual diet:

Estimate caloric intake of 2800-3000 kcal/day. Recommendation according to MyPlate-1800-2200 kcal/day depending on activity level.

Breakfast (Home)

Coffee                                          8 ounces

Half and half cream                     1 ounce

Bagel                                           1 large

Cream cheese                             2 Tbsp.

Orange juice                                8 ounces

Lunch (Work)

Chef Salad                                    2 cups

(Turkey, ham, cheese,

boiled egg)

French Dressing                            3 Tbsp

Bread Sticks.                                 2 small

Iced Tea (pre-sweetened)             12 ounces

Snack (Work)

Pretzels                                         1.5 ounce bag

Diet soda                                       12 ounces

Dinner (Home)

Spaghetti                                        2 cups

Tomato sauce                                1/2 cup

Beef meatballs                               3 ounces

Garlic bread                                   1 piece

Snack (Home)

Vanilla Wafers                               10 small

Lemonade                                     12 ounces

Questions

1. Write ADIME for the above case study.

2. Write at least two PES statement in diagnosis step.

Answer 1