Question

You are seeing a 50-year-old female for her annual physical. She is a long time patient in the practice that you have just joined. She has no complaints and states that she feels well. Her past medical history is notable for "borderline hypertension" and obesity. Last year, her lipid panel was acceptable for someone without known risk factors or coronary artery disease. TC 214; Trig 202; HDL 32; LDL 146 [reading in summer of 2015, fasting].

Her brother and mum have HTN and Type 2 diabetes.  You can tell from your review of her electronic health record that the NP that retired [the one you replaced] had counseled her on a low fat, low calorie diet and on the importance of a regular exercise regimen. However, patient admits to not having made any changes to her lifestyle. She states that she works full time and has three children; she finds it difficult to exercise. She admits that she and the family eat out frequently.

On her physical today, her BP is 148/94 and her BMI is 28 kg/m2. Her physical is remarkable for brown macules with a velvet appearance along the nape of the neck and under both axillae. In addition, in the axilla there are many small skin tags where the adipose tissues have rubbed upon one another. Her waist circumference is 38.5 inches. There are no gross abnormalities on her physical; her Pap is done [it appeared normal] and a mammogram is set up. The patient is fasting today and her blood sugar is 210 mg/dL. She takes a multiple vitamin and chewable Calcium and Vitamin D3 every day. Her last menstrual period was 3 weeks ago; she uses a diaphragm for birth control [she is married and in a monogamous relationship]. She has no known allergies and she has never had surgery.

Her labs last year were normal except for cholesterol panel as cited above. Patient is fasting today and the only lab that you can is a point of care in the office is the blood sugar, the results are listed above.   

What are her medical diagnoses?

What are her differential diagnoses, with rule outs?

What diagnostics are needed?

What prescriptions does she need?

What education does she need?

Answer 1

1.This client is diagnosed with metabolic syndrome also known as Syndrome X,insulin resistance syndrome and dysmetabolic syndrome, is a collection of risk factors that increase individual's chance of developing cardiovascular disease, stroke and diabetes mellitus

Metabolic syndrome is characterized by a cluster of health problems, including obesity, hypertension, abnormal lipid levels, and high blood glucose.

Acanthoses nigricans is medical sign characterized by brown-to-black poorly defined velvety hyperpigmentation of the skin. It is usually found in body folds such as posterior and lateral folds of the neck, the armpits, groin, navel,forehead and other areas.It is associated with endocrine dyfunction, especially insulin resistance and hyperinsulinaemia, as seen in diabetes mellitus. This activates insulin like growth factor receptors which leads to proliferation of keratinocytes, fibroblast and other cells in the skin

2. Differential diagnoses

Acanthoses nigricans should be distinguished from the "casal collar" (also known as 'casal necklace' is a clinical sign characterized by an erythematous pigmented skin rash in the distribution of broad collar (dermatomes C3 and C4) seen in patients with 'pellagra'(vitamin B3 deficiency)

Malignancy: it may be associated with tumour products and insulin like activity

Hence, these patients should be screened for pellagra and malignancy , it is likely to be improved when the known cause is removed

3.Metabolic syndrome is diagnosed if an individual has 3 or more of the conditions listed in the table below:

Criteria for Metabolic Syndrome

Measure	Criteria	Client findings
Waist circumference	> 40 in (102 cm ) in men > 35 in (89 cm) in women	Her waist circumfernce is 38.5 inches
Triglycerides	> 150 mg/dL	Patient value is 202 mg/dL
High Density Lipoprotein (HDL)	< 40 mg/dL in men <50 mg/dL	patient value is 32 mg/dL
BP	> 130 mm Hg of systolic BP OR > or = 85 mm Hg of Diastolic BP	Her BP is 148/94 mm Hg
Fasting Blood Glucose	>110 mg/dL	Her value is 210 mg/dL

4. There is no specific management for metabolic syndrome. You can assist patient by providing information on:

• Healthy diet
• Exercise
• Positive lifestyle changes

Diet

The diet should be low in saturated fats and should promote wieght loss. Weight reduction and maintenance of a lower weight should be the first priority in those with abdomenal obesity and metabolic syndrome

Exercise

Because sedentary life-style contribute to metabolic syndrome , increasing regular physical activity will lower a patient's risk factors. In addition to assisting in weight reduction, regular exercise has been found to decrease the triglyceride level and increase the HDL cholesterol level in patients with metabolic syndrome

Patients unable to lower risk factors with life-style therapies alone or those at high risk for a coronary event or diabetes may be considered for drug therapy. Although there is no specific drug therapy for metabolic syndrome , cholesterol -lowering and anti-hypertensive drugs can be used. Metformin(Glucophage) has also been used to prevent diabetes by lowering glucose levels and enhancing the cell's sensitivity to insulin