Obesity

By: Tiffany Ward

 Chief Complaint

Jessica is a 34 year old white female who presents to the office today in hopes to
control her weight. She currently weighs 325 pounds and has a BMI of 54. Her
weight gain started during her pregnancy with her third child and has had difficulty
losing weight since giving birth. She has tried to change her diet and exercise more
without any success. She has lost her motivation and has come to the office today
to find guidance.
 History of Present Illness

Jessica started gaining weight during her third pregnancy at a healthy rate. Jessica
was 250 pounds when she gave birth in December 2020. She has since gained 75
pounds over the last 8 months. She states she is eating healthy, well balanced meals
and exercising 1 to 2 times per week. She has lost motivation to lose weight and
noticed a decrease in her energy level. Patient states she wants to change in order to
more involved and present in her children’s lives.
 Past Medical History
Pre-diabetes: 2021

Hypertension: 2019

Obesity: 2020

Pregnancy: G3,P3, not currently on birth control, 3 vaginal deliveries

Hyperlipidemia: 2020

Depression: 2021
 Medications
Lisinopril 10 mg PO daily

Atorvastatin 40 mg PO nightly

Sertraline 25 mg PO nightly

Cetirizine 10 mg PO daily

Multivitamin 1 tablet PO daily

 Allergies

Penicillin (anaphylaxis)

Seasonal (nasal congestion)

 Social/Health History
Jessica is a 34 year old white female who lives in a two story home with her
husband and three small children age 6,4, and 9 months. She currently works as a
high school art teacher for the past 8 years. She states she has a strong family and
friend support group. She drinks 1-2 alcoholic beverages per week and smokes one
pack of cigarettes per day. She stopped smoking during her pregnancies. Denies
recreational drug use. Exercises 1-2 times per week. Used to walk 2 miles per day,
but is unable due to her weight. Relaxation techniques focus of her children’s
activities. Reports a “good and healthy” relationship with husband of 10 years. No
history of STDs. No history of abuse or neglect.
 Family History

Mother alive, age 56, history of HTN and DM.

Father alive, age 57, history of HTN.

Brother, age 36, history of HTN and obesity.

Married, Son age 6, Daughter age 4, and Son 9 months. Husband is healthy with a healthy BMI.

Paternal grandparents: Grandmother, deceased, Grandfather, age 78, history of COPD and DM.

Maternal grandparents: Grandmother, age 82, history of DM, Grandfather, age 83, history of CVA.
 Review of Systems
Neurological: Denies any loss of consciousness, dizziness, light-headedness, syncope, seizure
activity, tremors or trauma to the head. No complaints of headache or recent fevers. No difficulty
with balance, swallowing, speaking, or walking. No problems with memory or thought process.
No history of stroke, spinal cord injury, meningitis, encephalitis or congenital disorders.

EENT: Denies vision difficulty, pain, diplopia, redness or swelling of eyes, discharge, glaucoma.
Patient states she wears glasses and contacts. Last vision test in 2021. Denies earache, infections,
discharge from ears, hearing loss, tinnitus, or vertigo. No recall on last hearing test. Reports 1-2
colds per year. Denies nasal discharge, sinus pain or infections, nasal trauma, epistaxis, altered
smell or polyps. Patient does suffer from seasonal allergies. Denies bleeding gums, toothaches,
hoarseness, or altered taste. Last dental exam was 6 months ago.
 Review of Systems cont.
Cardiovascular: Denies chest pain, orthopnea, cough, cyanosis, pallor, edema or nocturia.
Patient states she feels short of breath and becomes easily fatigued with exercise. No past
history of heart murmur, rheumatic fever, anemia or heart disease. Patient does have
hypertension and hyperlipidemia. Exercises 1-2 times per week, mostly walking around the
neighborhood on weekends for 30 minutes. No EKG to date.

Pulmonary: Denies cough, orthopnea or hemoptysis. Patient states she gets short of breath
with exercise and has seasonal allergies. No past history of frequent colds, bronchitis,
pneumonia, emphysema, asthma, tuberculosis, or respiratory infections. Reports she smokes
1 pack of cigarettes per day for the past 14 years, only quitting while pregnant. Never has
had a CXR for any reason.
 Review of Systems cont.
Gastrointestinal: Denies nausea, vomiting, abdominal pain, dysphagia, hernia,
GERD, abdominal distention or bloating, intolerance to hot or cold foods, blood
in stool or urine. No changes in appetite, bladder or bowel habits, or food
intolerance. History of pre-diabetes. No history of thyroid disorders, gall bladder
or liver disease. Recent 75 pound weight gain within 8 months. Reports daily
bowel movements. No colonoscopy to date.

Integumentary: Denies any bruising, pruritus, rashes, hair loss, or changes in

pigmentation. History of seasonal allergies. No history of psoriasis, eczema or
other skin disorders.
 Review of Systems cont.
Renal/ Urinary: Denies dysuria, urgency, frequency or vaginal discharge.
Denies UTI, STDs, kidney stones, kidney disease, congenital disorders. Gravida
3, Para 3. No contraception. LMP 2 weeks ago. Menarche age 13 years. No
history of dysmenorrhea or endometriosis. Last PAP and GYN exam February
2021.

Musculoskeletal: Denies pain, cramps, weakness, stiffness, swelling, warmth or

heat to joints, muscles, or bones. No history of injury, trauma, arthritis, fracture,
or scoliosis. Denies use of mobility devices. No difficulty with active ROM or
ADLs.
 Physical Exam
General Survey: Jessica Chew, a 34 year old white female, appears stated age,
well developed, well nourished. Appears in no distress. VS: HR 88, BP 164/88,
Temp 98.4, Respirations 20, Pulse ox 97% on room air.

Neurological: Alert and oriented x4. Good judgement noted. Abstract thinking
intact. Recent and remote memory intact. Cognitive function intact. Cranial
nerves 1-12 intact. DTR 2+. Sensation proprioception normal.

Mental Status: Appropriate behavior, flat affect, tearful noted. Responds

appropriately to all questions.
 Physical Exam cont.
Head & Neck: Normocephalic, atraumatic, non-tender. Blonde, shiny and
evenly distributed hair, clean scalp, skull normal. No dandruff, parasites, or
lesions noted. Thyroid not enlarged, trachea mid-line. No masses or lesions. No
lymphadenopathy noted.

EENT: PERRLA, Pupils symmetrical with direct and consensual light reflexes.
Discs appear normal upon fundoscopic exam. External ear normal, free of
cerumen. Bilateral tympanic membranes translucent, pearly gray and intact.
Gingivae, tongue, and mouth normal. Tonsils 1+ normal. No pharyngeal
irritation. Teeth in good repair.
 Physical Exam cont.
Chest/Respiratory: Respirations easy and unlabored. No nasal flaring. No retractions noted.
Chest wall non-tender to palpation. No fremitus present upon palpation. No muscle spasm
noted. Respiratory excursion symmetrical. Resonance noted upon percussion to posterior,
anterior, lateral chest upon percussion. Clear breath sounds auscultated bilaterally to
posterior, anterior, and lateral chest. No adventitious breath sounds.

Cardiovascular/Peripheral Vascular: Pulse 88, Regular rate and rhythm. No murmurs,

gallops, or rubs. No JVD. Carotid pulses, palpable, regular bilaterally. No bruits. PMI non
palpable, no heaves, thrills present. S1 and S2 present. Upper and lower extremities warm
and dry to touch without visible varicosities. All pulses 2+ bilaterally. Good skin turgor
noted. No edema of upper or lower extremities present.
 Physical Exam cont.
Abdomen: Abdomen rotund, non-distended with no visible masses or hernias.
Soft, no tenderness. No bruits heard over aortic, renal, or femoral arteries. Bowel
sounds normal in all 4 quadrants. Liver, spleen and kidneys non-palpable. Liver
span 8 cm mid-clavicular line. Tympany predominately present upon percussion.
Negative Murphys sign. No rebound tenderness.

Musculoskeletal: Full ROM of head, upper and lower extremities. Muscle

strength 5+ of head, upper and lower extremities. No tenderness, crepitus,
inflammation present in joints. No edema, erythema, cyanosis. Spine is midline
and has normal C curvature. Balance and coordination intact.
 Lab Results
Urinalysis: Serum glucose: 1.5 mmol/L (normal 0-0.8 mmol/L)

CBC: WNL

TSH: 8 uU/mL

Lipid panel: LDL: 155, HDL: 60, total cholesterol: 250, triglycerides: 186

Liver Function: ALT: 34 , AST: 32, alkaline phosphatase: 77

BMP: Glucose: 276

A1C: 8.1
 Diagnostic Test Results

Gallbladder Ultrasound: negative for gallstones

CT abdomen: negative for hepatomegaly

EKG: normal sinus rhythm, heart rate 88

 Problem List
Obesity

Hypertension

Hyperlipidemia

Diabetes

Depression
 Differential Diagnosis

Obesity

Binge eating disorder

Hypothyroidism

Hyperinsulinemia
 Assessment

This 34 year old female present today with chief complaints of inability to lose
weight and continuous weight gain of 75 pounds within the past 8 months.
Describes she has made healthy changes in her diet and exercising 1-2 times per
week. States she has increased shortness of breath with exercise and fatigues easily.
Jessica is hypertensive upon exam and blood work in suggestive of diabetes and
hyperlipidemia. Patient has flat affect and is tearful when discussing weight gain.
No other problems identified upon exam. Familial risk of hypertension and diabetes
identified. Smoking cessation program and lifestyle modifications discussed.
 Treatment Plan
Dietary changes: Reduce daily calories by 500. Consume a low fat, moderate amount of carbohydrates, moderate in
protein, high in fiber diet. Eat whole grains, fruits, vegetables, and drink plenty of water (Harvard School of Public
Health, 2021).

Increase activity: Start low and slow. Spend 150-330 minutes each week of moderate physical activity to help with
weight loss. Increase activity to 4-5 times per week (Niemiro, Rewane, & Algotar, 2021).

Relaxation techniques: Stress is a key part of weight gain. Finding ways to relax can help reduce stress and ultimately
reduce your weight. Mediatation, avoid distractions, and finding activities just by yourself for 30 minutes a day can be
greatly beneficial to your health (Duncan, 2018).

Start Metformin 500 mg PO daily, continue rest of medications

Offer information about support groups and nutritionists

Follow up in 2 months
 Community Resources
The USDA website offers multiple articles regarding obesity and the positive
changes you can make. https://www.nutrition.gov/topics/diet-and-health-conditions/overweight-and-obesity

Local gyms with fitness classes

Support groups can be found on Facebook or at your local gym

Confine in your friends and family for support

Fitness apps on phones to track your dietary intake

 References
Butter, T., Trybulsiki, J., Bailey, P, Sandberg-Cook, J. (201&). Primary care: A collaborative practice (5th Ed). St. Louis, Elsevier

Duncan, A. (2018, November 15). Relax and lose weight: How relaxation helps with weight loss. Relax and Lose Weight: How

Relaxation Helps with Weight Loss. https://www.nifs.org/blog/relax-and-lose-weight-how-relaxation-helps-with-weight-loss.

Harvard School of Public Health. (2021, March 16). Healthy eating plate. The Nutrition Source.

https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/.

Niemiro, G. M., Rewane, A., & Algotar, A. (2021, June 8). Exercise and fitness effect on obesity. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK539893/.