Medicine Grand Rounds Clinical Vignette

1. Medicine Grand RoundsClinical Vignette Jack Naggar, MD PGY-2 March 5, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Mr. I is a 48 year-old gentleman who presents to primary care clinic to discuss weight loss

3. History of Present Illness 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

4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

5. Additional History • 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

6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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 normal

7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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%)

8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Abdominal Ultrasound: Diffusely increased echotexture of liver parenchyma consistent with fatty infiltration versus hepatocellular disease

9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • Obesity with multiple systemic complications • Diabetes Mellitus type II • Non-alcoholic fatty liver disease • Hyperlipidemia • Gastroesophageal reflux disease

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Clinic Course • 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