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-=-=-=-=-=> OBESITY Doorway information about patient The patient is a 40-year-old woman who comes to the clinic due to weight gain Vital signs . Temperature ; 36.7’C . Blood pressure : 150/90 mmHg . Pulse :68/min . Respiration: 16/min Approach to the patient initial assessment of obesity History&symptoms of obesity & obesity-related complications . Back pain . Osteoarthritis . Atherosclerotic cardiovascular disease . Sleep apnea Biometric measurements . Blood pressure & pulse . Weight . BMI . Waist circumference Laboratory studies . Glucose (or hemoglobin A1c) . TSH . Lipids . Hepatic enzymes Patient may come for evaluation of obesity due to cosmetic reasons , social discomfort , weight-related comorbidity (eg , diabetes , osteoarthritis), or concern for an underlying metabolic disorders (eg , hypothyroidism) . The evaluation has 3 parts : Ruling out any - underlying disorders - causing weight , identifying - complications - of obesity (eg, back pain , obstructive sleep apnea), and screening for - comorbid conditions _ that occur in association with obesity(eg, diabetes) Obesity is categorized based on BMI (weight in kilograms/ height in meters squared): . Normal : 18.5-24.9 kg/m2 . Overweight : 25-29.9 kg/m2 . Obesity : >=30kg/m2 . Severe obesity : >=40 kg/m2 (or >= 35 kg/m2 with weight -related complications ) The term ‘mobbed obesity “is often used interchangeably with severe obesity , but should generally be reserved for patient with weight -related complications. Different diagnosis In most cases . obesity is due to nonmediacal causes , such as sedentary lifestyle or overeating . Other common causes include pregnancy , menopause , smoking ,cessation , sleeping deprivation , and medications (eg, oral contraceptives , sulfonylureas , tricyclics) . Less often , an endocrine disorder (eg , hypothyroidism, Cushing syndrome )is responsible. History and physical examinations The following sections list the most common items that should be included in the evaluation of a patient with weight gain. HISTORY History of present illness . kHow long have you been gaining weight? . How many pounds have you gained ? . Can you think of any reasons for this weight gain ? . How is your appetite? . How may meals you eaten a day ? . Describe a typical meal. . Do you eat snakes between meals? . How often do you eat out ? . Have you tired diets or weight loss programs in the past ? . Do you sore excessively or have problems with breathing at night? . Do you feel thirstier than usual or urinate more than usual ? . Do you feel cold when these around you are comfortable ? . Do you are joint pain ? . For woman : when was your last period ? Have your periods been irregular? Past medical history . Do you have other medical conditions(eg, diabetes , hypertension )? . Have you had your cholesterol checked recently ? Medications / allergies . Do you take any medications? . Have you taken steroid medication (eg prednisone ) recently? Family history . Is there any obesity in your family? . Do any of your close family members have heart disease , diabetes , or a thyroid disorder ? Social history . Do you smoke ? When did you start& how much do you smoke ? . Do you drink alcohol ? how much & how often? . Have you used illicit drugs? If a tape measure is supplied , measure waist circumference (however , bringing a tape measure or any additional items to the USMLE Step 2 CS exam , other than a standard stethoscope , is not allowed). Physical examination General . Assess body habitus. . Assess gait & ambulation. HEENT . Examine for lid lag & exophthalmos. Neck . Examine for thyromegaly Lungs . Auscultate for breath sounds & adventitious sounds. Heart . Auscultate ofr murmurs , gallops & rubs. Extremities . Examine ofr peripherial edema. Closing the encounter The wrap-up discussion should be guided the patient primary concerns (eg, cosmetic issues, wight -related comorbidity) . Start by restating and clarifying the patient’s concerns (eg, “So you have noted a significant weight gain , and you are concerned your may have a thyroid disorder. Is that right ?”). Review the severity of the patient’s obesity , any complications or comorbidities, and any additional findings noted on examination. Treatment is not tested as part of the Step 2 CS exam . However , if a patient inquires about wight loss treatment , acknowledge the request and reassure the patient you will follow up to address appropriate options. Finally , be aware that most patients seeking medical attention for obesity have already attempted multiple diet and exercise programs . In light of this , remain empathetic and nonjudgemental . Condescending lectures and gilt pronouncements (eg “ You would lose weight if you didn’t eat so much”) are never appropriate. Diagnostic studies Extensive laboratory testing is not usually necessary , but a basic assessment for -complications- and -revesible causes - should include a - TSH -, - fasting glucose (or hemoglobin A1c) -, -liver function markers- (to rule out hepatic steatosis). and - lipid panel -. Testing for hypercortisolism (eg , 24 hour urine cortisol ) is not done unless there are additional findings of Cushing syndrome. Imaging is not usually necessary , although a plain dlim-x-ray of weight-bearing joints can be considered for patient with symptoms of osteoarthritis. -=-=-=-=-=>
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