| | 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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2018/05/24 09:45pm 
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