Marc S Jacobson MD Case Presentations 12122008 Case 08341 CC My triglycerides are high HPI this 15 yr old Female was referred by her pediatrician because she had gained 20lbs in the past year and had high cholesterol and triglycerides She had been trying to lose weight using Weight Watc ID: 762785
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Marc S. Jacobson MD Case Presentations12/12/2008
Case 08341CC: My triglycerides are high.HPI: this 15 yr old Female was referred by her pediatrician because she had gained 20lb’s in the past year and had high cholesterol and triglycerides. She had been trying to lose weight using Weight Watchers and by joining a gym with no effect. PMH: Hospitalizations: none, Operations: none, Medications: none, Allergies: none 12/12/2008
Case 08341(cont)ROS: CV nl, Resp nl, GI nl, GU nl, Neuro nl, Musculoskeletal nl, Endocrine and growth: Menarche was at age 12.5 yrs. She has never been regular but had not skipped more than a few weeks prior to 3months ago when she had her last normal period. 12/12/2008 M S Jacobson MD
Case 08341(cont)FH : positive for premature atherosclerosis (father had a CABG at age 54), obesity, hypertension, type 2 diabetes and hypercholesterolemia. SH : School, family and peer activities are age appropriate. She does not smoke. Physical activity level is low She plays Volleyball 1x per week during the season only, spends most of her free time on movies and shopping with friends. She belongs to a gym but does not use it consistently , attending 1-2 x per week and often skips weeks. 2-4 hours of sedentary activity per day (tv, video, computer) 12/12/2008 M S Jacobson MD
Case 08341(cont)PHYSICAL EXAMINATION : Blood pressure 132/85 mmHg >90 th%ile pulse 90 bpm, Height 66inWeight 160lb, BMI 26 kg/m 2 >90 th %ile General appearance : Adiposity is central. HEENT: benign. No Corneal arcus or Xanthelasma or facial hair noted 12/12/2008 M S Jacobson MD
Neck : without thyromegaly Neuro : intact. CV: RR, nl S1, nl S2. No Murmur. Pulses are present in all 4 extremities. Chest : lungs clear to auscultation. Tanner 5 breasts Musculoskeletal: wnlAbdomen: soft non-tender, no mass or organomegaly Skin: Xanthomas not present. < 10 Abdominal stria noted. Acanthosis Nigricans Grade 1 on her neck Case 08341(cont) 12/12/2008 M S Jacobson MD
Case 08341(cont) Labs (FASTING) LIPID PROFILE: Total Cholesterol 220 mg/dl Trigs 250 mg/dl LDL- C 140 mg/dl HDL-C 30 mg/dlTFT’S : TSH 5.0 mcg/dl LFT’S : ALT 22 mg/dl, AST 25 mg/dl GLUCOSE 95 mg/dl, INSULIN 55 mg/dlFree testosterone: >3% (nl < 1.4) 12/12/2008M S Jacobson MD
Case 08341(cont)ASSESSMENT: Dyslipidemia, Hypertriglyceridemia Pre Hypertension At risk for overweightMetabolic Syndrome, PCOSAcanthosis NigricansHyperinsulinemia 12/12/2008 M S Jacobson MD
Case 08341(cont) PLAN: 3 Day Food records and food frequency Menstrual calendarOne mile pace assessment of physical capacity.Increase physical activity: decrease screen time, walk 30 minutes daily or use her gym membership Decreased simple carbohydrates, focusing on sugar sweetened beverages, pasta, rice, and potatoes. Smoking prevention Supplements: multivitamin, Revisit monthly RD, 3 months MD 12/12/2008 M S Jacobson MD
Case 08341(Follow up) She was followed monthly for six months on a low glycemic index diet focused on her simple carbohydrate intake. Saturated fats were limited to 2gm per serving of snack and mealtime foods. Her menses began without progesterone challenge within the second month of the program and has been regular since. Her weight was monitored using BMI percentiles and has improved in a stair step fashion with periods of loss interspersed with periods of no change or small gains.Her acanthosis has faded and she has lost 2 inches in waist circumference. 12/12/2008 M S Jacobson MD
Case 08341 Age 13 65” 130 # bmi 21.5 Age 15 66” 160# bmi 26 Age 16 66” 152# bmi 24.8 follow up Labs LIPID PROFILE: Total Cholesterol 180 mg/dl Trigs 100 mg/dl LDL- C 120 mg/dl HDL-C 40 mg/dl GLUCOSE 95 mg/dl, INSULIN 15 mg/dl Free testosterone : 1.1% nl 12/12/2008 M S Jacobson MD Zoftig , Adelle
Case 07016CC: I’m not sure why I’ m here. HPI: this 18 yr old Male was referred by his pediatrician because he had gained too much weight (40lbs) since his last checkup. He had been trying to lose weight by dieting and exercise for the past two or three years. PMH: Hospitalizations: none, Operations: none, Medications: none, Allergies: none 12/12/2008 M S Jacobson MD
Case 07016(cont)ROS: CV nl , Resp, Mother reports he’s often out of breath after short walks, GI nl, GU nl , Neuro nl, Musculoskeletal c/o leg pains with walking, Endocrine and growth nl . All others negative. 12/12/2008 M S Jacobson MD
Case 07016(cont)FH : positive for premature atherosclerosis, obesity, hypertension, diabetes and hypercholesterolemia. mother is 63” and 180#, father is 69” 220# SH: School, family and peer activities are age appropriate. Does not smoke. Physical activity level : low Activities: plays football 2 x per week 4-5 hours of sedentary activity per day (tv, video, computer) 12/12/2008 M S Jacobson MD
Case 07016(cont)PHYSICAL EXAMINATION : Blood pressure 135/80 mmHg >90 th%ile pulse 90bpm, Height 70 in Weight 250lb >97th %ile, BMI 35kg/m2 >97th%ile General appearance : central adiposity, waist circumference 46” HEENT : benign. Corneal arcus, not present. Xanthelasma not present Neuro: intact. Neck: without thyromegaly 12/12/2008 M S Jacobson MD
Case 07016( PE cont)CV : RR, nl S1, nl S2. No Murmur. Pulses are present in all 4 extremities. Chest: lungs clear to auscultation. Gynecomastia not present. Musculoskeletal: wnl Abdomen: soft non-tender, no mass or organomegalyTanner Stage : 5 Skin : Xanthomas not present. Abdominal stria not present. Acanthosis Nigricans grade 5 12/12/2008 M S Jacobson MD
Case 07016 ( FASTING Labs ) LIPID PROFILE: Total Cholesterol 250 mg/dl Trigs 250 mg/dl LDL- C 165 mg/dlHDL-C 35 mg/dl TFT’S : TSH 5.0 mcg/DL LFT’S : ALT 65 mg/dl AST 65 mg/dl GLUCOSE 99 MG/DL, INSULIN 25 µU/ mL 12/12/2008M S Jacobson MD
Case 07016 Age 15 66” 190# Age 18 70” 250# Gigante , Alex 12/12/2008 M S Jacobson MD
Case 07016(cont)ASSESSMENT: Dyslipidemia, Hypertriglyceridemia Hypertension OverweightMetabolic Syndrome Acanthosis Nigricans Hyperinsulinemia 12/12/2008 M S Jacobson MD
Case 07016(cont) PLAN: 3 Day Food records and food frequency One mile pace assessment of physical capacity.Increase physical activity: decrease screen time, walk 30 minutes daily Decreased simple carbohydrates, focus on sugar sweetened beverages(SSB’s) Labs : Complete lipid profile, Liver, kidney,thyroid function studies, glucose, insulin prior to next visit Supplements: multivitamin, Revisit in 1 month RD, 3 months MD 12/12/2008 M S Jacobson MD
Case 07016 Clinical course: monthly visits were used to gradually improve his diet and exercise habits. His family was brought into the process by encouraging parents to get unhealthy foods out of the whole family’s diet, and to set TV limits. He worked his way up to walk/run of 4-5 miles per week in order to earn an IPOD. Age 15 66” 190# Age 18 70” 250# Age 19 71” 240# BP, Lipids and Insulin wnl Gigante , Alex 12/12/2008 M S Jacobson MD