Weight Gain

HISTORY:

Weight gain for ‍ ‍hoursdays

Weight increased by: ‍ ‍lbskg

Increase in calorie intake: ‍yesno

Decrease in physical activity: ‍yesno

Treatments tried: ‍none, ‍effectiveineffective

‍increased appetite

‍decreased appetite

‍shortness of breath

‍fatigue

‍orthopnea

‍paroxysmal nocturnal dyspnea

‍lower extremity edema

‍symptoms of hypothyroidism



EXAM:

General appearance: ‍well-appearing

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

Weight gain due to ‍lifestyle ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍HbA1c, ‍fasting glucose, ‍lipid profil, ‍TSH, ‍cortisol

- Increase physical activity

- Dietary counseling

- ‍Weight loss medications

- Behavioral therapy

- Referral to dietitian

- Referral to bariatric surgery

- Follow-up in ‍ months