Weight Gain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍month history of weight gain

Weight increased by approximately ‍ ‍lbskg

Increase in calorie intake

Decrease in physical activity

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍increased appetite

‍decreased appetite

‍shortness of breath

‍fatigue

‍orthopnea

‍paroxysmal nocturnal dyspnea

‍lower extremity edema, ‍rightleftsymmetrical

‍symptoms of hypothyroidism



Contributing factors:

‍sedentary lifestyle

‍high calorie diet

‍alcohol consumption

‍stress

‍smoking cessation

no history of: ‍hypothyroidism, ‍Cushing's syndrome, ‍polycystic ovary syndrome, ‍depression, ‍insulin resistance, ‍diabetes

no use of: ‍systemic steroids, ‍antidepressants, ‍antipsychotics, ‍beta blockers, ‍insulin, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

Weight gain due to ‍lifestyle ‍likelysuspectedpossible

DDx: overeating, poor diet, lack of exercise, hypothyroidism, Cushing's syndrome, medication side effect, insulin resistance, polycystic ovary syndrome, depression, fluid retention, heart failure, chronic kidney disease, liver disease, sleep apnea, genetic predisposition, pregnancy





PLAN:

Investigations:

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

Treatments:

- Increase physical activity

- Dietary counseling

- ‍Weight loss medications

- Behavioral therapy

Further care:

- Referral to dietitian

- Referral to bariatric surgery

- Follow-up in ‍ months