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    18 views2 pages

    Overweight Child With Insulin Resistance PDF

    Uploaded by

    merii

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    Case 1 Overweight Child with Insulin Resistance Andrew M.Tetshakovee! and Lisa Hark * Merck &Co, Ine, North Wales, PA * Jefferson Medical College, Philadelphia, PA Objectives “Take an appropriate dietary and medical insulin resistance, dytipidemia, seep apnea, ‘orthopedic problems, ete). Identify factors responsible for inereasing ‘weight in order to recommend suitable etary or ifestyie changes. AN is a year-old boy who comes to see bis physician for 2 health maintenance vist. His parents report that he has gained lt of weight Gover the past two summers while attending an ‘overnight ton tael camp that vole siting fon bus for many hours and eating all meas food courts, hotels, oF fast food restaurans ‘They are asking for help eeause AN as ‘become les interested in sports and prefers to play video games rather than play outside with bis ends as he used to Past Medical History AN wats fl- ter info (heth weight 2950 ‘is mother notes he was always thin as ted ad is now shorter than most of the boys is age. Groving up he always had a good appetite ‘ur rarely ate vegetables. AN' mother notes is weight gain ad been relatively stable until be reached the age of 12, when his rate of weight fin increased over the subsequent years. Family History AN's family history is positive for type 2 diabetes, obesity, and heart disease. His mother Tad gestational diabetes during her pregnancy. wth AN. She is 35 years old and has a BDI of 5 kg/m? (obesity class 11) and was recently fold she has an elevated blood glucose level Indicative of predabetes. His fthor (age 96) has a BMI of 28 kg/m? (overweight). tis ‘maternal grandmother (age 63) is obese (BMI 22 kg/m?) and has hypertension and type 2 Siabetes; his maternal grandfather (age 67) hed ‘myocardial infttion (MD at age 53 SociallDevelopmentPuberty AN’ carly childhood development is described 85 normal. He walked at age 15 months, was toilet rained at 3 years. Heis deseribed as an sverage student. He admits that he feels ‘encomfortable with his stomach and does not ‘vant fo fake his shirt of im the summer when he goes swimming, He has frends but now prefers to spend most of his fee time playing ‘deo. games. AN denies smoking, alcohol, drugs, or sexual activity: Social History A's mother works from 9 am. to § pm. daily fs. school administrators AN's father works 8 am. to 6 pm. as an optician. His parents Givoreed 4 ears ago and he splits his time ‘betwen his mothers and fathers homes. AN is fether alone fn the afternoon or watehed by ie srandmother before either parent comes home fom work He san only cl DieuPhysical Activity History ANS parents state that he as always had healthy appetite” When asked what he eats during the day (our recall), mother states that at her house he usually eats serambled gps, bacon, toast, and orange juice for Dreaiast and at fathers house he eats a donut corabagel with eream cheese and drinks orange jie. Both parents packs sandwich for neh at school (peanut butter and jelly with cookies, juice or chocolate mil, or turkey with Imayonnake ‘on white bread), AN usualy siugments what his parents provide at the School cafeteria with either a slice of pza oF Some chips or pretzels. When he comes home ‘rom school he will usually have a sac of more chips or a grilled cheese sandvieh and ‘orange juice He wil at fruit when bis parents provide it Mor or dad each eat out with AN fone a wee where he orders to slices of pizza ‘ors bacon chess burger with res and sb). AL home, they make baked chicken or burgers potatoes or rice and broccoli or string beans, ‘While stad is usualy served, he does nt eat it Fo drinks whole milk with dinner, AN's parents state that he is active with soccer and hasehal during the year but they have noticed that his performance stems to be suffering as he an sometimes not keep up wit the other boys. AN oes to bed between 9:30 and 20:00 pm. and senerallysleps atleast 9 hours. AN'S parents epors that he does snore and oecasionaly aps during the day Review of Systems ‘Skin: Nobistory of rashes [Neurologie No headaches, tremors, “Endocrine: No polyphagi, polyipsi, or polyuria ‘Pulmonary: Regular sooring noted, Some ‘dereaced in exercise tolerance noted with ‘weight gai Joints: No swelling; eomplains that his Tes bharthasto walk for long distance Physical Examination Vital Signs Temperature: 99 °F (37°C) Meart rate: 95 BPM Respiratory rate: 26 BPM. ‘Blood pressure: 90/80 mm Hg (-90-95th petcentile forage, sex, and height Current weight: 75h (165 Ib (95th percentile forage) ‘Current height: 180 em (63°) 25th percentile forage) ‘BME: 29.3 kg/m? (ogsth percentile for age) Weight history 9 y/o: 28 kg (Goth percentile for age) 11 y/o: 35 kx Goth percentile for ae) 13 y/o: 60 kg (goth perentle forage) Exam General: Overweight teeange boy in no ‘cute distress, no irstism, no edema, 90 ‘Cushingoid fextores ‘kin: Wrinkle, hypestrophied skin with lncreased pigmentation at bse of neck LHEENT: No abnormalities noted ‘Neck: Non-palpable thyroid ‘Byes: EOMI, PERL, normal dise margins Alsdomen: BS (4), so no masses or ‘rganomegaly palpable, liver span by Ppereusion 8 em, stretch marks note CCardiae: Regula rate and byt, Chest Clear Genitalia: Tanner 2 boy, phallus moderstcly ‘obscured by ftp testes normal [Neurologi: Alert strength 5/5, DTR +2 ‘upparand lower extremities, normal one Orthopedic: Wide-ased gait without a limp, mild bowing of lower aspect of legs Dilatrally, ful range of osion in both hips Laboratory Data Patient's Fasting [Normal Values Values (Glucose:92 mg/dL 70-99 mld. Insulin: 26 C/ml.—<20 U/mL Hare: 57%

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