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%