One to three pages of scholarly writing in paragraph format, not counting the title page or reference page Brief introduction of the case Identification

Case Analysis Tool Worksheet

Student's Name: Case ID: Internal Medicine 16: 45-year-old man who is overweight

I. Epidemiology/Patient Profile

Harrison James is a 45-year-old Caucasian male. He is obese. Denies smoking, but drink alcohol once a week.

II. Prioritized Cues from Hx and PE.(Do not include lab, x-‐ray, or other diagnostic test results here.) • Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem. • Tier 2: These are cues of intermediate importance (list only positive cues). • Tier 3: Of least importance (list only positive cues).

Tier 1 Tier 2 Tier 3 Weight 220lbs (BMI 34.5) Recent changes in personal life

(divorced from 2 years) No family history of diabetes

Last office visit: weight 208lbs (BMI 32.6)

Most men in the family gain weight over the years

Does not take any medication

Normal weight until a few years ago

Review of systems unremarkable

Waist circumference: 42 inches Usually eat a donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner Drinks a beer or two once a week Family history of hyperlipidemia and high blood pressure Father had heart attack at 68 year of age LDL- 141 mg/dL Total Cholesterol-206 mg/dL

III. Problem Statement

Harrison James, a 45-years-old Caucasian male, who is obese, came to clinic for a checkup. He is an accountant, and have a sedentary lifestyle both at work and home. His diet consists of coffee and a donut for breakfast, a burger and fries for lunch, and fast food for dinner. His weight is 220 lbs; and was 208 lbs at his last office visit. He denies exercising because he is too tired after work. He also reports being tired frequently and not able to fall asleep during the day, but able to sleep at night.

IV. Differential Diagnosis Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.

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Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.

Leading dx: Secondary Dyslipidemia (ICD 10: E78.5) (Grundy et al., 2018; Yang, 2018)

History Finding(s) Physical Exam Finding(s) obesity Weight 220lbs (BMI 34.5) Increased waist circumference Waist circumference- 42 inches Family history of hyperlipidemia and high blood pressure

LDL- 141 mg/dL Total Cholesterol-206 mg/dL

Unhealthy food: donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner

Review of system- unremarkable

sedentary lifestyle

Alternative dx: Metabolic Syndrome: ruled out because these patients usually have fasting blood glucose above 100. This patient’s blood glucose level is normal without medication. Moreover, patient does not meet the criteria for metabolic syndrome based on waist circumference, and triglyceride levels (Wang, 2020).

History Finding(s) Physical Exam Finding(s) Obesity, increased weight since last office visit Fasting glucose- 87 mg/dL

Unhealthy food: donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner

Waist circumference- 42 inches

Family history of hyperlipidemia and high blood pressure

Triglyceride- 136 mg/dL

sedentary lifestyle

Alternative dx: Diabetes: uncontrolled diabetes can secondary hyperlipidemia, but patient’s fasting blood glucose level was normal (Cash and Glass, 2017; Hill and Bordoni, 2021). Therefore, this differential diagnosis can be ruled out.

History Finding(s) Physical Exam Finding(s) Unhealthy food: donut and coffee for breakfast, a burger and fries for lunch, and fast food for dinner

Fasting blood glucose- 87 mg/dL

Obesity, increased weight since last office visit sedentary lifestyle

V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:

Diagnostic Plan Rationale Repeat labs in 3 months:

– Fasting glucose – Fasting lipid profile

Since patient is not on drug therapy, and wants to control the cholesterol levels by lifestyle modifications; the total cholesterol should be

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– Hemoglobin A1c measured in 3 months to evaluate the progress and to determine initiating pharmacological approach (Cash and Glass, 2017).

Treatment Plan Rationale Nonpharmacologic interventions: (Yang, 2018) Lifestyle modifications:

– Weight loss – Increased physical activity – Increased dietary fiber – Reduction of saturated fats in diet

Lifestyle modifications are usually initiated before starting any pharmacological therapy. Weight loss, and diet can help lowering the cholesterol regardless of weight status (Yang, 2018).

Follow up in 3 months To reevaluate the lipid profile, and progress of weight, and diet ( Cash and Glass, 2017).

I have adhered to the honor system:

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References

Cash, J. C. & Glass, C. A. (2017). Family practice guidelines, (4th ed.). New York, NY: Springer LLC.

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de

Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A.,

Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A.,

Saseen, J. J., … Yeboah, J. (2019). 2018

AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the

Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart

Association Task Force on Clinical Practice Guidelines. Circulation, 139(25), e1082–e1143.

https://doi.org/10.1161/CIR.0000000000000625

Hill, M. F., and Bordoni, B. (2021). Hyperlipidemia. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK559182/

Wang, S. S. (2020). Metabolic syndrome. Medscape. https://emedicine.medscape.com/article/165124-overview

Yang, E. H. (2018). Lipid management guidelines. Medscape. https://emedicine.medscape.com/article/2500032-

overview#a3

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