https://padlet.com/mjone5/j7t9g466kcdw en-us 2015-03-03 14:35:19 UTC 2016-03-08 16:53:42 UTC hello@padlet.com mjone5 https://padlet.com/mjone5/j7t9g466kcdw/wish/99661692 Case #2
CC: “I am tired of being tired. I want more energy”
HPI: JM is a 59 yo male presenting to the CV Disease Risk Reduction clinic for an initial evaluation. He was referred by his PCP for aggressive weight management. The patient states that he rarely eats healthy but his wife is at least making a healthy dinner each night. Over the past 6-7 months he and his wife have attended Weight Watchers. However, he does not attend every week.  He prefers to eat meals high in fat and carbohydrates. He snacks on chips several times per day. He usually follows a salty snack with sweet-tasting foods, such as cookies or candy. He rarely consumes fruit. He drinks a glass of juice for breakfast. He drinks regular soda. Because of his work schedule, he finds it difficult to exercise. He has lost weight in the past using fad diets like South Beach. Each drop in weight resulted in him feeling more energetic and thus he appears ready to lose weight.
PMH: HTN x 5 years; Migraines x 7 years
FH: Father-CHD died following second MI at 63. Mother-Alive at 89 with Type 2 diabetes. 
SH: Patient is married and lives with wife. He owns a flooring business. Denies tobacco use. 1-2 beers on the weekend.
Allergies: NKDA
Medications:
Metoprolol succinate 50mg po daily
Depakote ER 500mg po daily
Ibuprofen 400mg 2-3 times day for a migraine; uses 2-3 x per month
ROS: Gen- Gained 10lb in the last year. 2-3 migraines a month
Skin-No rashes or other skin changes
HEENT-Hearing good; no infections
Neck- neg lumps, goiter
Resp-Neg for cough, wheezing, SOB
CV- neg for dyspnea, CP, or palpitations
GI-Appetite good; no n/v; reg BM; heart burn with “heavy meals”
Urinary- no changes in urinary frequency
Neuro- non syncope or loss of consciousness
PE: Gen WDWN middle-aged male in no acute distress
VS: BP 132/74; HR 58 BPM; RR 12; T 96.8F
       Wt 225lb
        Ht 65 inches
       Waist 46.5 cm
Skin: (-) Lesions; nails w/o clubbing or cyanosis
HEENT: PERRLA, EOMI; oral mucosa pink
Neck: supple no LAD; trachea midline; no enlarged thyroid; no thyroid nodules; no bruits
Chest: CTA
CV: RRR, no S3 or S4
Ab: NTND; +BS
Neuro CNS II-XII intact; strength 5/5; normal gait
Extremities Warm and without edema bilaterally
LABS: Na 140 K 4.3 Cl 106 CO2 24, BUN 12 Scr 0.9 Glu 96 AST 29 ALT 38
TSH 1.498
TC286 LDL201 HDL 31 TG 272 10-year risk of atherosclerotic cardiovascular disease: 19.1%


1. Calculate and Classify BMI
2. Determine Initial Weight Loss Goal
3. Provide specific non-pharmacologic strategies that could work for this patient.
                   a. 1 thing he can change with diet
                   b. 1 thing he can change with exercise
4. Provide a specific recommendation for adjunctive pharmacotherapy. Indicate why you chose that agent over the others
5. Provide a monitoring plan for his weight loss and medication
6. Provide 3 counseling points
7. Provide recommendations you may have for his other disease states

]]> 2016-03-08 14:41:41 UTC https://padlet.com/mjone5/j7t9g466kcdw/wish/99661692 https://padlet.com/mjone5/j7t9g466kcdw/wish/99701792 1. 37.4 kg/m2 -- Obese Class II
2. 10% -- 22.5lbs
3. a. Replace carby snacks (chips) with one high in protein.
b. Start with a short (10-20 minute) walk and increase duration as tolerated
4. Change depakote to topiramate for migraine prophylaxis AND weight loss. His depakote could be contributing to weight gain and topiramate can cause weight loss, so switching them may be beneficial.
5. Weigh weekly and monitor for weight loss of 1 pound/week and 5-6 pounds per month. Also monitor for migraine control with topiramate. 
6. Possible ADRs with topiramate include fatigue, cognitive dysfunction, and paresthesias. Monitor for hypotension as weight loss continues.
7. Recommend beginning ASA 81mg daily and a high intensity statin (atorvastatin 80mg) for ASCVD risk and LDL >190.]]> 2016-03-08 16:20:24 UTC https://padlet.com/mjone5/j7t9g466kcdw/wish/99701792 https://padlet.com/mjone5/j7t9g466kcdw/wish/99702494 4. get a fitbit- track your exercise. its very motivating ]]> 2016-03-08 16:22:07 UTC https://padlet.com/mjone5/j7t9g466kcdw/wish/99702494 https://padlet.com/mjone5/j7t9g466kcdw/wish/99702855 2. Decrease by 5-10% (11.25-22.5 lbs)
3a. Decrease fat intake to less than 30% of calorie intake - likely needs to reduce overall calorie intake
3b. Walking -- Begin as tolerated, continue to increase with goal of 2 miles in 30  minutes
4. Why is pharmacotherapy necessary? -- Monitor success of non-pharmacologic interventions. Depakote may be causing weight gain -- consider switching to topiramate (Can provide ~6.5% weight loss) - 100-200mg daily in divided doses
5. Keep food and physical activity diary. Set realistic, attainable, and time-specific weight loss goal. 
6. ]]> 2016-03-08 16:23:04 UTC https://padlet.com/mjone5/j7t9g466kcdw/wish/99702855