Department of Medicine Grand Rounds Case Vignette

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Department of MedicineGrand Rounds Case Vignette

• Josh Olstein M.D.
• February 14, 2007

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• Chief Complaint A 52 year old male presents with
  difficulty losing weight
• History of Present Illness The patient has been
  obese since his teenage years. He has tried
  multiple diet and exercise programs over the last
  five years since being diagnosed with diabetes,
  however worsening osteoarthritis of both knees
  has limited his ability to remain active.

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Additional History

• Past Medical History Type 2 Diabetes Mellitus,
  Hypertension, Hyperlipidemia, Osteoarthritis
• Family History Both his parents had obesity and
  diabetes. His father died from a myocardial
  infarction at age 67.
• Medications Metformin 1gram twice daily,
  Simvastatin 20mg daily, HCTZ 25mg daily, aspirin
  81mg daily.

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Physical Exam

• Obese male in no acute distress
• T 98.6 HR 88 BP 142/88 RR 16
• Wt 354 lbs Height 510 BMI 51 kg/m2
• Lungs decreased breath sounds at bases
• Abdomen obese, non-tender, normal bowel sounds
• Extremities trace lower extremity edema and
  evidence of chronic venous stasis

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Laboratory Studies

• Normal serum chemistries and hepatic panel
• Hemoglobin A1C 7.6
• LDL Cholesterol 135

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Presumptive Diagnosis

• Morbid obesity, refractory to conservative therapy

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Therapeutic Course

• The patient is referred to a bariatric surgery
  center to be evaluated for surgical treatment of
  his obesity
• He was deemed appropriate for surgery and
  underwent a Roux-en-Y gastric bypass
• He had an uncomplicated post-operative course and
  has so far lost 80lbs in the last year

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Roux-en-Y gastric bypass
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Final Diagnosis

• Morbid Obesity, treated surgically

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Question

• Which of the following states is true? (Choose
  one)
• Obesity is defined as a BMI 25 kg/ m2
• Liposuction can significantly reduce fat mass and
  weight. It has been consistently shown to
  improve insulin sensitivity and cardiovascular
  risk
• Several long-term prospective studies found that
  the relative risk of coronary and cardiovascular
  deaths increased with weight fluctuations gt 5 kg
  over a 10 year period
• Mice (ob mice) overexpressing the leptin gene
  have hyperphagia, insulin resistance,
  hyperinsulinemia, and infertility

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Answer

• C is true. Several long term studies have failed
  to show improvement in all-cause mortality and CV
  deaths with weight loss.
• Obesity is defined as a BMI 30 kg/ m2
• Liposuction can significantly reduce fat mass and
  weight. It has NOT been shown to improve insulin
  sensitivity and cardiovascular risk
• Leptin-deficient mice (ob mice) have hyperphagia,
  insulin resistance, hyperinsulinemia, and
  infertility