Obesity Medicine

Match the following characteristics with the clinical disorders pictured in the photographs of Cases 1 and 2. Then read the brief descriptions that follow on the next page to see how well you did.

A 58-year-old African American woman comes for a follow-up visit after sustaining a fracture of the right radius, which occurred when she tripped on loose carpeting and broke her fall with an outstretched hand.

What are the long-term effects on the child of maternal health before conception?

For every recognized case of celiac disease, 8 more remain undiagnosed. The reason for this disparity is contingent on the varying presentations of the disease.

American medicine is undergoing the greatest financial scrutiny in its history. The hue and cry for reform stems primarily from the soaring costs of health care. However, placing the blame for these costs solely on increased utilization of technology, cutting-edge pharmaceuticals, cost-shifting hospitals, and physicians misses a bigger mark.

What is the highest dose of insulin that can be used in a patient whose diabetes remains uncontrolled on a regimen of insulin plus an oral antidiabetic agent?

A 38-year-old man had fever and fatigue for the past 6 days and tenderness in the left upper abdominal quadrant for the past 3 days. He also had a facial butterfly rash that had been present for 10 years and a 1-year history of lupus nephritis, treated with prednisone and mycophenolate. He denied respiratory complaints or recent weight loss.

Urologists and pediatricians are puzzling over an apparent substantial increase in renal lithiasis among children.1 In 2007, a singlecenter study found a nearly 5-fold increase in the number of children presenting with kidney stones.

For 1 month, a 60-year-old white man has had increasing fatigue, generalized weakness, and exertional dyspnea. He becomes short of breath after he walks only 100 to 150 yards on level ground or climbs only 1 flight of stairs. In addition, he has unintentionally lost 12 lb in the past month and has experienced intermittent dysphagia with solid foods. He attributes this last symptom to long-standing gastroesophageal reflux disease (GERD), for which he regularly takes over-the-counter omeprazole.

For 3 months, a 43-year-old Bolivian woman had worsening thoracic and lumbar pain associated with tingling and tightness in the anterior upper and lower abdominal area, and numbness in the lower extremities. Her symptoms also included difficulty in walking (with frequent falls from imbalance), occasional urinary incontinence for the past few weeks, occasional afternoon low-grade fevers, and poor appetite with an associated 10-lb weight loss within the past 4 months.

The multiple, symmetrically distributed, soft, nontender swellings on the shoulders and torso of a 56-year-old Hispanic man are characteristic of multiple symmetric lipomatosis (MSL), also known as Madelung disease or Launois- Bensaude syndrome.

I read with interest Dr Adam Breinig’s Practical Pointer, “For Easier Pap Smears, Use a Condom” (CONSULTANT, August 2009, page 488). I agree that this is an excellent way to retract the lateral vaginal walls during the speculum examination in an obese patient.

Body mass index (BMI) facilitates meaningful comparison of the weights of children of varying heights. It is useful in population studies, providing a measure of “fatness” that can be easily plotted and compared.

Case 4: An obese 59-year-old man presents with a chronic malodorous, itchy rash in his groin.

Nail lesions shown here: Onychogryphosis, pseudomonal infection, myxoid cyst, onycholisis.

This abdominal rash developed while a 63-year-old woman was traveling in Israel. She was admitted to the hospital, where she received intravenous antibiotics, and was discharged after 5 days. She now returns to the United States and wonders what she had, because she did not understand what the physician in Israel had told her. She has brought all of her medical records.

I understand that patients with refractory hypertension have a high risk of obstructive sleep apnea (OSA) syndrome. Can this be screened for in an office setting?

Case 1: Mr A. is a 55-year-old man who comes to your office for a routine physical examination. He is a traveling salesman and has recently gained weight. He does not exercise much and is a frequent visitor to fastfood establishments. His father had “a touch of diabetes” and died of a myocardial infarction (MI) at age 59.

No matter what primary care demographic your practice represents, it would be most unusual not to encounter patients infected with hepatitis C virus (HCV). Since HCV infection is chronic and can lead to cirrhosis (occurring in 20% of patients over a period of 10 to 20 years), decisions regarding its management, referral, and follow-up are of the utmost importance.

One of your patients is a 30-year-old woman whose BMI is 42. She has been treated for a compulsive eating disorder for the past 10 years, but medications and psychotherapy have not been effective.

Progressively worsening nasal congestion and headaches with diplopia and left proptosis for 2 months prompted an ophthalmology consultation for a 67-year-old woman. She had been evaluated multiple times for allergic rhinitis and recurrent sinusitis.

For a month, an obese 50-year-old woman with type 2 diabetes mellitus, hypercholesterolemia, and hypertension had blurry vision in both eyes. During this time, she also had ataxia and right-sided numbness. For the past 2 days, she had had horizontal, binocular diplopia with right gaze.

I have been using the finger of a non-sterile glove

Performing Papanicolaou tests in obese patients can be difficult

Unilateral polythelia is suggested by a sequence of supernumerary nipples that follow the embryonic milk line. No areolae are associated with these accessory nipples.