1. Medicine Grand Rounds Clinical Vignette Jack Naggar, MD PGY-2 March 5, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. Mr. I is a 48 year-old gentleman who presents to primary care clinic to discuss weight loss Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. He finds that it is difficult to maintain a healthy diet and exercise regimen as he works long hours (often working the night shift) as a taxi cab driver, and has the majority of his meals at Indian buffets For exercise he enjoys going on walks with his wife, but has not done so recently because of the cold weather His mood is good, though he reports that working the night shift can be draining History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: Obesity Diabetes Mellitus type II – diagnosed in 2008 Non-alcoholic fatty liver disease Hyperlidemia Chronic atypical chest discomfort – workup to date un- revealing Gastro-esophageal reflux disease Past Surgical History: None U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Social History: –Born in Bangladesh, emigrated to US in 2000 –Currently employed as Taxi cab driver – work schedule is erratic –Lives with wife and 2 children –No history of drugs, tobacco, alcohol use Family History: –Father – Tuberculosis –Brother – asthma Allergies: –No Known Drug Allergies Medications: –Aspirin 81mg daily –Metformin 1000mg twice daily –Glimepiride 2mg daily –Simvastatin 20mg twice daily –Omeprazole 40mg daily Additional History

6. Physical Examination General: Well-appearing, sitting upright in no acute distress Vital Signs: list T:98 BP:126/80 HR:79 RR:12 O2 sat: 98% RA Weight: 83kg BMI: 33 Physical exam remarkable for Acanthosis nigricans on bilateral axilla Hepatomegaly Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings CBC: Within normal limits Basic Metabolic panel: Glucose 102 (70-99) Remainder of basic was within normal limits Hepatic panel: AST 46 (11-39) ALT 58 (11-35) Remainder of hepatic panel was within normal limits Other Laboratory Data LDL 71 (<100) HDL 42 (30-64) Cholesterol 142 (<200) Triglycerides 143 (55-320) Hemoglobin A1C: 7.2% (<5.7%) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Other Studies Abdominal Ultrasound: Diffusely increased echotexture of liver parenchyma consistent with fatty infiltration versus hepatocellular disease U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Obesity with multiple systemic complications –Diabetes Mellitus type II –Non-alcoholic fatty liver disease –Hyperlipidemia –Gastroesophageal reflux disease Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. He was referred to diabetic nurse educator for diabetic teaching He was referred to nutritionist regarding healthy diet Options regarding healthy eating while at work were discussed He was continued on all current outpatient medications Referral for weight loss surgery will be considered at the next visit Clinic Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS