Transcript Case-Studies - Dr. Moulton

Case Studies
Case Study #1:
Patient with
Controlled Hypertension
Patient Information
• 52 year old African American female
• Presented in September 2004 for 1 yr minimum
lifestyle change intervention
• Referred by PCP
Patient Information
• Measurements
– Height: 5’ 3”
– Weight: 215 lbs
– Waist Circumference: 41 inches
– BMI: 38.1
Patient Information
• Initial BP: 130/90 mm Hg
• Pulse: 76
• Resting ECG normal
• Laboratory
–
–
–
–
–
Glucose 91
TSH: 1.78
LDL-C: 89
HDL-C: 65
TG: 62
Patient Information
• Psychological Screen
– Minimal to mild depression
• Binge Eating Disorder Screen
– Negative
Patient Information
• Pertinent Past Medical History
– Hypertension x 7 years
– Off treatment for several years
– Recently, PCP started ARB/diuretic combination
– Compliant with medication
– Monitors BP at home frequently
− Generally 130/80
− Systolic occasionally hits 140 “with stress”
Patient Information
• Weight History
– Weighed 150 lbs at age 42 when 18 year old son left
for college
– Has gained steadily since that time
– Self-described “emotional eater”
− Between supper and bedtime
Clinical Course
• Entered lifestyle change program September
2004
• Hypocaloric diet
– Weight loss of 1 lb per week
• Daily walking program
– Step log with pedometer
– Goal of 7000 – 10,000 steps/day
Clinical Course
• Initial medical evaluation
• Basic nutrition and exercise tips from physician
and / or staff
• Follow-up
– Physician visits (minimum once monthly)
– Lifestyle change group support classes (if
available)
Monthly BP and Weight Loss
Month Weight
BP
Weight Loss Rx
None
Notes
1
215
138/90
2
218
138/90
Sibutramine 10 mg Home BP - 128/80
3
212
130/80
More relaxed; feels
Sibutramine 15 mg better; night eating
improved
4
206
130/90
Sibutramine 15 mg
5
203.4
130/88
Sibutramine 15 mg
Thanksgiving thru
Christmas
6
203.8
140/88
Sibutramine 15 mg
Christmas thru New
Years
7
202
122/80
Sibutramine 15 mg
8
201.2
120/80
Sibutramine 15 mg
9
200.6
122/78
Sibutramine 15 mg 7% body wt lost
Discussion Points
• In this patient with controlled hypertension, no
additional difficulty with sibutramine
• Patient has achieved modest but significant
weight loss to date, with improvement in blood
pressure and emotional eating. Small changes
can produce big results!
• Having the patient participate in her own care by
recording home blood pressure readings gives
the physician an extra measure of safety and
involves the patient directly in her own care
Discussion Points
• Patient did not have metabolic syndrome
• Two criteria out of five met; three needed
• Criteria met:
– Waist circumference > 35 in
– Note that any patient with a BMI > 35 does not need a
waist circumference measured, as it will be elevated.
– Hypertension
Case Study #2:
Patient Preparing for
Weight Loss Surgery
Patient Information
• 20 year old Caucasian female
• Presented in June 2004 for 6 months of
lifestyle change preparation prior to open
gastric Roux n Y procedure
• Surgeon had initially refused her requests for
gastric bypass surgery, but had consented to
do the procedure pending proof of her fulfilling
her pre-operative lifestyle change commitment
Patient Information
• Measurements
– Height: 5’ 10”
– Weight: 303 lbs
– Waist Circumference: 46.5 inches
– BMI: 43.5
− Accepted criteria for surgery
– BMI 40 without comorbidities
– BMI 35 with comorbidities, in particular type 2
diabetes
Patient Information
• Initial BP: 128/88 mm Hg
• ECG normal
• Initial Lab (fasting)
–
–
–
–
–
–
Glucose: 92
TSH: 2.912
Total Cholesterol: 155
LDL: 91
HDL: 41
TG: 115
Patient Information
• Psychological Screen
– Minimal to mild depression
• Initial diagnoses of:
– Morbid obesity
– Mild depression
– Metabolic syndrome (elevated waist circumference,
low HDL, elevated diastolic BP)
Clinical Course
• Hypocaloric meal plan
– Minimum of 1 lb per week
• Physical activity
– Pedometer – avg 6,000 steps daily
– Swimming or walking – 30-45 minutes, 3-4 times per
week
– Resistance bands or dumbbell work– 2-3 sessions
per week
• Sibutramine – 10 mg daily
Clinical Course
• Follow-up
– Monthly physician visit
– Lifestyle change group support classes
Outcomes
• Month 2
– Sibutramine increased to 15 mg
– BP = 120/84
– Weight loss at least 1 lb per week
– Patient felt medication was helping, and was willing to
increase the dose to optimize intended effects. No
adverse effects noted at 10 mg.
Outcomes
• Month 5
– Weight loss = 32 lbs
– Surgeon agreed to proceed with surgery at BMI 39.0
– Underwent surgery in December 2004
− Sibutramine discontinued immediately preoperatively
Outcomes
• Post-op
– Weight loss = 53 lbs in first five months
– Exercises frequently
– Continues in lifestyle change program
− Monthly physician visits
− Group support classes
• March 2005
– Weight: 218.5 lbs
– Blood pressure: 120/74
Discussion Points
• Bona fide lifestyle change programs will become
mandatory for pre-certification of obesity surgery
• Pre-operative sibutramine during initial lifestyle
change supported this highly motivated patient
Case Study #3:
Obese Patient Participating
in INTENSIVE Lifestyle
Modification Program
Intensive Lifestyle Change Program
• This case illustrates one type of comprehensive
multi-disciplinary approach
• The purpose is not to discourage PCPs, but
rather to stimulate the practitioner to consider
create their own system, within “what works” in
their own practice
Patient Information
• 53 year old Caucasian female
• Presented in February 2004
• Heard about program through a hospital sponsored event, featuring a bariatric surgeon
and the director of the medical weight loss and
lifestyle change program
Patient Information
• Married, with two grown children
• Family relationships are stable
– Husband is supportive of participation in the program
• IT professional in a high stress office
management position
Patient Information
• Measurements
– Height: 5’ 7”
– Weight: 260 lbs
− Desired goal weight: 140 lbs
– Waist Circumference: 47 inches
– BMI: 41
Patient Information
• Weight History
– Age 25: 125-130 lbs
− Pregnancies resulted in large weight gains
– Two previous attempts at significant weight loss
− 1989: Lost 30 lbs (Weight Watchers); regained in 1 year
− 1998: Lost 70 lbs (dietitian coach); regained in 2 years
– Both parents are obese
– Husband is 50 lbs overweight
– One child is overweight
• No current physical activity
Patient Information
• Medical History
– Hypercholesterolemia
– Menopause
• Medications
– Simvastatin
– HRT
– Calcium-D
• Psychological
– Screening evaluation normal
– Binge Eating Disorder not present
Clinical Course
• One-year, multidisciplinary lifestyle change,
weight loss, and weight loss maintenance
program for high body mass index adults
• After one year, she will have the option to
continue for additional six-month or one-year
increments
Clinical Course
• Initial office evaluation
– Medical and nutrition history
– Cardiovascular risk factor/obesity focused physical
examination
– Laboratory and EKG
– Body composition by impedance technique (repeated
every three months)
– Depression and binge eating disorder screening
– Prescription medication option discussed, if
appropriate
− Patient chose no meds
Clinical Course
• Saturday workshop (group class)
– 6 hour all-day session
− Entry point into system for all new patients
– 120 page workbook on nutrition, exercise, mind-body
connections
– Personal plan for 1 lb per week weight loss
− Balanced ADA-AHA type approach
– Hands-on label reading, healthy recipe substitutions,
supermarket product demonstration, pulse taking,
target heart rate, weight training, and walking session
Clinical Course
• Follow-up monthly doctor visit
– Weight and vital signs check
– Support group attendance reviewed
– One-on-one personal coaching
– Workshop “promises” continually reviewed and
updated
– Weight loss medication refilled
− If support group attendance requirements met
Clinical Course
• Follow-up one hour support group classes
– Six one-hour classes available monthly
– Two classes monthly required for medication refill
– Rotating topics (nutrition, exercise, behavior change,
medical)
– Morning and evening classes available
Results
Months 1-5
Month Weight
Start
262
1
244
(- 18)
2
237.4
(- 6.6)
3
226.5
(- 10.9)
4
220.6
(- 5.9)
5
216
(-4.6)
# Support
Classes
Exercise
Initial wkshp
5
Comments
No weight loss rx
Pedometer at
6000 steps/day
Keep food logs;
Not eating enough
4
Same, plus
Calories at 1500;
resistance bands Food log 2 d/wk
4
Pedometer at 8K, 10% weight loss;
plus bands
continue to journal
4
Adding weight
training
Husband has lost
10 lbs
2
6K pedometer
daily, weights at
night 3-4x/wk
Excited about
getting under 200
lbs
Results
Months 6-10
Month Weight
# Support
Classes
Exercise
Comments
Rotate upper/lower
body weight work
6
207.5
(- 8.5)
2
Weights and
cardio 5x/wk
7
205.2
(- 2.3)
2
Same
PCP to stop
simvastatin soon
8
201.0
(-4.2)
2
Same
“This is my plan!”
9
197.5
(-3.5)
Same
Under 200 lbs.
Thanksgiving is
next week
10
200.8
(+ 3.3)
2
1
Down to 3x/wk
First month at < 2
classes. Not quite
back on track.
Back to basics
Results
Months 11-13
Month Weight
11
200.8
12
197.5
(- 3.3)
13
194.6
(-2.9)
# Support
Classes
1
2
3
Exercise
Comments
45 min, 5
days/wk
Feeling better with
↑ exercise. Good
Xmas and New
Year. Goal was to
not gain and
restart exercise
9000 steps daily
Feels back on
track
Starting pilates
LDL normal; off
simvastatin for 3
months
Total Loss = 67.4 lbs
BMI = 30.4
Discussion Points
• What qualifies as a bona fide lifestyle change
program?
• What coaching/expectations are reasonable
between Thanksgiving and New Years?
Case Study #4:
Patient with
Obesity, Hypertension and
Type 2 Diabetes
Patient Information
• 32 year old African American female
• Divorced with 2 children
• Works as a legal secretary in a high pressure
law firm
• Presents to new PCP after being “burnt out” by
her last two physicians
Patient Information
• Measurements
– Height: 5’ 3”
– Weight: 246 lbs
– BMI: 39
Patient Information
• Initial BP: 146/94 mm Hg
• Laboratory
–
–
–
–
–
–
–
–
Glucose 136 (fasting)
LDL-C: 130
HDL-C: 36
TG: 198
Total cholesterol: 149
SGOT: 19
SGPT: 14
Alk Phos: 86
• Cardiac Risk Ratio: 4.1
Patient Information
• Pertinent Past Medical History
– 2 normal pregnancies/deliveries
– No current medications
– Describes herself as “tense, anxious, sleep deprived
and fat”
Clinical Course
• Initial medical evaluation
• Opportunity for patient to vent frustrations. With
listening, the physician built the patients trust and
inspired hope
• Physician-patient discussion re: hypertension, type 2
diabetes and the relationship of both to her weight. The
metabolic syndrome and its relationship to CHD and
sudden cardiac death was also discussed
• Follow-up
– Physician visits (minimum once monthly)
Clinical Course
• Medication prescribed:
– Enalapril 2.5mg daily
– Metformin 500mg BID, with meals
• Basic nutrition, exercise tips and diabetes
education from physician and / or staff
• Patient motivated to decrease weight when she
understood that all of her medical problems
could possible be resolved by weight loss
Monthly Summary/Progress
Month Weight
1
2
3
4
246
238
231
224
BP
Rx
146/94
Enalapril, Metformin
138/90
Still feeling motivated,
taking stairs at work.
Enalapril, Metformin Feels “healthier”,
reports having more
energy
125/80
129/80
Notes
Metformin
D/C enalapril, pt
continues to be
motivated, do well
Metformin
Pts blood sugar
improving, will D/C
metformin next month
if continuing to do well
Case Study #5:
Patient with
Obesity and
Hypercholesterolemia
Patient Information
• 54 year old white male
• Married with 1 grown son
• Works at a high stress/high pressure advertising
agency. Must socialize with clients over meals
frequently.
• Is motivated to lose weight, but does not want to
use an “appetite suppressant” or any drug which
might affect his mind or personality
Patient Information
• Measurements
– Weight: 252 lbs
– BMI: 35
• Laboratory
–
–
–
–
–
–
–
–
–
Glucose 98
Cholesterol (total) 310
Triglycerides 264
LDL 146
HDL 35
Cardiac Risk Ration 6.0
SGOT 31
SGPT 34
Alk Phos 48
Patient Information
• Pertinent Past Medical History
– Mild osteoarthritis in both knees
– Seasonal allergies
– No current medications
– Feels he eats out of “obligation and duty” and that
hunger is not his problem, but the presence of too
much high fat food in a business/social environment
Clinical Course
• Initial medical evaluation
• Started on low calorie, reduced fat and
carbohydrate diet amounting to 1800-2000
calories/day in a structured eating pattern.
Allows for no snacks or alcohol.
• Physician-patient discussion re: orlistat, its
benefits and side effects.
• Follow-up
– Physician visits (minimum once monthly)
Clinical Course
• Medication prescribed:
– Orlistat 120 mg daily with his biggest meal
• Basic nutrition and diet instruction
• Patient started medication on a Friday and reported that on
Saturday after a low fat meal he went to the movies and “forgot” not
to eat buttered popcorn. He experienced an episode of lower
abdominal cramps and rectal urgency with increased flatus and a
large amount of oily stool. He was unable to get to the bathroom to
avoid soiling his pants. The patient was initially angry and
frustrated. He called the office on Monday, and realized he had
learned about orlistat the hard way. However, he felt motivated
because he could see the drug working
• After 3 months, the patient is doing well and has lost 18 pounds (7%
of total body weight). He is aware of the drug side effects and
wishes to continue with the program.