1. Marc S. Jacobson MD Case Presentations 12/12/2008
9/17/2018
Marc S. Jacobson MD Case Presentations 12/12/2008
Marc S Jacobson MD

2. Case 08341 CC: My triglycerides are high.
HPI: this 15 yr old Female was referred by her pediatrician because she had gained 20lb’s in the past year and had high cholesterol and triglycerides. She had been trying to lose weight using Weight Watchers and by joining a gym with no effect.
PMH: Hospitalizations: none, Operations: none, Medications: none, Allergies: none
9/17/2018

3. Case 08341(cont)
ROS: CV nl, Resp nl, GI nl, GU nl, Neuro nl, Musculoskeletal nl, Endocrine and growth: Menarche was at age 12.5 yrs. She has never been regular but had not skipped more than a few weeks prior to 3months ago when she had her last normal period.
9/17/2018
M S Jacobson MD

4. Case 08341(cont)
FH: positive for premature atherosclerosis (father had a CABG at age 54), obesity, hypertension, type 2 diabetes and hypercholesterolemia.
SH: School, family and peer activities are age appropriate. She does not smoke.
Physical activity level is low
She plays Volleyball 1x per week during the season only, spends most of her free time on movies and shopping with friends. She belongs to a gym but does not use it consistently, attending 1-2 x per week and often skips weeks.
2-4 hours of sedentary activity per day (tv, video, computer)
9/17/2018
M S Jacobson MD

5. Case 08341(cont) PHYSICAL EXAMINATION:
Blood pressure 132/85 mmHg >90th%ile pulse 90 bpm,
Height 66in
Weight 160lb,
BMI 26 kg/m2 >90th %ile
General appearance: Adiposity is central.
HEENT: benign. No Corneal arcus or Xanthelasma or facial hair noted
9/17/2018
M S Jacobson MD

6. Case 08341(cont) Neck: without thyromegaly Neuro: intact.
CV: RR, nl S1, nl S2. No Murmur. Pulses are present in all 4 extremities.
Chest: lungs clear to auscultation. Tanner 5 breasts
Musculoskeletal: wnl
Abdomen: soft non-tender, no mass or organomegaly
Skin: Xanthomas not present. < 10 Abdominal stria noted.
Acanthosis Nigricans Grade 1 on her neck
9/17/2018
M S Jacobson MD

7. Case 08341(cont) Labs (FASTING) LIPID PROFILE: TFT’S : TSH 5.0 mcg/dl
Total Cholesterol mg/dl
Trigs mg/dl
LDL- C mg/dl
HDL-C mg/dl
TFT’S : TSH mcg/dl
LFT’S : ALT 22 mg/dl, AST 25 mg/dl
GLUCOSE mg/dl,
INSULIN mg/dl
Free testosterone: >3% (nl < 1.4)
9/17/2018
M S Jacobson MD

8. Case 08341(cont) ASSESSMENT: Dyslipidemia, Hypertriglyceridemia
Pre Hypertension
At risk for overweight
Metabolic Syndrome, PCOS
Acanthosis Nigricans
Hyperinsulinemia
9/17/2018
M S Jacobson MD

9. Case 08341(cont) PLAN: 3 Day Food records and food frequency
Menstrual calendar
One mile pace assessment of physical capacity.
Increase physical activity: decrease screen time, walk 30 minutes daily or use her gym membership
Decreased simple carbohydrates, focusing on sugar sweetened beverages, pasta, rice, and potatoes.
Smoking prevention
Supplements: multivitamin,
Revisit monthly RD, 3 months MD
9/17/2018
M S Jacobson MD

10. Case 08341(Follow up)
She was followed monthly for six months on a low glycemic index diet focused on her simple carbohydrate intake. Saturated fats were limited to 2gm per serving of snack and mealtime foods.
Her menses began without progesterone challenge within the second month of the program and has been regular since. Her weight was monitored using BMI percentiles and has improved in a stair step fashion with periods of loss interspersed with periods of no change or small gains.Her acanthosis has faded and she has lost 2 inches in waist circumference.
9/17/2018
M S Jacobson MD

11. Case 08341 Zoftig, Adelle Age 13 65” 130 # bmi 21.5
follow up Labs
LIPID PROFILE:
Total Cholesterol 180 mg/dl
Trigs mg/dl
LDL- C mg/dl
HDL-C mg/dl
GLUCOSE mg/dl, INSULIN mg/dl
Free testosterone: 1.1% nl
9/17/2018
M S Jacobson MD

12. Case 07016 CC: I’m not sure why I’ m here.
HPI: this 18 yr old Male was referred by his pediatrician because he had gained too much weight (40lbs) since his last checkup. He had been trying to lose weight by dieting and exercise for the past two or three years.
PMH: Hospitalizations: none, Operations: none, Medications: none, Allergies: none
9/17/2018
M S Jacobson MD

13. Case 07016(cont)
ROS: CV nl, Resp, Mother reports he’s often out of breath after short walks, GI nl, GU nl, Neuro nl, Musculoskeletal c/o leg pains with walking, Endocrine and growth nl.
All others negative.
9/17/2018
M S Jacobson MD

14. Case 07016(cont)
FH: positive for premature atherosclerosis, obesity, hypertension, diabetes and hypercholesterolemia.
mother is 63” and 180#, father is 69” 220#
SH: School, family and peer activities are age appropriate. Does not smoke.
Physical activity level : low
Activities: plays football 2 x per week
4-5 hours of sedentary activity per day (tv, video, computer)
9/17/2018
M S Jacobson MD

15. Case 07016(cont) PHYSICAL EXAMINATION:
Blood pressure 135/80 mmHg >90th%ile pulse 90bpm, Height 70 in
Weight 250lb >97th %ile, BMI 35kg/m2 >97th%ile
General appearance: central adiposity, waist circumference 46”
HEENT: benign. Corneal arcus, not present. Xanthelasma not present
Neuro: intact. Neck: without thyromegaly
9/17/2018
M S Jacobson MD

16. Case 07016( PE cont)
CV: RR, nl S1, nl S2. No Murmur. Pulses are present in all 4 extremities.
Chest: lungs clear to auscultation. Gynecomastia not present.
Musculoskeletal: wnl
Abdomen: soft non-tender, no mass or organomegaly
Tanner Stage: 5
Skin: Xanthomas not present. Abdominal stria not present.
Acanthosis Nigricans grade 5
9/17/2018
M S Jacobson MD

17. Case 07016 (FASTING Labs ) LIPID PROFILE: TFT’S : TSH 5.0 mcg/DL
Total Cholesterol mg/dl
Trigs mg/dl
LDL- C mg/dl
HDL-C mg/dl
TFT’S : TSH mcg/DL
LFT’S : ALT 65 mg/dl AST 65 mg/dl
GLUCOSE MG/DL,
INSULIN µU/mL
9/17/2018
M S Jacobson MD

18. Case 07016 Age 15 66” 190# Age 18 70” 250# Gigante , Alex 9/17/2018
M S Jacobson MD

19. Case 07016(cont) ASSESSMENT: Dyslipidemia, Hypertriglyceridemia
Hypertension
Overweight
Metabolic Syndrome
Acanthosis Nigricans
Hyperinsulinemia
9/17/2018
M S Jacobson MD

20. Case 07016(cont) PLAN: 3 Day Food records and food frequency
One mile pace assessment of physical capacity.
Increase physical activity: decrease screen time, walk 30 minutes daily
Decreased simple carbohydrates, focus on sugar sweetened beverages(SSB’s)
Labs: Complete lipid profile, Liver, kidney,thyroid function studies, glucose, insulin prior to next visit
Supplements: multivitamin,
Revisit in 1 month RD, 3 months MD
9/17/2018
M S Jacobson MD

21. Gigante , Alex
Case 07016
Clinical course: monthly visits were used to gradually improve his diet and exercise habits. His family was brought into the process by encouraging parents to get unhealthy foods out of the whole family’s diet, and to set TV limits. He worked his way up to walk/run of 4-5 miles per week in order to earn an IPOD.
Age ” 190# Age ” 250#
Age ” 240#
BP, Lipids and Insulin wnl
9/17/2018
M S Jacobson MD