A 41-year-old woman comes to the office because of a 40-pound weight gain in the past 6 months. She is very upset because she has always been thin and never had to watch her diet before. She has no change in appetite, no change in eating habits, and has no other symptoms. She takes no medications, does not drink alcohol, and smokes a pack of cigarettes a day for the past 10 years. She rollerblades with her daughter every evening and tries to eat a well-balanced, low-fat diet. She denies anxiety and any psychiatric problems. She tells you that her mother and sister have always been overweight and they always complain about their "apple-shaped" bodies. Her temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and respirations are 16/min. Physical examination shows an obese abdomen and thin lower extremities, but is otherwise unremarkable. The most appropriate next step is to
A. determine thyroid stimulating hormone levels
B. order a biochemical profile
C. order a dexamethasone suppression test
D. refer her to a nutritionist
E. schedule a CT scan of the abdomen
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Explanation:
The correct answer is B. The initial work-up for weight gain is a detailed history, including medication and drug use and recent smoking cessation, and a biochemical profile. A biochemical profile may indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes will most likely lead to an elevated glucose, while Cushing is sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis, hyperglycemia, and hypercholesterolemia. An individual with an "apple-shaped" body typically has a large abdomen and chest and thin legs. A "pear-shaped" body typically refers to a thin torso with larger hips, buttocks, and legs. This is included in the vignette to show that the patient's "obese abdomen" is consistent with her family's body type and is not necessarily associated with Cushings or any other conditions.
Determining thyroid stimulating hormone levels (choice A) is appropriate in the evaluation of weight gain if there is a negative drug history, no recent smoking cessation, and a normal biochemical profile. Since hypothyroidism is part of the differential diagnosis for weight gain, you should consider it early in the work-up, but a biochemical profile should be performed first.
A dexamethasone suppression test (choice C) is part of the initial evaluation of Cushing syndrome. You should first order a biochemical profile to determine if this diagnosis is more likely than diabetes mellitus.
Referring her to a nutritionist (choice D) is inappropriate at this time. The case says that the patient has had weight gain with no change in appetite or eating habits. She requires evaluation for a medical condition, such as Cushing syndrome, diabetes mellitus, thyroid disease, (even though this is usually associated with a poor appetite), and fluid overload.
A CT scan of the abdomen (choice E) may be used to visualize an adrenal mass leading to Cushing syndrome and weight gain. It may be ordered after a biochemical profile, dexamethasone suppression test, and plasma cortisol. This study is not appropriate at this time.
Well this woman can have a hypothyroidism , why NOT TSH Levels....
Why we nee dto jump immediatelly for dexa for Cushings ????
Don't w enee dto order urine free cortison first-just loud thinking ...
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