Dr. Gretl Lam recently presented a case of a 19-year-old obese male seen in primary care clinic for 80 lb unintentional weight loss. Drs. Kaleb Keyserling and Emily Watkins from the VA primary care clinic were present for this report and provided valuable outpatient perspective in the assessment and management of this patient.
We began by creating a framework for unintentional weight loss, to help target our history, exam and diagnostic work up, while keeping pretest probabilities in mind.
Unintentional Weight loss: A framework
Malignancy: lymphoma and testicular cancer being most likely in the age cohort
GI Disorders: PUD, Malabsorptive processes (Celiac), Inflammatory Bowel Disease
Endocrinopathies: Diabetes Mellitus, Hyperthyroidism, Adrenal Insufficiency
Infectious Diseases: HIV, TB (though less likely in the absence of risk factors)
Chronic Disease: Lung, Liver, Kidney
Psychiatric Illnesses: Depression, Anxiety, Eating Disorder
Given the patient’s age and lack of prior medical history the residents felt psychiatric illness and or substance use disorder was high on the differential.
Back to our case
On interview, the patient endorsed excess thirst, polydipsia and polyuria. He denied substance use or mood disorder, though history was obtained in the presence of his mother. Physical exam was grossly normal. Given this history, an endocrinopathy, particularly new onset diabetes was felt to be high on the differential. CBC, CMP, UA, Hemaglobin A1c and TSH were checked, which were grossly normal with the exception of Hemaglobin A1c of 12.7.
The patient was started on insulin while workup for auto-antibodies (GAD 65) was initiated to help differentiate between type 1 and type 2 diabetes. This work up was negative. Insulin was subsequently discontinued for metformin, with thought that this case of undifferentiated diabetes was most likely early onset type 2 diabetes.
Dr. Emily Watkins’ Pearls
1) Every teenage patient, part of the encounter should be conducted in the absence of the parent. Dr. Watson shared that she would set this expectation with every teenage patient and their parent and in doing so would normalize the situation. Meaningful discussions regarding substance use and sexual habits will most often only be obtained when a parent is out of the room.
2) Eating disorders can be difficult to broach with teenage patients. Dr. Watson’s practice is to initiate the conversation by asking “how do you feel about your body?”
3) Any patient with family history of autoimmune disorder should be screened for diabetes, thyroid disorder and celiac disease at the same time.
4) A patient with a new diagnosis of diabetes in the outpatient setting, can be managed outpatient if clinically stable and good access to care/ability to follow-up.