Chief Complaint:
"I've put on 6 pounds since the beginning of December and I don't know what's wrong!!"
HPI:
DC is a 22YO AF who bothers to post a stupid case study on her blog. She is moderately depressed by her unusual weight gain. She claims that she has not changed her diet lately and she always consumes at least 5 servings of fruits & vegetables daily. Due to the recent cold weather, she has been going to Starbucks more often and has a cup of hot chocolate every night before going to bed.
PMH:
Has a history of dark chocolate dependency 2 years ago (tapered off from chocolate containing 80% cocoa to Hershey's milk chocolate).
FH:
Parents alive and well; one brother also in pharmacy school.
SH:
Pt is under some stress due to final exams in 2 days. She wants to stay awake and study so she has been drinking Starbucks coffee with extra espresso shots 4-5 times a week. She has not been exercising at all since October and does not plan to jog outdoor until next spring. Contributing to her inactivity is the amount of handouts she has to study and a new internet buddy that she gets to know recently.
Meds:
None currently
All:
NKDA
ROS:
skipped
PE:
didn't bother to take one
Labs:
none
Assessment:
1. Inactivity with possible increase of caloric intake.
2. Stress is contributing to her weight gain.
