Weight Loss

Subjective

• 46 yo female
• Virtual consultation for weight management and lifestyle redesign
• Progressive weight gain, daytime fatigue, and bilateral knee pain with prolonged standing
• Previously trialed phentermine 15 mg PO OD for 3 months in 2022; currently taking lisinopril 10 mg PO OD and metformin 500 mg PO BID
• Experienced insomnia, dry mouth, and palpitations with phentermine, leading to discontinuation
• Requests occupational therapy support for sustainable routine modifications, meal prep strategies, and initiation of GLP-1 receptor agonist therapy in coordination with PCP
• Weight gain has been gradual over 5 years, with a 7 kg increase over the past 12 months in the context of transitioning to a sedentary remote desk job. Knee pain is bilateral, dull, 4/10 severity, worse in the evenings
• Fatigue and knee pain worsen with prolonged sitting (> 2 hours) and poor sleep; partially relieved by short walks and stretching. Self-treated weight gain with intermittent fasting (16:8) for 2 months, which yielded a 2 kg loss before plateauing due to evening binge eating
• Weight has steadily increased from baseline 78 kg to 98 kg over 5 years; energy levels have progressively declined over the past 6 months
• Lost 10 kg in 2019 using a commercial point-based diet tracking program, but regained the weight within 14 months following a foot injury that limited mobility
• Decreased stamina limits ability to complete heavy household chores (e.g., vacuuming, gardening) and IADLs (grocery shopping); relies on food delivery 4x/week due to post-work exhaustion
• Reports loud snoring and non-restorative sleep; denies chest pain, SOB at rest, cold intolerance, or constipation

Past Medical History

• Class II obesity, HTN, prediabetes, bilateral knee OA
• Lab results (10/05/2024): HbA1c 6.2%, fasting glucose 114 mg/dL, TSH 2.1 mIU/L, total cholesterol 215 mg/dL, LDL 135 mg/dL, HDL 42 mg/dL, triglycerides 190 mg/dL, eGFR > 60 mL/min/1.73m²

Objective

• Visual inspection via telehealth shows central adiposity; ergonomic assessment of home workspace reveals low monitor height and non-supportive seating
• Height 165 cm, Weight 98 kg, BMI 36.0 kg/m²
• Vitals: Unable to obtain during the virtual consultation
• General: Appears well, without acute distress
• HEENT: Unable to assess during the virtual consultation
• Neck: Unable to assess during the virtual consultation
• Respiratory: No observable shortness of breath or coughing during the virtual consultation
• Cardiovascular: Unable to assess during the virtual consultation
• Abdomen: Unable to assess during the virtual consultation
• Musculoskeletal: Mild difficulty rising from low seated position observed; otherwise no observable joint swelling or restricted upper extremity range of motion during the virtual consultation
• Neurological: Alert and oriented, with no observable focal deficits during the virtual consultation
• Psychiatric: Appropriate affect, without observable distress or agitation during the virtual consultation
• Skin: Unable to assess fully during the virtual consultation; no visible rash or lesions
• CMP (10/05/2024): AST 24 U/L, ALT 28 U/L, Cr 0.8 mg/dL

Assessment & Plan

1. Class II Obesity (BMI 36.0 kg/m²) with functional limitation in IADLs

• Implement occupational therapy lifestyle redesign focusing on energy conservation, structured meal prep routines, and workstation ergonomics; coordinate with PCP regarding initiation of semaglutide (Wegovy®) 0.25 mg SC weekly
• Follow-up virtual OT session in 2 weeks to review food/activity logs and assess tolerance to routine changes
• Educated on pacing techniques for household chores, batch cooking on weekends to reduce reliance on takeout, and setting hourly movement reminders during work hours

Plan

• Establish structured daily schedule incorporating 15-minute low-impact walking intervals BID
• Restructure kitchen environment to keep high-protein snacks accessible and remove trigger foods from immediate sight
• Utilize a digital habit tracker for water intake (goal 2.5 L/day) and sleep hygiene (consistent 22:30 bedtime)
• Refer to sleep medicine for home sleep apnea testing given snoring and daytime fatigue