Case 9915: George
Patient: George M., a 47 year old male

Principal Complaints: Fatigue, constipation while dieting, hypertension and hypercholesterolemia.

At a recent workplace screening George was informed that his cholesterol and blood pressure were high and that he was overweight. He is quite concerned about this, since his father had his first heart attack at age 48 and died from another heart attack at age 50. George immediately called you for an appointment and began his "Fat Diet". This is a diet he followed in his thirties to lose weight fast.
When George graduated from high school he weighed 180 pounds and was 5'11". He married at age 25 and gradually gained weight so that by age 30 he weighed 210 pounds. That was when he first tried the "Fat Diet". On the diet, he ate all the meat and fat that he wanted but had to avoid all carbohydrates. He lost about 20 pounds in two months, but he gained it all back in 6 months when he stopped the diet. When he was 35, he tried it again only this time he joined a gym and worked out regularly. He kept the weight off for two years. He stopped going to the gym when his first child was born and he has been gaining weight ever since. At the screening, he weighed 250 pounds. Since he started the diet 3 days ago, he has lost 8 pounds. He knows he should exercise but feels too tired. He is also very uncomfortable since he is constipated all the time.

Significant observations from the physical exam: Alert and oriented overweight male. Fruity breath odor. Blood pressure 150/95.

Laboratory tests:
Cholesterol: 240 mg/dl (normal <200 mg/dl)
Urine: positive for ketones

Diet Recall: George eats three meals a day. On this diet, he tries to avoid carbohydrates. A twenty four hour recall and analysis is attached.