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Differential diagnosis

Differential Diagnosis table for Obesity in adults
Condition Differentiating signs/symptoms Differentiating tests
Hypothyroidism, primary
  • Fatigue

  • Depression

  • Cold intolerance

  • Excessive sleepiness

  • Dry, coarse hair

  • Constipation

  • Dry skin

  • Muscle cramps

  • Decreased concentration

  • Free T4: <9.0 picomoles/L

  • TSH: >10 mU/L

Hypothyroidism, central
  • Fatigue

  • Depression

  • Cold intolerance

  • Excessive sleepiness

  • Dry, coarse hair

  • Constipation

  • Dry skin

  • Muscle cramps

  • Decreased concentration

  • Free T4: <9.0 picomoles/L

  • TSH: inappropriately low or normal

Cushing's syndrome
  • Central obesity

  • Moon facies

  • Striae

  • Hirsutism

  • Lipodystrophy

  • Hypertension

  • Diabetes

  • Depression

  • Urinary free cortisol level: >300 micrograms/24 hours

  • Low-dose dexamethasone suppression test: serum cortisol >50 nanomoles/L

Workup

Laboratory Studies

  • Full lipid panel, at minimum, test of fasting cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-C) levels
    • These levels may be normal, or the typical dyslipidemia associated with metabolic syndrome X may be found.
    • This is characterized by reduced HDL-C, increased low-density lipoprotein cholesterol (LDL-C), normal-to-marginally increased total cholesterol, and elevated fasting triglyceride concentrations.
  • Hepatic panel: This test is expected to yield normal results, but findings may be abnormal (eg, elevated transaminase levels in the setting of NASH or fatty infiltration of the liver).
  • Thyroid function tests
    • The results are typically normal, but checking them to detect primary hypothyroidism (characterized by increased serum thyrotropin and normal or reduced levothyroxine and/or triiodothyronine levels) is worthwhile.
    • Screening with a serum thyrotropin level is usually sufficient. Of importance, hypothyroidism itself rarely causes more than mild obesity.
  • For screening purposes, 24-hour urinary free cortisol test
    • This test is needed only when Cushing syndrome or other hypercortisolemic states are clinically suspected.
    • Approximately 4% of patients with Cushing syndrome have normal urinary free cortisol values.
  • Fasting glucose and insulin test
    • Obesity is associated with insulin resistance, though these levels are normal in many subjects who are obese.
    • In other people, insulin levels may be elevated.
    • In those with impaired glucose tolerance, the fasting serum glucose level is elevated to higher than 100 mg/dL.

Procedures

  • Among the various procedures relevant to the treatment of patients who are obese are procedures to estimate the degree of visceral and subcutaneous fat.
  • These procedures include the standard anthropometric measurements and caliper-derived estimates of skin thickness.

Histologic Findings

Hypertrophic obesity characterized by enlarged fat cells is typical of android abdominal obesity. Hypercellular obesity is more variable than hypertrophic obesity. Hypercellular obesity is typical of obesity with an onset in childhood or adolescence, but it is also invariably found in subjects with severe obesity.

 

 

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