Mounjaro Weight Control Clinic Template

History:
- The patient, a 45-year-old female, presents with concerns regarding weight management. She notes a gradual weight increase over the past five years, totaling approximately 20 kg. She also experiences occasional joint pain and fatigue.
Past Medical History:
- The patient has a history of hypertension and type 2 diabetes. Her family history includes obesity and cardiovascular disease. She is currently on metformin and lisinopril. She does not smoke and drinks alcohol socially. She has no known allergies.
History of Weight Gain:
- The patient indicates that her weight gain started following a stressful period at work, which led to increased snacking and decreased physical activity.
Diet:
- The patient follows a diet high in carbohydrates and fats, with irregular meal timings and large portion sizes.
Exercise:
- The patient participates in minimal physical activity, walking only once a week for about 30 minutes.
Alcohol:
- The patient drinks wine approximately twice a week, consuming 2-3 glasses per occasion.
Smoking:
- The patient is a non-smoker.
Sleep:
- The patient reports sleeping for 6 hours per night, with frequent awakenings and difficulty falling back asleep.
Examination:
- BP: 140/90 mmHg
- Weight: 95 kg
- BMI: 32 kg/m²
- Pulse: 78 bpm
Advice:
- Lifestyle: The patient is advised to incorporate stress management techniques such as meditation.
- Diet: A balanced diet with reduced carbohydrate intake and smaller portion sizes is recommended.
- Sleep: The patient is advised to establish a regular sleep schedule and avoid caffeine in the evening.
- Exercise: The patient is encouraged to engage in at least 150 minutes of moderate-intensity exercise per week.
- The patient is advised to monitor her blood pressure regularly and follow up in 3 months.
Starting Mounjaro Medication:
- How to Use: The patient is instructed to take Mounjaro 5 mg once weekly, with or without food. She is advised to rotate injection sites and report any side effects.