Mary is a 44-year-old African American female who is reporting to her primary care provider for a follow-up visit for evaluation of her diabetes, hypertension and dyslipidemia. During her last visit 3 months ago, her provider increased the dosage of one anti-hypertensive medication and added a second anti-hypertensive medication to her regimen due to her blood pressures hanging around 160/100. A second agent to assist with the management of her diabetes was also added to her plan of care at that time because her blood sugars were averaging 250-300, and her HA1C was 10.4%. She had lab work drawn two days ago so that it would be available for this visit.
Medical Diagnoses: Stage 2 hypertension, dyslipidemia, type 2 diabetes mellitus
Current Medications:
Review of Systems Subjective Data
General: Denies excessive fatigue, fever or problems other than dizziness when getting out of bed in the morning or standing up too quickly
Skin: Denies rashes or lesions but does report having dry skin, especially her extremities
HEENT: Denies visual or hearing changes, allergies, dizziness, rhinorrhea, colds or respiratory changes
Cardiac: Denies chest pain, tightness or palpitations; blood pressure readings at home 130s/80s
Respiratory: Denies shortness of breath or breathing difficulties; denies infections or cough
GI: Reports occasional bloating and GI upset
GU: Denies pain, burning, hesitancy, blood or urgency with urination
MS: Denies issues other than frequent leg cramps/pain in the evening time most days for the past couple of weeks. The pain seems to be getting more severe.
Neuro: Denies weakness, paresthesias or changes in speech or memory
Psych: Denies feeling depressed or down
Physical Examination
Ht: 60 inches, Wt: 170 pounds
General: No acute distress
BP 138/86, T 98.1°F, P 78, R 20
Heart: RRR, S1 and S2, no murmurs
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, no bruits; Normoactive bowel sounds x 4
Lower Extremities: Pedal pulses 1+ bilaterally; skin warm and dry; capillary refill 3 seconds
Laboratory Results:
Glucose: 188
Creatinine: 1.1 mg/dl
Carbon dioxide: 28 mEq/L
Chloride: 100 mEq/L
Potassium: 3.0 mEq/L
Sodium: 139 mg/dl
Calcium: 9 mg/dl
BUN 14 mg/dl
Microalbumin 50 mg/24 hours
eGFR 58 mL/min
TC: 200
TG: 150
HDL: 50
LDL: 120
Case Analysis Discussion Points
Mary is a 44-year-old African American female who is reporting to her primary care provider for...
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