Marianna M. is a 61-year-old female who is in the clinic for a check-up. Her last examination was 5 years ago. She has no complaint other than leg numbness and tingling from time to time. She also reports feeling thirsty and tired.
What major problems can you identify for this patient? What subjective and objective information in the case supports each of those problems? What is your assessment and plan for each problem? What medications and doses are appropriate for this patient? Differential diagnosis?
Social history: no smoking or alcohol consumption.
Physical examination:
GEN: well nourished, slightly obese female.
VS: BP 180/103 HR 73 RR 13 T 98.4 Wt 90 kg, HT 5’6â€
HEENT: PERRLA
COR: RRR, NMRG
CHEST: CTA
NEURO: monofilament test shows decreased peripheral sensation
EXT: normal
Laboratory (fasting):
Na 139
K 3.8
ALT 34
Ca 9.1
CL 102
HCO3 22
AST 39
TP 6
BUN 33
SCr 1.8
Alb 4.1
Cholesterol 254
BG 275
UA: SG 1.013, pH 6.5, +++ protein
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