Case Study related to diabetes

Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She

reports that lately she has been very fatigued and just does not seem to have any

energy. This has been occurring for 3 months. She is also gaining weight since

menopause last year. She joined a gym and forces herself to go twice a week, where

she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact

she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states

that exercise seems to make her even more hungry and thirsty, which is not helping her

weight loss. She wants get a complete physical and to discuss why she is so tired and

get some weight loss advice. She also states she thinks her bladder has fallen because

she has to go to the bathroom more often, recently she is waking up twice a night to

urinate and seems to be urinating more frequently during the day. This has been

occurring for about 3 months too. This is irritating to her, but she is able to fall

immediately back to sleep.

Current medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin

PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to

date.

GYN hx: G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No

history of abnormal Pap smear.

FH: parents alive, well, child alive, well. No siblings. Mother has HTN and father has

high cholesterol.

SH: works from home part time as a planning coordinator. Married. No tobacco history,

1-2 glasses wine on weekends. No illicit drug use

Allergies: NKDA, allergic to cats and pollen. No latex allergy

Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular

Height 5’2.5”, weight 185 pounds

General: obese female in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted

HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without

exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light

reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx

moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior

cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small

and firm without palpable masses.

CV: S1 and S2 RRR without murmurs or rubs

Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen- soft, round, nontender with positive bowel sounds present; no

organomegaly; no abdominal bruits. No CVAT.

Labwork:

CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC

34 g/dl RDW 13.8%

UA: pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small

protein; negative for ketones

CMP:

Sodium 139

Potassium 4.3

Chloride 100

CO2 29

Glucose 95

BUN 12

Creatinine 0.7

GFR est non-AA 92 mL/min/1.73

GFR est AA 101 mL/min/1.73

Calcium 9.5

Total protein 7.6

Bilirubin, total 0.6

Alkaline phosphatase 72

AST 25

ALT 29

Anion gap 8.10

Bun/Creat 17.7

Hemoglobin A1C: 6.9 %

TSH: 2.35, Free T 4 0.7

Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides

232

EKG: normal sinus rhythm