History and Assessment

History

Patient W.B. is a 63 year old Caucasian male who is at the clinic for the first time.  The patient presents with recent unintentional weight loss and fatigue.  W.B. also states that he has noticed that his legs seem to “fall asleep” quite often and for no apparent reason.  The patient denies any other symptoms, and has only sought treatment at the clinic at the behest of his wife and daughter.

W.B. has no surgical history.  The patient had childhood asthma that has since resolved.  W.B. said that his previous physician had urged him to lose weight because his blood pressure was “a little too high,” but he has never been medicated for this.  The patient is not currently taking any medications.

The patient has not had a primary care provider since his previous physician retired two years ago.  W.B. lives with his wife, and neither of them drinks alcohol.  The patient states that he smoked cigarettes, one pack per day for forty years, having quit four years ago.  W.B. states that his mother was healthy for seventy-seven years, until she experienced a rapid decline and succumbed to bone cancer.  The patient’s father was an overweight, but muscular laborer who passed away at the age of fifty-nine from a myocardial infarction.

Assessment

  • Temperature 98.9
  • Pulse 96, regular
  • BP 138/84
  • 5’9″ and 234 pounds
  • Clinically obese with BMI of 34.6
  • Finger-stick blood glucose 146, 3 hours postprandial
  • Abdominal-visceral adiposity
  • Foot exam – skin intact, loss of vibration and monofilament sensation in great toe of both feet

Lab Results

  • Hemoglobin A1C – 8.1%
  • Low-density lipoprotein – 140 mg/dL
  • Triglycerides – 200 mg/dL
  • Metabolic panel – Glucose of 150 mg/dL
  • Complete blood count – unremarkable
  • Thyroid function tests – unremarkable

Leave a Reply

Your email address will not be published.