Chief Concern
“I feel so tired lately and can’t seem to shake this sinus infection.”
History of Present Illness
Ms. Yazzie, a 63 year old Navajo female and long-time patient of your primary care office presents today with concerns related to general fatigue and ongoing sinusitis-like symptoms. She states that while her symptoms are “not so serious,” she has grown “sick and tired of being sick and tired.” Over the last four or five months Ms. Yazzie has grown fatigued and weak at times, as well as having symptoms of sinusitis and two back-to-back yeast infections. She recently bought a water bottle because she noticed she was thirsty “all the time.”
Two years ago, at a routine screening you diagnosed Ms. Yazzie as pre-diabetic. At that time, she appeared motivated to make lifestyle changes. She states that shortly after that appointment her sister fell ill and she moved back to the Navajo Nation to care for her. The last two years Ms. Yazzie has been dedicated to caring for her sister and sorting out her sister’s affairs since she passed. Ms. Yazzie states that she did not have time to take “good care of herself.” She says healthcare on the reservation was not easily accessible or of high quality and that exercise and a balanced diet were not priorities.
Past Medical History
- Pre-diabetes: age 61
- Hypertension: age 52
- Hyperlipidemia: age 49
- Obesity: age 38
- Varicella: 8
Allergies
- Latex
- Shellfish
Medications
Ms. Yazzie is not currently taking any medications but she previously had the following medications:
- Bumex 0.5 mg po BID
- Zocor 40 mg po daily
Family History
Both of Ms. Yazzie’s parents are dead. Her father died of a heart attack when he was 52 years old. Ms. Yazzie does not know much about his health because he, “didn’t like going to the doctor.” Her mother died fifteen years ago at the age of 71. Ms. Yazzie’s mother had type 2 diabetes mellitus and well-controlled hypertension.
Ms. Yazzie’s sister died at age 64, the specific cause is unknown. She had been diagnosed with obesity, hypertension, diabetes, and suspected coronary artery disease.
Ms. Yazzie’s other sister is alive at age 59. She was diagnosed with obesity at age 37 and hypertension at age 49.
Social History
Ms. Yazzie lives alone in a one bedroom apartment. Prior to moving to Arizona she worked as an artist’s assistant and docent at the art museum. She is currently volunteering again at the museum and looking for work.
She was married for 12 years but divorced nearly 30 years ago. Ms. Yazzie has one son who lives in town: she helps care for his three teenage children.
Ms. Yazzie denies drinking alcohol but says she smokes cigarettes. She says she’s been a smoker since she was 17 and smokes about a half pack a day (22 pack years).
Focused Physical Exam
- VS: HR – 85, RR – 16, Temp – 94.3, BP – 136/86, O2 – 99% on room air
- General: A&Ox4, appearance appropriate for age and race, central obesity (waist diameter 38”)
- Skin: cool and dry. A 2” abrasion on right ankle that the patient says, “just won’t heal.”
- HEENT: patient notes some floaters in her right eye “recently.”
- GU: recent yeast infections, polyuria
- GI: active bowel sounds in all quadrants
- Respiratory: clear breath sounds in all fields
- Cardiac: clear S1 and S2 noted. Absence of any murmur or rub.
Labs
You ask Ms. Yazzie to come back in for some diabetes-related diagnostic tests and a lipid profile over the following two weeks.
- Fasting blood glucose: 145 mg/dL first test; 138 mg/dL second test
- Glucose tolerance test: 212 mg/dL; 222 mg/dL second test
- HbA1c: 6.5%
- Triglycerides: 168 mg/dL
- HDL: 46 mg/dL
- LDL: 174 mg/dL
- Total: 220 mg/dL