Chief Complaint: the patient’s wife is bringing the patient in after a fall at their home
Presentation:
J.S. a 50-year-old African American male who presents with his wife after he fell at home. After the fall, he told his wife “I will be fine, I think my vision just needs checked.” The patient reports, “I was walking very fast because I really had to pee and I accidentally ran into the table and got off balance. The next thing you know I was on the ground.” The patient reports having blurred vision for the past couple of months but just has not had the time to go to the eye doctor. His wife is more concerned about other changes she has noticed such as, J.S. has been waking up 3 times a night to go to the bathroom and he has had slight confusion and forgetfulness at times. J.S. thinks he has been using the bathroom more frequently because he has been so thirsty lately due to the warmer weather. When asked further about the fall the patient does report some tingling in both his feet occasionally. The patient’s wife also thinks her husband’s legs are getting weaker because he hasn’t been able to go on as long of a walk, like they normally do. She also expressed concern about a cut J.S. got on his leg that has not healed. The patient believes he got the cut about 2 months ago while mowing the lawn.
Past Medical History:
Obesity (1999)
GERD (2005)
Anxiety (2015)
Obstructive Sleep Apnea (2017)
Surgical History:
Appendectomy (1995)
Tonsillectomy (2017)
Pertinent family history:
Father—alive; type 2 diabetes, hypertension
Mother—hyperlipidemia, died of a stroke at age 70
Sister—alive, unremarkable medical history
Pertinent Social history:
J.S. works at a bank where he is primarily sitting at a desk all day. He reports gaining more weight recently so he and his wife have started going on walks around the neighborhood each night for exercise. He reports it is hard for him to eat healthy because he works long hours and “fast food is easy”. J.S. does report having “a bad smoking habit” of half a pack a day (12 pack years). He says it helps with his anxiety and stress of his job. The patient only reports social drinking (~2 drinks per week).
Current Medications:
Xanax-.5 mg BID
Prilosec-20 mg Daily
Assessment & Vitals:
Height: 5’9”
Weight: 255 lbs.
BMI: 37.7
Temp: 98.7°F
P: 85 bpm, apically, regular rhythm
RR: 16 breaths/minute, unlabored
BP: 127/78 mmHg, left arm, sitting
Pain: patient reports no pain at this time
Skin: open cut on lower left leg ~2 inches in length, erythema surrounding cut, no drainage
Peripheral neurovascular: positive for tingling in bilateral lower extremities
Lab Results:
A1C: 10%
Lipid panel:
HDL: 45 mg/dL
LDL: 105 mg/dL
Triglycerides: 140 mg/dL
Total: 190 mg/dL
Fasting blood glucose: 240
TSH: 2.0 mU/L
Urine Analysis: normal except:
Glucose: 3.0 mmol/L
Chem 7: within normal limits