Adeline Mason, a 35 year old white female has an appointment today at your office. She was seen 6 months ago for her comprehensive exam. At that time, the PE was normal, but she was 20 pounds overweight. Her CBC, FBS, BUN, creatinine, LFTs, pap smear and mammogram were normal. You referred her to the dietician and asked her to start walking 3-4 times per week. She has not been following a diet or exercising. She has been otherwise healthy, and she takes no medications. She is in today because she does not feel well.
CC: “Urinating more over the last few weeks & fatigue for one month”
HPI: Mrs. Mason says that she has been getting up at least one time
per night to urinate for a couple of months, but in the last week has gotten up 2-3 times at night. She also c/o frequency during the day. She states that she feels tired, but her appetite is okay. She states that she sleeps 7-8 hours per night.
CHS: as per information above
PMH: Mild Obesity; no previous surgeries
SH: she is a secretary
PE: VS: 97.8-80-20-150/100 67” 170#
General: 35 y/o white female in NAD
HEENT: PERRLA; EOMs intact; no AV nicking or tortuous vessels on fundoscopic exam
Cardiac:RRR; no m/g/r
Lungs: CTA a/p; no increased work of breathing; no CVA tenderness
Abdomen: truncal obesity; BS x 4 Q; no tenderness; no organomegaly
Lab: 2 hour postprandial glucose is 344 mg/dl
Dip UA shows 3+ glucose; no RBCs; 1+ WBCs; no ketones
The next morning, Mrs. Mason returns to your office for a fasting glucose, which is 202 mg/dl; her BP is 160/94.
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