Chief Complaint
“My left foot feels weak and numb. I have a hard time pointing my toes up.”History of Present IllnessD.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications.
Except for a number of “female infections,” she has felt fine recently.Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone.Past Medical HistorySeasonal allergic rhinitis (since her early 20s)Breast biopsy positive for fibroadenoma at age 30Gestational diabetes with second child 10 years agoMultiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bathHypertension for 10 yearsPast Surgical HistoryC-section 14 years agoOB-GYN HistoryMenarche at age 11Last pap smear 3 years agoFamily HistoryType 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late 40s. Brother takes both pills and shots.Mother alive and wellFather has COPDTwo other siblings alive and wellAll three children are alive and wellSocial HistoryMarried 29 years with 3 children; husband is a school teacherFamily lives in a four bedroom single family homePatient works as a seamstressSmokes 1 pack per day (since age 16) and drinks two alcoholic drinks 4 days per weekDenies illegal drug usesNever exercises and has tried multiple fad diets for weight loss with little success. She now eats a diet rich in fats and refined sugars.AllergiesNKDAMedicationsLisinopril 10 mg dailyLoratadine 10 mg dailyReview of SystemsGeneralAdmits to recent onset of fatigueHEENTHas awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speakingCardiacDenies chest pain, palpitations, and difficulty breathing while lying downLungsDenies cough, shortness of breath, and wheezingGIDenies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipationGUHas experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinenceEXTDenies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling or numbness in arms or legs prior to this episodeNeuroHas never had a seizure and denies recent headachesDermHas a rash under her bilateral breast and in groin areaEndocrineDenies a history of goiter and has not experienced heat or cold intoleranceVital SignsBP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20 non labored, WT 210 lbsWhat you need to do:Develop an evidence-based management plan.Include any pertinent diagnostics.Describe the patient education plan.Include cultural and lifespan considerations.Provide information on health promotion or health care maintenance needs.Describe the follow-up and referral for this patient.Prepare a 3–5-page paper (not including the title page or reference
