Mr Jones, a 57 year old African American male, presents to the office for a planned 6 month follow up visit for hyperlipidemia and weight loss recommendations. Lifestyle recommendations were recommended at that time. He has been following dietary recommendations “as good as he could remember” and exercising, he reports some new concerns today. He reports that he has been experiencing increased fatigue for about the last 12 weeks. He has a health club membership and attends 3-4 times a week. He walks on the treadmill at least 30 minutes as you directed and lifts weights but he has not lost any weight, in fact he has gained 8 pounds. He doesn’t understand what he is doing wrong and is requesting more education. He reports that exercise makes him even more hungry and thirsty. He requests evaluation as to why he is so tired. He reports he has to go to the bathroom more often- he is waking up during the night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. No other GU symptoms have been noted.
Current medications: Simvastatin, 10 mg daily, Tylenol 500 mg 2 tabs in AM for knee pain. Daily multivitamin and turmeric.
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PMH: Hyperlipidemia. Right knee OA (for 2 years) Had measles as a child. Vaccinations up to date. Colonoscopy WNL 7 years- to repeat at 10 years
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. Business executive, job required frequent travel. 1-2 beers daily. Former smoker, quit 5 years ago. No illicit drug use.
Allergies: allergic to Bactrim, strawberries, cats and pollen. No latex allergy
Vital signs: BP 119/79; pulse 84, regular; respiration 16, regular
Height 5’9.5”, weight 210 pounds
General: male in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT: head normocephalic. Hair thinning distribution across crown. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.
GU: bladder nontender upon palpation
Labwork: (fasting labs drawn this morning)
CBC: WBC 6,300/mm3 Hgb 13.8 gm/dl Hct 42% RBC 4.6 million MCV 93 fl MCHC 34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.006, Leukocyte esterase negative, nitrites negative, 1+ glucose; negative protein; negative ketones
CMP:
Sodium 139
Potassium 4.2
Chloride 100
CO2 29
Glucose 136
BUN 12
Creatinine 0.7
GFR est non-AA 99 mL/min/1.73
GFR est AA 101 mL/min/1.73
Calcium 9.0
Total protein 7.6
Bilirubin, total 0.5
Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.8 %
TSH: 2.31, Free T 4 0.9 ng/dL
Cholesterol: TC 202 mg/dl, LDL 134 mg/dl; VLDL 36 mg/dl; HDL 32mg/dl, Triglycerides 225
EKG: normal sinus rhythm
