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Patient Case Presentation
Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%. Glucose 180 mg/dL (fasting). FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.
Past medical history
Diagnosed with diabetes (type 2) at 32 years old
Overweight, BMI of 31
Had a cholecystomy at 38 years old
Diagnosed with dyslipidemia at 32 years old
Past family history
Mother alive, diagnosed diabetic at 42 years old
Father alive with Hypertension diagnosed at 55 years old
Brother alive and well at 45 years old
Sister alive and obese at 34 years old
Pertinent social history
Social drinker on occasion
Smokes a pack of cigarettes per day
Works full time as an IT technician and is in graduate school
COMMENTS
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Patient Case Presentation. Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without ...
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