C.B. is a significantly overweight, 48-year-old woman from the Winnebago Indian tribe who had high blood sugar and cholesterol levels three 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 that her fasting blood sugar was 141 and her cholesterol was 225. However, she felt "perfectly fine at the time" and could not afford any more medications. Except for a number of "female infections," she has felt fine until recently.

Today, she presents to the Indian Hospital general practitioner complaining that her left foot has been weak and numb for nearly three weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. However, she reports 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 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone.

• Seasonal allergic rhinitis (since her early 20s)
• Breast biopsy positive for fibroadenoma at age 30
• Gestational diabetes with fourth child 14 years ago
• Morning sickness with all four pregnancies
• HTN X 10 years
• Moderate-to-severe osteoarthritis involving hands and knees X 4 years
• Multiple yeast infections during the past 3 years that she hasself-treated with OTC antifungal creams and salt baths
• Occasional constipation

C-section 14 years ago

OB-GYN History

• Menarche at age 12
• Menopause, natural, at age 46½; despite problematic hot flashes, she has chosen not to initiate HRT
• First child at age 17, last child at age 34, G4P4A0, all babies were healthy, 4th child weighed 10 lbs 6½ oz at birth

G= Gravida means # of Pregnancy
P= Parity means # of deliveries
A= # of Abortion

• Last Pap smear 4 years ago

• Type 2 DM present in younger sister and maternal grandmother; both were diagnosed in their late 40s; maternal grandmother died from kidney failure while waiting for a kidney transplant; sister is taking "pills and shots"
• Father had emphysema
• Two older siblings are alive and apparently well
• All four children are healthy

• Married 29 years with 4 children; husband is a migrant farm worker
• Family of 5 lives in a 2-bedroom trailer
• Patient works full-time as a seamstress in a small, family-owned business
• Smokes 2 ppd (since age 14) and drinks 2 beers most evenings
• Has "never used illegal drugs of any kind"
• Rarely exercises and admits to trying various fad diets for weight loss but with little success; has given up trying to lose weight and now eats a diet rich in fats and refined sugars

General

Admits to recent onset of fatigue

HEENT

Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing; denies vertigo, head trauma, ear pain, ringing sensations in the ears, difficulty swallowing, and pain with swallowing

Cardiac

Denies chest pain, palpitations, and difficulty breathing while lying down

Lungs

Denies cough, shortness of breath, and wheezing

GI

Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits to occasional episodes of constipation

GU

Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence

Ext

Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling, or numbness in arms or legs prior to this episode

OB-GYN

Menses stopped 2 years ago; is not sexually active but denies sexual dysfunction; also denies any vaginal discharge, pain, or itching

Neuro

Has never had a seizure and denies recent headaches

Derm

No history of chronic rash or excessive sweating

End

Denies a history of goiter and has not experienced heat or cold intolerance

Sulfa drugs → confusion

Medications

• Lisinopril 20 mg po QD
• Acetaminophen 500 mg with hydrocodone bitartrate 5 mg 1 tablet po Q HS and Q 4h PRN
• Naproxen 500 mg po BID (for mild-to-moderate osteoarthritis X 3½ years)
• Omeprazole 20 mg po QD
• Docusate sodium 100 mg po TID
• Loratadine 10 mg po QD PRN

General

• Significantly overweight Native American woman who appears slightly nervous
• The patient is alert, oriented, and uses appropriate words
• She does not appear to be acutely distressed and looks her stated age

Vital Signs

See Patient Case Table 54.1

Skin

• Dry and cool with tenting/poor skin turgor
• Significant xerosis on both feet with cracking
• Erythematous scaling rash in the axilla bilaterally
• (-) petechiae, ecchymoses, moles, or tumors upon careful inspection
• Normal capillary refill throughout

• PERRLA
• EOMI
• Pink conjunctiva
• R & L funduscopic exams showed mild arteriolar narrowing but without hemorrhages, exudates, or papilledema
• Non-icteric sclera
• TMs intact
• Nares and oropharynx clear without exudates, erythema, or lesions
• Mucous membranes dry

• Supple
• ( - ) thyromegaly, adenopathy, JVD, or nodules
• ( + ) bruit auscultated over right carotid artery

Chest and lungs

• No chest deformity; chest expansion symmetric
• Clear to auscultation and percussion throughout

• Regular rate and rhythm with no murmurs, gallops, or rubs
• Apical impulse normal at 5^th ICS at mid-clavicular line
• Normal S1 and S2
• No S3, S4

Abdomen

• Soft, NT with prominent central obesity
• ( + ) BS in all four quadrants
• ( - ) organomegaly, distension, or masses
• Faint abdominal bruit auscultated

No masses, discoloration, discharge, or dimpling of skin or nipples

Genitalia/Rectum

• ( - ) vaginal discharge, erythema, and lesions
• ( - ) hemorrhoids
• Good anal sphincter tone
• Stool is guaiac-negative

• Normal ROM in upper extremities
• Reduced ROM in knees
• ( - ) edema or clubbing
• Peripheral pulses diminished to 1 + in both feet
• Feet are cold to touch and dry with cracking, but no ulceration observed
• Strength 5/5 throughout except 2/5 in left foot

• Alert and oriented X 3
• Cranial nerves II-XII intact (including good visual acuity)
• Sensory response to light touch, proprioception, and vibration subnormal in both feet with abnormalities greater in the left foot
• DTRs 2 + throughout
• Gait normal except for left foot weakness

See Patient Case Table 54.2

Note: Normal values, please refer to Laboratory Values posted on Canvas

See Patient Case Table 54.3

Electrocardiogram

Findings consistent with early left ventricular hypertrophy

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations