A.S , 50 y.o male, presents to her family physician with a 3month history of back pain
HISTORY
PMH : Patient states that she has enjoyed excellent health
Mother and brother have been diagnosed with Type 2 DiabetesMellitus
Family history negative for heart disease / hypertension
On Metformin (decreases hepatic glucose production
Social History : Married with three children – ages 20, 15, and10, driver, denies smoking or use of drugs . Inactive lifestyle
Diet History:
Estimate energy intake of approximately 2800 kcal/day withapproximately 1400 kcal from carbohydrates .
Patient states that he consumes sandwich with sweetened pop (24oz)-as Dinner, ice cream and chocolate candy daily
ANTHROPOMETRICS
Height 5’9’’
CurrentWeight 225#
Usualweight 200# ( for the past five years )
Lowest adult weight was 170 pounds at the age of 25
Waist Circumference 54 inches
PHYSICAL EXAMINATION
Blood Pressure 130/85 mm Hg
Review of systems normal
LABORATORY VALUES
TZValues ReferenceValues
Fasting BloodGlucose 150mg/dL <100mg/dL
A1C 7.0% 4- 6 %
TotalCholesterol 300mg/dL <200 mg/dL
HDL 40mg/dL >40 mg/dL
LDL 140mg/dL <130 mg/dL
Triglycerides 250mg/dL <150 mg/dL
PROBLEM LIST
- Type 2 Diabetes
- Obese
- Prehypertension
PLAN
Lifestyle modifications (diet and physical activity). RD toconsult
- Write ADIME including PES statement for thiscase.
