Mellitus Case Studies

I was well versed with the patient’s medical history and current treatment, as I was the Long Call IM PGY – II Resident who supervised the medical intern when this patient was being downgraded from the ICU to the medical floor on 5/20/17 (and even suggested to the medical intern to add in her notes that the patient would benefit from statins, ACE inhibition and Spironolactone given CAD, CVA and HFrEF (LVEF < 35%.) The medical team subsequently started the patient on Atorvastatin 40 MG PO QHS, Lisinopril 10 MG PO QD and Spironolactone 12.5 MG PO QD.

Patient is a high school counselor. He participates in physical activities by running 2 to 3 times a week, playing golf, and volunteering at a nursing home. The patient is married with one daughter and one son. He does not use tobacco and periodically drinks at

Hypertension. His blood pressure is great here in the office. I will have him continue with his same medication and I will continue to follow along and he was asked also monitor for signs of hypotension and I did review with him what to be monitoring for.

has been normal, because he limited is sodium intake and he takes his medications as prescribe.

The member is being treated for chronic conditions without evidence of a significant new impairing event.

He denied recent changes in weight or appetite. He reported having a sinus infection approximately 6 weeks ago (congestion, sore throat, sinus inflammation). No fever, chills, malaise, chest pain, dyspnea, abdominal pain, diarrhea, constipation, urinary symptoms, joint pain, or back pain. Neurological complaints as per CC and HPI.

This is 51 year old AAM. Patient has a history of HTN and DM, his current medications are glipizide 5 mg QD and lisinopirl 5 mg QD, but hasn't been taking them for more than one week. Patient reports neuralgia, tingling and prickling sensation at his bottom of his feet. Patient is a current resident at a Group Home and unable to afford any of the medications and needs community resources. Patient also report blurred vision, denies chest pain, SOB, N/V/ D,or fever. Patient is a current tobacco user, denies use of alcohol or illicit drugs.

This report is of a 20 year old man who is normally fit and well and is currently studying law, plays football for his university team but has noticed some changes in his health over the last couple of months. These changes include:

The patient is a 70-year-old gentleman who presented to the ED with the complaint of numbness, noticeable changes mental status and is also noted glucose of 43. His medical history is significant for long-standing history of insulin-dependent diabetes mellitus, chronic alcoholism, chronic pancreatitis, paroxysmal atrial fibrillation, he is on no coagulation because of a history frequent falls, coronary artery disease, past history of a CVA, as well as COPD. Review of the chart and discussion with the patient reveals that he attends a daycare center five days a week. He lives alone, his sister and his niece do his food shopping for him. He prepares his own meals and he gives himself his insulin on the weekend otherwise it’s given to him

The patient has a history of being hospitalized numerous times for exacerbation secondary to smoking,

A review of the medical records indicates that he suffers from multiple medical illness, which includes chronic COPD/heart failure for which he is oxygen dependent due to debilitating shortness of breath, chronic stable HTN-manage with medication, chronic stable hyperlipidemia-manage with medication, chronic poorly controlled anemia, chronic GERD, chronic phantom limb syndrome with pain- LAKA. He also has a history of DVT. He has had multiple hospitalization. His last hospitalization was in April for pneumonia. He is current on antibiotic therapy fro pneumonia.

This is 37 year old white male. Patient reports history of asthma, but unable to get his inhaler because of his current homeless situation. Patient reports his asthma is mild and well controlled at this time, he may use his inhaler 1 -2 time per month as needed. Patient has chronic bilateral knee joint pain, and lumbar neuopath. Patient is a non-tobacco user, denies use of alochol or illicit drug use. Patient denies chest pain, SOB N/V/ D, or fever.

This is 47 year old AAM. Patient reports he haven't been tiaking his insulin as prescribed. Patient stated that he at times he is fotgetting to take the insuline at all. Patient deneis chest pain, SOB, N/V/ D, or fever.Current pain 2/10, gas pain per patient. Patient is a current tobacco user, denies use oa alcohol, or illicit drug use. Denies dperessive moods.

The patient’s paternal grandparents are unknown, since his father was adopted. His father had history of heavy smoking (2 packs a day), hypertension, and died of ruptured brain aneurysm at the age of 47. On the maternal side, his grandfather died of lung cancer at the age of 75, otherwise no other medical problems. His maternal grandmother, who is 86 years old and still living, but with multiple medical problems, such as coronary heart disease,

Present concerns: Blood glucose levels go from really high one day to really low the next