CHIEF COMPLAINT: "I'm here to check the results of my urine test." HPI: Allen Jackson is a 62 yo man with diabetes melitius who visited his PCP 2 weeks ago for a routine examination. His laboratory tests revealed a serum creatinine of 1.6 mg/dL, which was elevated over his baseline of 1.3 mg/dL 1 year ago. A 24-hour urine collection was performed last week, and he was scheduled to return to the clinic today for further evaluation of his kidney function. He states that he has not been checking his blood glucose at home because his machine is not working. However, he asserts that he has been taking his medications faithfully. PMH: Type 2 DM x 16 years(failed glyburide, currently on insulin) HTN x 2 years Hypercholesterolemia x 5 years(non-compliant with diet) FH: His father had DM and dies in an MVA 3 years ago; his mother had HTN and died at the age of 50 secondary to MI. SH: A high school teacher, married with 1 child (24 yo). No tobacco use but occasional alcohol (2 to 3 beers on weekend). Usual diet includes eggs and sausage for breakfast, turkey sandwiches for lunch, and pasta and salad for dinner. ROS: Occasional headaches; no c/o polyuria, polydipsia, polyphagia, sensory loss, or visual changes. No dysuria, flank pain, hematuria, pedal edema, CP, or SOB. MEDS: Humulin N35 units SQ Q am, 20 units SQ Q pm Humulin R 12 units SQ Q am, 8 units Q pm Hydrochlorothiazide 25 mg po QD(x 2 years) Pravastatin 40 mg po QD(x 5 years; on current dose for 1 year) Acetaminophen 650 mg po Q6H PRN headaches ALLERGIES: Sulfa (anaphylaxis) PE: GEN: The patient is a moderately obese African-American man in NAD VS: BP 150/95, sitting and standing in both arms, HR 76, RR 16, T 97.2 C; Wt 88.5 kg, Ht 68 in. SKIN: Warm, dry HEENT: PERRLA, EOMI, fundi revealed microaneurysms consistent with diabetic retinopathy, no retinal edema or vitreous hemorrhage. TMs intact. Oral mucosa moist with no lesions NECK/LN: Supple; no cervical adenopathy or thyromegaly LUNGS/THORAX: CTA CV: Heart sounds are normal ABD: NT; no masses or organs palpable. No abdominal bruits. GENT/RECT: Not done. MS/EXT: No CCE NEURO: A&O x3; CNs intact; normal DTRs LABS: Na 140 mEq/L K 4.8 mEq/L CL 108 mEq/L CO2 26 mEq/L BUN 27 mg/dL SCr 1.6 mg/dL Glu 194 mg/dL HgbA1C 9% Hgb 12.2 g/dL Hct 36.5% WBC 10.8 Plt 148 Ca 9.3 mg/dL Phos 2.5 mg/dL Uric acid 6.9 mg/dL UA (1 week ago) 1+ glucose, (-) ketones, >3+ protein, (-) leukocyte esterase & nitrite; (-) RBC; 2-5 WBC/hpf
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