clinical diagnostic work-up

clinical diagnostic work-up

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Diabetes Case Study

Chief Complaint

“My left foot feels weak and numb. I have a hard time pointing my toes up.”

History of Present Illness

D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 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 her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently.

Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report 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 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone.

Past Medical History

Seasonal allergic rhinitis (since her early 20s)
Breast biopsy positive for fibroadenoma at age 30
Gestational diabetes with second child 10 years ago
Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bath
Hypertension for 10 years
Past Surgical History

C-section 14 years ago

OB-GYN History

Menarche at age 11Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bath
Hypertension for 10 years
Last pap smear 3 years ago
Family History