Case Study Scenario Chief Complaint J.T. is a 48-year old male who presents to the primary care clinic with fatigue, weight loss, and extreme thirst and increased appetite. History of Present Illness ... J.T. has been in his usual state of health until three weeks ago when he began experiencing symptoms of fatigue, weight loss, and extreme thirst. He reports that he would like to begin a walking program, but he feels too fatigued to walk at any point during the day. Now he is very concerned about gaining more weight since he is eating more. He reports insomnia due to having to get up and urinate greater than 4 times per night. Past Medical History • Hypertension • Hyperlipidemia • Obesity Family History • Both parentsdeceased • Brother: Type 2diabetes Social History • Deniessmoking • Denies alcohol or recreational druguse • Landscaper Allergies • No Known DrugAllergies Medications • Lisinopril 20 mg once daily bymouth • Atorvastatin 20 mg once daily bymouth • Aspirin 81 mg once daily bymouth • Multivitamin once daily bymouth Review of Systems • Constitutional: - fever, - chills, - weightloss. • Neurological: denies dizziness ordisorientation • HEENT: Denies nasal congestion, rhinorrhea or sorethroat. • Chest: + Tachypnea. Deniescough. • Heart: Denies chest pain, chest pressure orpalpitations. • Lymph: Denies lymph nodeswelling. General Physical Exam • Constitutional: Alert and oriented male in no acutedistress • Vital Signs: BP-136/80, T-98.6 F, P-78, RR-20 • Wt. 240 lbs., Ht. 5'8 [Show More]
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