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GU: Denies pain with intercourse, or penile dischargeExtremities: No edema (+) radial pulsesMSK: Moves all extremities symmetrically with no significant weakness.Situation:40-year-old Hispanic male presents to the clinic with an abnormal blood sugar of 350 mg/dl 2hours post prandial with HgbA1C-13 g/dl, and elevated BP 150/95 and BMI 31 (obese).Background:Mr. Jones recently moved from Nevada, he works as an accountant. His PMH is unremarkable.Allergic to Azithromycin-rash, he takes MVI. Smokes 1ppd. His FH reveals HTN, DMII,hyperlipidemia and COPD. His wife was in about a week ago and treated for an URI.Assessment:Mr. Jones presents to the clinic with feeling malaise, nauseous with ongoing intermittentabdominal pain. He c/o “draining fatigue” with periods of lightheadedness and “almost passingout.” He is tachycardic with HR of 98 bmp and reported polyphagia. He has checked his BP athome and obtains high readings of 140-90-160/100 mm/hg.Differential diagnosis: Diabetes, Hyperthyroidism, HyperaldosteronismRecommendation:1.)DMII due to ethnicity (Hispanic), obese (BMI31), sedentary lifestyle (accountant),family history, age (40), HgbA1C 13, blood glucose 350 mg/dl, increased appetite,fatigue.Lifestyle changes (diet, exercise, nutritional consult)Diabetic education (glucometer use, insulin administration and hypo/hyperglycemia s/s)Metformin 1000 mg PO BID and Lantus 10 units SQ QHS2.)Primary HTN: consistent high blood pressure readings and family historyLisinopril 5 mg PO daily Follow up
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