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PATIENT PRESENTATION

Chief Complaint

“I’ve been waking up at night with a burning and tingling feeling in my fingers and toes.”

History of Present Illness

AP is a 64-year-old African American male who presents to the primary care clinic with a glucometer and medication list. The patient states that he has been adherent to his medications including insulin glargine, metformin, and his newly prescribed dulaglutide. The patient states that he has been attempting to “live healthier” by jogging 30 minutes at least four times a week and minimizing fast food. Of note, the patient reports experiencing distal symmetric peripheral neuropathy (DSPN) over the last year in the tips of his fingers and toes that wakes him up at night. The patient also states that he has been experiencing bloating, nausea, and vomiting over the past 6 months, however the vomiting has become more pronounced over the past 3 months, especially after eating meals.

Past Medical History

Type 2 diabetes (diagnosed 2001)

Hypertension

Dyslipidemia

s/p STEMI (2015)

Surgical History

CABG (2015)

Family History

Mother: history of T2DM, alive at 96 years of age

Father: HTN, deceased

No siblings

No children

Social History

Lives with wife of 30 years.

Drinks beer occasionally.

No cigarette or recreational drug use.

Immunization

Up to date

Insurance

Medicaid

Allergies

Aspirin (anaphylaxis)

Home Medications

  • Atorvastatin 40 mg, 1 tablet PO daily

  • Clopidogrel 75 mg, 1 tablet PO daily

  • Insulin glargine 100 units/mL, 32 units SC QPM

  • Dulaglutide 0.75 mg/0.5 mL, 0.75 mg SC once weekly (initiated 2 months ago)

  • Amlodipine 5 mg, 1 tablet PO daily

  • Levothyroxine 50 mcg, 1 tablet PO daily

  • Losartan 100 mg, 1 tablet PO daily

  • Metformin 1000 mg, 1 tablet PO bid

  • Metoprolol succinate, 1 tablet 50 mg daily

  • Multivitamin, 1 tablet PO daily

Physical Examination

Vital Signs

Temp 99.1, P 78, RR 18, BP 128/86 mmHg, Ht: 5′9″, Wt: 185 lbs

General

Well-nourished male.

HEENT

PERRLA, EOMI.

No sore throat, oral ulcers or pain, or trouble swallowing.

No change in hearing/vision.

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