Ima Ferguson is a 56-year-old woman who presents to the clinic for
her yearly follow-up. The patient states that she feels fine and has
been in her usual state of health since last clinic visit. She also states
she is not sure why she has to come to clinic every year, indicating;
“There is nothing wrong with me.” The patient’s former primary
care provider has transferred to a different facility.

Morbid obesity (BMI 35.6 kg/m2)
HTN for 24 years
IFG diagnosed 1 year ago
Osteoarthritis bilateral knees
Leg cramping >three blocks walking
Seasonal rhinitis since childhood
Perimenopausal—has OB/GYN screening yearly

Father; age 71 with Type 2 diabetes, COPD, hypertension
Mother; age 71 with advanced Parkinson’s, “heart disease” diagnosed
at age 66
Patient does not have contact with her two younger brothers, their
medical history is unknown
Of her children, the only significant medical history is one daughter
with epilepsy

Patient is a widow; she has four adult children, one of whom lives
with her in her home along with his three children
Completed the 9th grade and provides day-care in her home
Denies alcohol, tobacco, or illicit drug use

Enalapril 10 mg po BID
OTC potassium gluconate 595 mg po PRN for leg cramps
Diphenhydramine 25–50 mg po PRN rhinitis
Ibuprofen 200 mg, 4 tabs po PRN HA, knee pain


Patient states that she is in her normal state of health. She denies
unilateral weakness, numbness/tingling, or acute changes in vision
(although over the course of the past year her vision prescription
has changed twice). She additionally denies CP, SOB, changes in
bowel habits, or po intake. She states that she has noticed more
frequent leg cramps that begin after walking shorter distances than
usual. In the past she was able to walk ~6 blocks without pain, but
now she gets cramping/pain walking just 2–3 blocks. She has also
noticed some swelling of the lower legs and feet, especially at the end
of the day and has had increasingly severe AM knee pain over the
past several months. She admits to taking ibuprofen most days of
the week.

 Physical Examination
Obese Caucasian woman in NAD

BP 147/92, P 83, RR 16, T 37.2°C; Wt 97 kg, Ht 5'5''

Warm and moist, normal turgor, acanthosis nigricans noted in
axilla bilaterally

PERRLA; EOMI; funduscopic exam deferred; TMs intact; oral
mucosa clear
Neck/Lymph Nodes
Neck supple, no lymphadenopathy, thyroid smooth and firm without
CTA bilaterally, no wheezes, crackles or rhonchi
Normal, slightly fibrotic, no lumps or discharge
RRR, no MRG, normal S1 and S2; no S3 or S4
(+) BS, no hepatosplenomegaly
1+ pedal edema, pulses 2+ throughout
No gross motor–sensory deficits present

 Labs (fasting)
Na 142 mEq/L Ca 8.6 mg/dL WBC 5.3 × 103/mm3 Lipid Profile:
K 4.9 mEq/L Mg 2.1 mEq/L Hemoglobin 11.5 g/dL TC 259 mg/dL
Cl 104 mEq/L AST 34 U/L Hematocrit 34.6% HDL 37 mg/dL
CO2 24 mEq/L ALT 31 U/L Platelets 151 × 103/mm3 LDL 167 mg/dL
BUN 21 mg/dL T. bili 0.5 mg/dL TG 280 mg/dL
SCr 1.3 mg/dL T. prot 7.1 g/dL
121 mg/dL

Yellow, clear, SG 1.003, pH 5.3, (–) protein, (–) glucose, (–) ketones,
(–) bilirubin, (–) blood, (–) nitrites, RBC 0/hpf, WBC 1/hpf, no
bacteria, 1–5 epithelial cells

Ms. Ferguson is an obese woman who presents to primary care clinic
for her yearly exam. Patient has OA and seasonal rhinitis, both of
which she self-treats with OTC medications. She also has uncontrolled
HTN, which is currently treated with an ACE inhibitor. IFG
was diagnosed last year. Patient has new onset anemia, hyperlipidemia,
renal insufficiency, and symptoms suggestive of possible PAD.
When questioned about exercise and dietary habits, the patient
immediately became very defensive about her weight and stated that
she is just “big boned” and has a “slow metabolism.”