Mr Jones, a 60 year old African American male, presents to the office for a planned 6
month follow up visit for hyperlipidemia and weight loss. At the previous visit, Mr Jones
was educated on lifestyle recommendations. He reports he has been following dietary
recommendations “as good as he could remember” and exercising as
recommended. He reports some new concerns today. He reports that he has been
experiencing increased fatigue for about the last 10 weeks. He has a health club
membership and attends 3-4 times a week. He walks on the treadmill at least 30
minutes as you directed and lifts weights but he has not lost any weight, in fact he has
gained 7 pounds. He doesn’t understand what he is doing wrong and is requesting more
education and suggestions for weight loss. He reports that exercise makes him even
more hungry and thirsty. He requests further evaluation for his fatigue. He reports he
has to go to the bathroom more often- he is waking up during the night to urinate and
seems to be urinating more frequently during the day. This has been occurring for about
2 months. No other GU symptoms such as painful urination, dribbling or changes in
sexual functionhave been noted.
Current medications: Simvastatin, 10 mg daily, Tylenol 500 mg 2 tabs in AM for knee
pain. Daily multivitamin and turmeric.
PMH: Hyperlipidemia. Right knee OA (for 2 years) Had chicken pox as a child.
Vaccinations up to date. Colonoscopy WNL 7 years- to repeat at 10 years
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. Business executive, job requires frequent travel. Drinks 1-2 beers daily.
Former smoker, quit 5 years ago. No reports illicit drug use. No CBD use.
Allergies: allergic to Bactrim, strawberries, cats and pollen. No latex allergy
Vital signs: BP 119/77; pulse 80, regular; respiration 16, regular
Height 5’9.5”, weight 210 pounds
General: AA male in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT: head normocephalic. Hair thinning distribution across crown. Eyes without
exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light
reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx
moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior
and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no
organomegaly; no abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.
GU: bladder nontender upon palpation.
Rectal: DRE: prostate not enlarged, rubbery texture, no nodules noted. Guaic negative
Labwork: (fasting labs drawn this morning)
CBC: WBC 6,300/mm3 Hgb 13.8 gm/dl Hct 42% RBC 4.6 million MCV 93 fl MCHC
34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.006, Leukocyte esterase negative, nitrites negative, 1+ glucose;
negative protein; negative ketones
GFR est non-AA 99 mL/min/1.73
GFR est AA 101 mL/min/1.73
Total protein 7.6
Bilirubin, total 0.5
Alkaline phosphatase 72
Anion gap 8.10
Hemoglobin A1C: 6.9 %
TSH: 2.30, Free T 4 0.9 ng/dL
Cholesterol: TC 202 mg/dl, LDL 134 mg/dl; VLDL 36 mg/dl; HDL 32mg/dl, Triglycerides
EKG: normal sinus rhythm