PATIENT CASE I History of Present Illness: Patient G.O., a 52 y/o white male in
ID: 6179 • Letter: P
Question
PATIENT CASE IHistory of Present Illness:
Patient G.O., a 52 y/o white male in for routine yearly physical exam and evaluation of hypertension, diabetes mellitus, chronic back pain, lipid disorder and peripheral neuropathy. He has generally felt fine except for recurrent episodes of malaise and fatigue over the past three or four months. He stresses strict compliance with all medicines and has a good history of compliance. He says his finger stick Tracer glucometer has been showing his fasting blood glucose levels running 135-150 two weeks ago. He checks his sugars usually once or twice weekly. He also says his home blood pressures have shown 135/80 to 140/90 on a regular weekly basis.
Past Medical History
Childhood Illnesses: Usual childhood illnesses.
Adult Illnesses: Hypertension 25 years; non-insulin dependent diabetes mellitus 22 years (controlled by diet for the first ten years); chronic back pain that waxes and wanes from muscle spasms arising from a motor vehicle accident at age 18. Was hospitalized 11 months ago due to a severe case of influenza resulting in noncompliance with medications that led to dangerously elevated blood pressure, heart rate, and blood sugar. Past history of ingrown toenails.
Trauma: Motor vehicle accident at age 18 w/ resulting back pain.
Surgeries: Patient had 2 smallest toes on left foot amputated 3 years ago to control gangrene. Patient had laser surgery on both eyes 7 years ago to correct retinopathies.
Habits: (-) EtOH, (-) smoking, light sleeper, drinks 3 cups of coffee per day and occasional diet cola.
Immunizations: Gets flu shots annually. Can't remember date of last tetanus booster.
Family History: Father died from a blood clot to the brain from a "failed pacemaker" at age 55. Unknown if he had a history of hypertension or lipid disorder. Mother 78 y/o and in good health except for hip fracture five years ago and osteoporosis with a Dowager's hump. No family history of diabetes. No sibs.
Social History: Married 28 years w/ two college age children. Lives at home w/ wife. High school graduate + 2 years college. Owns a successful business and only eats once or twice daily due to his busy work schedule. He has not followed his proper diabetic diet in over six months. No financial or personal complaints. Aetna health insurance through his group policy at work.
Review of Systems
General Appearance: No complaints of fever or chills. Reports feeling run down for several months.
Head: No headaches or dizziness.
Eyes: Denies diplopia, blurring, pain or discharge.
Ears: Denies past infections, tinnitus, pain or discharge. Reports normal hearing.
Nose: Chronic congestion and sinusitis during allergy season.
Mouth and throat: Complains of dry mouth. No history of thyroid disease. No recent sore throats.
Chest: No cough, no pain, shortness of breath, wheezing, hemoptysis, or sputum production. Last chest x-ray at previous annual physical examination (normal). Last skin test for tuberculosis at previous annual physical examination (nonreactive).
Cardiovascular: Denies chest pain, dyspnea on exertion. No history of palpitations or heart murmur. No history of rheumatic fever as a child, claudication or Raynaud's phenomenon. Complains of lightheadedness. Reports history of hypertension.
Gastrointestinal: Good appetite, but eating is irregular. Poorly compliant to diabetic diet. Complains of occasional constipation. No complaints of heartburn, nausea, vomiting. Doesn't generally take antacids or laxatives.
Genitourinary: No history of sexually transmitted diseases, urinary tract infections, or urethritis, denies polyuria.
Neuromuscular: Reports mild tingling sensation and numbness in feet. Denies tingling in hands.
Has chronic low back pain. No history of psychiatric illness.
Skin: No photosensitivity or rashes.
Physical Examination
General appearance: Well developed, well nourished white male, no apparent diseases; appears stated age of 52 y/o.
Vital Signs: 140/92 sitting, 120/80 standing, pulse 97, respiration 20, temperature 98.4, 198 lbs, 72".
Skin, hair and nails: No abnormal pigmentation, scars, bruises, or skin turgor. Minor ulceration and cracking on feet.
Nodes: None palpated.
Head: Normal cephalic, atraumatic.
Eyes: Pupils equal, round, reactive to light and accommodating. Funduscopic reveals some
arterial/venous nicking w/ preproliferative retinopathy changes. No exudates, papilledema or
hemorrhages.
Ears: Normal.
Nose: Normal.
Mouth and throat: Normal dentition with old dental repairs noted. No lesions.
Neck: Supple. No thyroid enlargement appreciated. No jugular venous distension.
Chest and lungs: Normal.
Heart: Regular rate and rhythm w/ borderline elevated rate. No murmurs, rubs or gallops.
Abdomen: Normal.
Rectum: Unremarkable.
Extremities: Pulses symmetric bilaterally. Joints with good mobility; no deformity. Normal muscle mass.
Back: Normal contour of spine. Slight tenderness in lower back. No sacral edema.
Neurologic:
Mental Status: Alert; normal memory, judgement, mood.
Cranial Nerves: Intact.
Cerebellum: Normal gait, finger-nose, heel-shin, no tremor.
Motor: Normal grip strength, Deep tendon reflexes (+).
Sensory: Reduced sensitivity to touch, pain, vibration, heat, cold, in feet and hands.
Medication Use History
Rx: Glynase 6 mg BID.
Cardizem CD 240 mg QD.
Tenex 2 mg QD.
Elavil 50 mg qHS for sleep and back pain.
Zocor 20 mg qAM.
Dyazide 1 cap q week.
OTC: Ibuprofen 200 mg 1-2 tabs prn pain.
Icy Hot to shoulder hHS.
Vit E 400 IU QD.
Allergies: No known drug allergies.
HERE IS THE QUESTION:
Give one effect that an amino acid or amino acids in blood may have on any of G.O.’s medical conditions. Explain why or how.
Explanation / Answer
Insulin deficiency produced complex alterations in the concentrations of amino acids in plasma and heart muscle; the concentrations of some (alanine, valine, leucine and isoleucine) increased, others decreased and a small number were unchanged. The complexity of the results may in part be attributed to the diverse hormonal and metabolic changes that accompany diabetes.
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