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Chief Complaint: “frequent urination” History of Present Illness: A 42-year-old man with a history of hypertension and substance use disorder comes to the primary care clinic for a mandatory health checkup. He is on court probation and living in a sober house that requires an intake physical. He complains of fatigue, frequent urination, excessive thirst, and blurred vision. He also reports gradual weight gain and tingling and numbness in his extremities, which make performing chores in the sober house difficult. His symptoms started about 2 years ago but have never been checked as he has been in and out of jail. His urination frequency and the volume output are getting worse. He drinks a lot of water (about half gallon daily), but there been has no improvement. He was concerned about these symptoms because his older brother was diagnosed with diabetes and both parents had died from complications of diabetes. Review of Systems: Positive for polyuria, polydipsia, paresthesia, blurred vision, fatigue, and weight gain. The patient reports dry skin, cuts, and bruises that are slow to heal, poor dentition, and abdominal bloating. He reports cravings and feeling down but denies significant opioid withdrawal symptoms. The ROS is negative for fever, chills, headaches, diarrhea, or vomiting. He denies any blood in the urine, dysuria, or urge incontinence and has no known history of sexually transmitted diseases. He has no chest pain, stomachache, backache, extremity pain or edema Relevant History: The patient has a medical history of hypertension (diagnosed 5 years prior but is not on antihypertensives). He also has a history of substance use disorder involving inhaled cocaine and occasional intravenous heroin use. He has no history of surgery or hospitalization. Both parents died in their early 60s from complications of diabetes. An older brother was diagnosed with type 2 diabetes at age 42 and prostate cancer at age 50. His younger sister is in good health. Since graduating from high school, he has worked as a truck driver, transporting beverages from Connecticut to Florida. He is planning to resume this job after completing his court probation. He is divorced and has two adult sons; both are in good health. For a long time, he depended on fast foods and never had time to exercise. He uses alcohol socially and smokes half a pack per day. He is unemployed and uninsured and has no support system except for the counselors at the sober house. Allergies: No known drug allergies. No known food allergies Medications: Methadone (50 mg daily) Physical Examination: Vitals: T 37°C (98.6°F), P 80, R 14, BP 150/88, WT 109 kg (240.3 lbs), HT 175 cm (68.9 in.), waist circumference 42 in., BMI 35.6. General: Well-developed and nourished middle-aged African American man in no acute distress. Psychiatric: Mildly anxious with a flat affect. Skin, Hair, and Nails: Skin dry with discoloration in body folds, no rashes, or bleeding tendency. Hair intact. Nails yellow and brittle. Head: Normocephalic. Eyes: Vision reduced bilaterally; pupils equal and reactive to light. Intraretinal hemorrhages, exudates, and cotton wool spots in both eyes. ENT/Mouth: Tympanic membrane pearly, grey with no fluid. Oral mucosa moist; dentition in bad repair with easy gum bleeding. Neck: Supple with no adenopathy or thyroid enlargement. Chest: No deformities noted. Lungs: Clear to auscultation bilaterally. Breasts: Non-tender; no lumps. Heart: RRR, without murmur, gallop, or rubs. Peripheral Vascular: Faint dorsalis pedis and posterior tibial pulses (1/4). Abdomen: Soft with no masses, organomegaly, or tenderness. Active bowel sounds in all four quadrants. Genital/Rectal: No penile or testicular abnormalities noted. Prostate within normal limits. Lymphatics: No axillary or inguinal lymphadenopathy. Musculoskeletal: No deformities, tenderness, or edema. Full range of motion in all joints. Neurologic: A&O×3; cranial nerves II to XII grossly intact. Reflexes present in all extremities. Mild defects on proprioception, vibration, and monofilament sensation. Point-of-Care Testing: Point-of-care laboratory testing revealed a random blood glucose of 340 mg/dL, 3+ glucose in urine, and no ketones. HbA1C was 8.8%. CASE QUESTIONS: Use the template provided to put your answers in 1. What is your assessment? List all differential diagnoses with positives and negatives and most likely final diagnosis (20%) 2. List your final diagnoses with ICD Codes with rationale ( may be more than one) (any final dx MUST be in the differential list above) (20%) 3. List any test/labs etc. that you are considering ordering be specific with your rationale (DO NOT PUT PHYSICAL EXAM AS A TEST) (20%) 4. Develop a comprehensive plan of care following the guide below (30%) a. Lab/tests identify which labs/test from your list above you are actually going to order at this visit b. Pharmacological Medications with calculated dosages and prescription (if needed) & non pharmacological treatments c. Patient Education (make sure this is written to the caregiver/patient in easy to understand working and using bullet points) d. Referrals (if needed) e. Follow up (next primary care visit, any other needed visits & reasons to go for emergency care) 5. Put references ONLY at the end of your assignment. List appropriate references used to diagnose and treat the patient using correct APA format. (10%)

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