While seeing patients with your preceptor, you have the opportunity to meet a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity. Last year her fasting lipid profile was acceptable. Her mother and brother have diabetes and hypertension. At prior visits, your preceptor has counseled her on a low calorie, low fat diet and recommended her to start an exercise program. With her full time job and four children, she finds it difficult to exercise, and she eats out most of the time. She is 67” tall and weighs 213lbs today, no current medication, takes fish oil supplements when she remembers. She doesn’t smoke, only drinks juice or soda with each meal, 3-4 cups of coffee per day. Today: BP 145/95mm Hg, TC 230 mg/dL, LDL 132 mg/dL, HDL 38 mg/dL, triglycerides 240mg/dL, fasting plasma glucose is 177 mg/dL; HgbA1C is 8.4mg/dL. Her examination is notable for acanthosis nigricans at the neck but otherwise is normal. MT is a 48 year old diabetic woman who presents with thickened, yellow toenails that are painful when she wears dress shoes. She also has some peeling of the skin on the soles of her feet. MT’s blood sugar levels are well controlled and last HbgA1C was 6.6mg/dL and fasting today 114mg/dL.  BP in office 120/84, P78, R 16, T 98.2, htg 66 inches, weight 165 lbs.  Medications are metformin 1000mg bid, Cimetidine 300mg tid, accupril 10mg po qd. Toenail culture comes back positive for fungus

Introduction

In this case study, we will be examining two patients: a 46-year-old woman with borderline hypertension and moderate obesity, and a 48-year-old woman with diabetes. Both patients present with specific symptoms and medical histories that require further evaluation and management.

Patient 1: 46-year-old Woman

Medical History and Risk Factors

The 46-year-old woman has a medical history notable for borderline hypertension and moderate obesity. Her family history is also significant, as both her mother and brother have diabetes and hypertension. Last year, her fasting lipid profile was within acceptable ranges. She has been advised by her preceptor to follow a low calorie, low fat diet and start an exercise program, but she finds it difficult to exercise due to her full-time job and four children. Additionally, she frequently eats out.

Physical Examination Findings

During the physical examination, acanthosis nigricans is observed at the neck, indicating a possible metabolic abnormality. However, the rest of the examination is noted to be normal.

Laboratory Results

Several laboratory values are obtained for this patient. Her blood pressure is measured as 145/95 mm Hg, indicating hypertension. Her total cholesterol (TC) level is 230 mg/dL, which is above the recommended range. The low-density lipoprotein (LDL) cholesterol level is 132 mg/dL, also considered high. The high-density lipoprotein (HDL) cholesterol level is 38 mg/dL, below the optimal range. Triglyceride levels are measured at 240 mg/dL, indicating increased risk for cardiovascular disease. Most significantly, her fasting plasma glucose level is 177 mg/dL, which exceeds the threshold for diabetes diagnosis. The glycated hemoglobin (HbA1c) level is 8.4%, confirming poor glycemic control.

Patient 2: 48-year-old Woman

Medical History and Risk Factors

The 48-year-old woman has a diagnosis of diabetes. Her blood sugar levels have been well controlled, as evidenced by a previous HbA1c level of 6.6% and a fasting blood glucose level today of 114 mg/dL. She is currently taking metformin, cimetidine, and accupril as medications.

Symptoms and Physical Examination Findings

MT presents with thickened, yellow toenails that are painful when she wears dress shoes. She also experiences some peeling of the skin on the soles of her feet. Although her blood sugar levels are well controlled, these symptoms could indicate complications related to her diabetes.

Management Considerations

The positive toenail culture for fungus suggests a fungal infection, which may require treatment. Additionally, the peeling of the skin on the soles of her feet could be indicative of diabetic neuropathy.

Conclusion

In conclusion, these case studies highlight the importance of thorough evaluation of patients with multiple risk factors such as hypertension, obesity, and diabetes. The 46-year-old woman requires further management of her elevated blood pressure, dyslipidemia, and uncontrolled hyperglycemia, while the 48-year-old woman should receive treatment for her toenail fungus and evaluation for diabetic neuropathy. Both patients would benefit from lifestyle modifications including appropriate diet and exercise recommendations. The comprehensive management of these patients is essential to mitigate the long-term complications associated with their medical conditions.