“My left foot feels weak and numb. I have a hard time pointing my toes up.”
History of Present Illness
D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently.
Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone.
Past Medical History
Past Surgical History
C-section 14 years ago
Review of Systems
Admits to recent onset of fatigue
Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speaking
Denies chest pain, palpitations, and difficulty breathing while lying down
Denies cough, shortness of breath, and wheezing
Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation
Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence
Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling or numbness in arms or legs prior to this episode
Has never had a seizure and denies recent headaches
Has a rash under her bilateral breast and in groin area
Denies a history of goiter and has not experienced heat or cold intolerance
BP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20 non labored, WT 210 lbs
What you need to do:
The paper should be no more than 3–5 pages (not including the title page and reference pages.
use APA 6th Edition format
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