Sally Martin, (DOB March 7th) 24 year old female, presents with complaints of abnormal menstrual cycles, extreme fatigue, occasionally “feeling down” and muscle cramping in both legs in the late afternoon. She has gained 20 pounds over the past 2 years despite a “healthy” diet and exercising at least 4 days each week.
PMH:
Allergies – none known
Current medications – none
Surgery/hospitalizations – childbirth at 22 years old (uncomplicated vaginal delivery). Gravida 1 Para 1
Medical history – gestational diabetes during pregnancy; elevated serum triglycerides in last year.
OB/GYN – LMP – 15th of last month; last Pap – “Whatever they might have checked during pregnancy or postpartum visit.”
Social history: no tobacco, no alcohol intake; drinks about 3 to 4 cups of coffee daily, 2 glasses of sweet tea, and occasionally a Mt. Dew
Family history: Father with hyperlipidemia, mother in good health, siblings in good health
Exam:
Vital signs: BP 102/80, HR 92, RR 18, T 98.8
Height 64”; weight 164 lbs.
General appearance: pale for ethnicity, well groomed, slightly dry skin with no visible lesions
HEENT: WNL; thyroid not palpable
Lungs: CTA in all lobes
Heart: RRR, no murmur or gallop, S1/S2 auscultated
Neurologic: AAO x3; DTRs WNL
Diagnostics:
CBC: H/H 14.4/39.1; WBC 5.5; MCV 103; MCH 36.3; MCHC 35.3; platelets 206; RBCs 4.2
Urine Hcg: negative
CMP: WNL
Lipids: total cholesterol 251, triglycerides 256, LDL 198
HgB A1C 5.4
Thyroid: TSH 77.09; T3 24.8; Free T4 0.3
Based on your history and lab results, what will you prescribe? Make sure to include your diagnosis with ICD10. When will you need to follow-up with Ms. Martin? What do you plan to recheck when she returns for a follow-up visit