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Benjamin is a 58-year-old government official with a 2-year history of type 2 diabetes (T2D) and stable angina after a myocardial
infarction (MI) 4 years ago which required a stent in the anterior descending coronary artery. He has come to the primary
care office today for his annual check-up and to review his recent laboratory results. His medical history and the results
of his physical exam and laboratory tests are shown in Table 1.
You note that his blood pressure (BP) is 148/98 mmHg despite adherence to an angiotensin converting enzyme inhibitor and beta-blocker.
His glycated hemoglobin (HbA1c) is 6.8% on metformin. His kidney function is good, with no sign of albuminuria.
Table 1. Benjamin’s Medical Record
History |
Findings |
---|---|
Medical |
T2D x 2 years, stable angina from MI 4 years ago, HTN x 10 years, dyslipidemia x 7 years, and obesity |
Current medications |
Metformin 1000 mg twice daily, lisinopril 20 mg/d, metoprolol 100 mg twice daily, simvastatin 20 mg/d, ezetimibe 10mg/d, acetylsalicylic acid 100 mg/d |
Social/occupational |
Government official, married, lives with wife and dog; non-smoker, non-drinker; has 2 adult sons. Sedentary lifestyle. High-fat diet, poor intake of fruit, vegetables, and whole grains |
Physical Exam |
Findings |
Vital signs |
BP: 148/98 mmHg HR: 78 bpm |
Body measurements |
Weight: 85.2 kg, waist circumference: 108 cm, BMI: 32 kg/m2; class 1 obesity |
Extremities |
No edema |
Neck |
No distended neck veins |
Heart |
LVEF: 60% |
Lungs |
No rales |
Abdomen |
Soft, nontender |
CBC |
Results |
|
Normal |
Metabolic Panel |
Results |
FPG |
122 mg/dL |
HbA1c |
6.8% |
Lipid panel |
LDL: 75 mg/dL; HDL: 35 mg/dL, TG: 155 mg/dL |
eGFR |
91 mL/min/m2 |
UACR |
9 mg/g |
BMI, body mass index; CBC, complete blood count; eGFR, estimated glomerular filtration rate; FPG, fasting plasma glucose; HDL, high density lipoprotein; HTN, hypertension; HR, heart rate; LVEF, left ventricular ejection fraction; LDL, low density lipoprotein; TG, triglycerides; UACR, urine albumin-to-creatinine ratio.