1456 - 38-year-old male reports to the clinic for an annual physical examination and to establish care. The client reports no acute concerns but does admit to gaining a few pounds over the past several months. The client reports having decreased physical activity. He reports his dietary habits have changed because of his job, where he relies on fast food for breakfast and lunch. On assessment, the client is alert and completely oriented to person, place, and situation. The skin is warm and dry—patches of darkening and thickening of the skin around the skin folds. Lung sounds are clear; S1/S2 heart tones are auscultated. Peripheral pulses palpable, 2+. Bowel sounds are active in all quadrants. He denies any dysuria and reports his sex drive has decreased over the past several months. He reports occasional constipation, which causes him to use stool softeners. He reported no medical or surgical history besides an appendectomy four years ago. His parents are living, his mother is being treated for ovarian cancer, and his father has hypothyroidism and had a myocardial infarction two years ago. He recently started taking daily over-the-counter aspirin because of his father's cardiovascular disease. He takes a multivitamin 'when he remembers.' He is separated from his wife and currently going through what he describes as a bitter divorce which has been 'stressing him out.' He has one child. He denies using tobacco products but drinks one to two glasses of wine weekly. Current weight 269 pounds (122.27 kilograms); Body Mass Index 29. 41 inches (102 cm) waist size. Oral temperature 98.6°F (37° C) Pulse 92 Respiratory Rate 17 Blood Pressure 141/92 mm Hg Pulse oximetry 96% on room air

Basic Metabolic Panel (fasting)

• Serum calcium 9.6 mg/dL (2.39 mmol/l) [9.0-10.5 mg/dL (2.24 - 2.61 mmol/l)
• Serum chloride 94 mEq/l (94 mmol/l) 90 to 110 mEq/L (90 -110 mmol/l)
• Serum glucose 126 mg/dL (6.99 mmol/l) 70-110 mg/dL (3.88 - 6.10 mmol/l)
• Serum potassium 4.2 mEq/l (4.2 mmol/l) 3.5 to 5.0 mEq/l (3.5 to 5.0 mmol/l)
• Serum sodium 136 mEq/l (136 mmol/l) 135 to 145 mEq/l (135 to 145 mmol/l)
• Serum creatinine 0.9 mg/dl (79.5 mcmol/l) 0.6 to 1.1 mg/dl (53 to 106 mcmol/l)
• Blood urea nitrogen 19 mg/dl (6.78 mmol/l) 10 to 20 mg/dl (3.57 to 7.14 mmol/l)

Lipid Panel (fasting)

• Total cholesterol 235 mg/dl (6.07 mmol/l) [less than 200 mg/dl (<5.18 mmol/l)]
• High-density lipoprotein (HDL) 35 mg/dl (0.91 mmol/l) [more than 45 mm/dL (>0.75 mmol/L) for men; more than 55 mg/dL (>0.91 mmol/L) for women]
• Low-density lipoprotein (LDL) 135 mg/dl (3.49 mmol/l) [less than 130 mg/dL (< 3.36 mmo/l)]
• Triglycerides 299 mg/dL [Females: 35-135 mg/dL or 0.40-1.52 mmol/L; Males: 40-160 mg/dL or 0.45-1.81 mmol/L]

Thyroid Panel

• Triiodothyronine (T3) 87 ng/dL (1.3 nmol/L) [80-200 ng/dL (1.2-3 nmol/L)]
• Thyroxine (T4) 5.4 µg/dL (69 nmol/L) [5.4-11.5 (69-148 nmol/L)]
• Thyroid-stimulating hormone (TSH) 4.0 µIU/mL (4.0 mIU/L) [0.45-4.5 µIU/mL (0.45-4.5 mIU/L)]

1345 - Client presents for a one-week follow-up appointment to review his laboratory results. The client reports no acute complaints, denies pain, and states he has been checking his blood pressure while at the grocery store "with the top number being in the 150s". Oral temperature 98.6°F (37° C) Pulse 88 Respiratory Rate 16 Blood Pressure 143/91 mm Hg Pulse oximetry 95% on room air. Current weight 270 pounds (122.72 kilograms); Body Mass Index 29. 41 inches (102 cm) waist size.

1355 - One-week follow-up appointment with a 38-year-old male. Labs show serious metabolic derangements, including high fasting blood glucose and hyperlipidemia. VS shows essential hypertension. Diagnosis - 1. essential hypertension 2. metabolic syndrome. Will perform additional diagnostics and follow up with the client in six weeks.

• 12-lead electrocardiogram (ECG)
• atenolol 25 mg by mouth daily
• pitavastatin 1 mg by mouth daily
• fenofibrate 45 mg by mouth daily with food