"Ellen" is a 62 year old who is a house wife.  She has ahigh school diploma, but has spent her life raising children and being a wifeto "Jim" who work in insurance sales.  He is 65 and will be retiring soon,per her report.  Her 3 adult children are grown with kids of their own andlive out of state.  She is Caucasian and middle class.

Per the nurse's notes - Ellen weighs 162 lbs and is 5'2". She is seen annually for her type 2 diabetes that was diagnosed 5 yearsago.  She has hypercholesterolemia as well.  She takes metformin andLipitor.  Her last Hgb A1C was 8.5 mmol/mol. She is here today for herannual check up and follow on her diabetes.  Historically, she does not goto the doctor, except for the occasional acute illness, more often than annually. She refused seeing the diabetic educator when she was first diagnosed as shecited concern that her insurance wouldn't cover it.

The nurse reports to you that she tearfully confided in her at aprevious appointment, that she does not have much support from herhusband.  It appears that they are somewhat emotionally distant, but shehas also shared with the nurse that she does not have work history or educationfor her to support herself, thus feels like his retirement savings is her onlyresource for the future.

Ellen reports increased fatigue.  She volunteers at herchurch once/week with a children's program, but is contemplating giving thisup, because she is concerned about some numbness in her feet as well asshortness of breath and some chest tightness when she moves much.

Questions:

1) What is your plan to work up this patient?  Whatfurther questions do you need to ask her?  Is there additional data youneed to gather?

2) What would be your follow up plan for this patient?

3) What future health concerns might this patient need to be aware of?

4) What, specifically nutritionally, should you focus on with thispatient?  How would you pursue this nutritional work up?