Chief Complaint: BL is a 63 Y/O F retired elementary school teacher presenting to your primary care clinic today with complaint of constant burning, shooting pain in both of her feet which started becoming bothersome 3 months ago. It gets worse with the colder weather. She has tried acetaminophen with no relief! She is frustrated that the pain is impacting her ability to play with her grandkids. She is requesting a medication to help!  

Past Medical History:  

  • Essential hypertension 
  • Hyperlipidemia 
  • Type 2 diabetes x 15 years  
  • Generalized Anxiety Disorder  

Social History

  • Tobacco: Denies 
  • Alcohol: 1 glass of wine each night 
  • Recreational/Illicit: Denies 

Allergies: NKDA 

Pertinent Medications

  • Atorvastatin 40mg PO daily 
  • Canagliflozin 300mg PO daily 
  • Lisinopril 10mg PO daily 
  • Lorazepam 0.5mg PO daily PRN (using 1-2 doses per week) 
  • Metformin 1000mg PO 2x/day 


Weight: 81 kg 

Height: 160 cm 

Temperature: 98.8⁰F 

Systolic Blood Pressure: 124 mmHg 

Diastolic Blood Pressure: 76 mmHg 

Heart Rate: 66 bpm 

Respiratory Rate: 20 bpm 


Labs: CBC WNL, A1C=8.2%, Fasting Blood Glucose=140mg/dL, Creatinine WNL  


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