Mrs. S, a 67-year-old patient, presented for her first visit to a primary care provider in more than 10 years. She appeared generally unwell. She stated she was told years ago that she was diabetic and said, “they wanted me to take medicine.” But she refused and insisted on “taking care of it naturally.”

Since Mrs. S never returned for further care, she was lost to follow-up. She came into the office because she was too tired to do her household chores. She had lost weight and was “really afraid there’s something wrong.”

Mrs. S lived in a rural area and was a widow with three grown children who resided too far away to see her regularly. “I don’t want to bother them,” she stated when asked if her family knew she was ill.

The only other health history she relayed was a broken tibia three years ago. “I just slipped, and it broke,” she stated. A local emergency department casted the break and she returned there requesting the cast be removed six weeks later.

Mrs. S’s initial assessment showed a height of 4’11” and weight of 98 pounds. Her blood pressure was 147/89mm/Hg, pulse 87 BPM, and respirations 16 per minute. Her posture was kyphotic. Breath sounds were clear bilaterally, and heart rhythm was regular with a 3/6 systolic murmur.

Her skin was dry and flaking. She had 2+ pitting edema of her ankles and feet. Nail beds and mucous membranes were pale.

This article originally appeared on Clinical Advisor