, Patient Information
Name: Shane Peterson
Age: 31 years
Gender: Female
Setting: Primary Care Outpatient Clinic with Laboratory
Capabilities
Chief Complaint: Annual physical examination with concerns
about prediabetes risk and immunization status
Date of Visit: July 17, 2025
History of Present Illness (HPI):
Shane Peterson, a 31-year-old Caucasian female, presents to the
primary care clinic for her annual physical examination, expressing
concern about her risk for prediabetes due to a strong family history of
type 2 diabetes mellitus (T2DM) in her mother and maternal
grandmother, coupled with recent weight gain and lifestyle changes.
She reports mild fatigue over the past 6 months, particularly noticeable
in the late afternoon, which she attributes to her demanding desk job
and reduced physical activity. The fatigue is described as a general lack
of energy, rated 4/10 in severity, and does not interfere significantly
with daily activities but is bothersome. Shane denies associated