Case file

A  34-year-old obese woman presents to your office with a chief complaint  of recurrent yeast infections and increased thirst. She also has noticed  increased urinary frequency, but she believes this is related to her  yeast infection. Over the last several years, she has gained more than  40 lb despite having tried numerous diets, most recently a  low-carbohydrate, high-protein and fat diet. The patient’s only other  pertinent history is that she was told to “watch her diet” during  pregnancy because of excessive weight gain. Her baby had to be delivered  at 38 weeks via cesarean section 2 years ago because he weighed more  than 10 lb (> 4500 g). Her family history is unknown, as she is  adopted. On physical examination, her blood pressure is 155/94 mm Hg,  her pulse is 72 beats/min, and her respiratory rate is 16 breaths/min.  Her height is 65 inches, and her weight is 223 lb (body mass index [BMI]  = 37.1 kg/m2).  On examination, she has darkened skin that appears to be thickened on  the back of her neck and moist, reddened skin beneath her breasts. Her  pelvic examination reveals a thick, white vaginal discharge. A wet  preparation from the vaginal discharge shows branching hyphae consistent  with Candida species. A urinalysis is negative for leukocyte esterase, nitrites, protein, and glucose.

Questions

What is the most likely primary diagnosis for this patient?

What physical findings are suggestive of the diagnosis and have implications for management?

What diagnostic studies should be ordered at this time? 

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