5. 1 week prior to consulation the
patient had noticed the urinary
frequency is higher than the
normal, which is around 8 times a
day. The patient had diabetes so
she has done the FBS last week
and noted that the FBS and HbA1c
is higher.she usually takes
glycoside 600mg and metformin
500mg twice a day but there is no
relief. Hence decided to seek the
consultation today.
3 HISTORY OF PRESENT ILLNESS
6. • The patient has diabetes from past 12years
and uses glycoside 600mg and metformin
500mg twice a day.
• Patient also has hypertension from past 26
years and uses losartan 100mg once a day.
• No history of hosptalization
• No surgery
• No asthma
• Fully immunized
PAST MEDICAL HISTORY
4
7. FAMILY HISTORY
5
• Both the mother and the father has the
hypertension.
• No history of cancer
• No heredofamilial diseases
8. • Follows Filipino diet
• Walks regulary
• Non smoker
• Non alcoholic
• No known allergies
7 PERSONAL & SOCIAL HISTORY
9. • Ob score is G3P3
• Menarche is at 11 years of age
• Menopause is at 52 years of age
OB/GYN HISTORY
6
12. SKIN: no rashes/lesions, petechiae or ecchymosis are not
present, no melisma, no clubbing of nails, no cyanosis
is present. CRT≥ 2 sec
HEAD: Configuration- normocephalic
Hair- normal texture, symmetrical distributed, no deformities
Skull- size and contour is normal. No lesions, No
tenderness, No lumps
EYES: Eyes are symmetric in size, shape, colour and position.
Puffy eyes are present .No scars, erythema, or growths are
noted on lid or conjunctiva.
Cornea is clear; pupil is round, equal and black. Pinkish
palpebral conjunctiva, moist and without discharge.
EARS: External ear- symmetrical auricles, no lesions, no
masses, no tenderness
13. THROAT AND MOUTH
Inspection:
Teeth: Present and in good dentition
Tongue: No lesions
Gums and Mucosa: no swelling, bleeding, infection
Pharynx and Tonsil Fossa: normal
Palpation:
no tenderness in temporomandibular joint, sub
mandibular joint.
14. CHEST AND LUNGS:
Inspection -symmetric respiratory movements are full
without retractions, no paradoxic movement on
expiration, breathing is regular-19 per minute,
without apparent effort of accessory muscles.
Palpation - symmetrical chest expansion,
symmetrical tactile fremitus.
Percussion- there is no dullness heard and lung field
are resonant.
Auscultation –normal inspiratory and expiratory
pattern, no adventitious sounds, clear breath sounds
on both lung fields.
15. CARDIOVASCULAR SYSTEM:
Inspection- dynamic precordium, no lesions or rashes,
regular heart
Palpation- PMI at the apex, no heaves or thrills
noted.Percussion- No pericardial effusion
Auscultation-distinct heart sounds, no murmur, no
splitting of S1 and S2 sounds.
16. ABDOMEN
Inspection- symmetric without bulges, scaphoid,
smooth, no rashes and venous pattern is minimal,
peristalsis and pulsations visible. Umbilicus is small,
inverted, midline and without signs of inflammation or
herniation.
Auscultation: normal active bowel sounds (30clicks/
per minute), no presence of rubs or vascular bruits.
Percussion- tympanic sounds were noted, no
splenomegaly, no hepatomegaly
Palpation-No tenderness on the hypogastric area ,
no abdominal distention noted,
17. Extremities :The patient's arms are symmetric, well developed and well
formed. There are no scars or growths. The muscles are of normal bulk and
contour.
Neurological Examination:
Mental Status: conscious, coherent, not in respiratory distress.
Cranial Nerves :
CN I - able to perceive smell in both nostrils
CN II - corneal reflex positive, can read without eye glasses
CN III, IV, VI - EOM and pupillary reaction intact
CN V - sensory- senses cotton on both sides of face motor-contracts
muscles of mastication, jaw movements performed on both sides.
CN VII - Smiles appropriately, blowing elicited adequately.
CN VIII - Hearing appropriate, negative Weber, Rinne test.
CN IX - positive gag reflex
23. , METFORMIN
-Blocks production of glucose by
liver.
-Decreases resistance of cells to
insulin
-Dosage: 500mg - 850mg twice a
day (with meals)
, SULFONYLUREAS
-Glipizide
-Increases insulin production in
pancrease
-Dosage: 5mg once in a day.
-Must take before 1st meal
, DPP-IV inhibitors
-ORAL: Linogliptine, Sitagliptin.
-INJECTABLES: GLP-1A
-prevents breakdown of incretin
hormones.
-Increase insulin production in
pancreas and decreases insulin
resistance
-Dosage: Linogliptin 5mg once in a
day with or without meals
MEDICATIONS
25. Title WELLNESS PLAN FOR THE PATIENT
• Monitor your blood sugar levels regularly
• Adhere to your treatment plan
• Make lifestyle changes
• Manage stress
• Schedule regular follow-up appointments
• Get regular check-ups for complications
