- 62-year-old female patient presented with complaints of increased urination, thirst, hunger, tiredness, and constipation. - She has a history of hypertension for one year and was diagnosed with uncontrolled diabetes and peripheral neuropathy. - Her blood sugar was 489 mg/dL, HbA1c was 14.0%, and blood pressure was 160/100 mm Hg. - She was treated in the hospital with insulin, oral hypoglycemic drugs, and antihypertensives. Her blood pressure and symptoms improved over three days. - She was discharged on medications including oral hypoglycemics and antihypertensives with counseling on lifestyle modifications like diet, exercise, and avoiding

2. PATIENT DEMOGRAPHIC
DETAILS:
Name: XYZ DOA: 26/03/2013
Age : 62yr Unit : A (Med)
Sex : Female
Complaints on Admission:
C/O: Polyuria, Polydipsia, Polyphagia and
generalized tiredness, malaise and
constipation.

3. PAST MEDICAL HISTORY:
k/c/o type HTN since one year

4. • SOAP analysis:
• S- Subjective findings
• O- Objective findings
• A- Assessment
• P- Planning

5. Subjective:
C/o: Polyuria, Polydipsia, Polyphagia
C/o: Generalized tiredness, malaise and constipation.
k/c/o HTN since one year

6. Objective:
• Lab data:
RBS : 489 mg% (180 to 210 mg%)
HbA1C: 14.0%(4.5-5.6%)
BP: 160/100 mm Hg(120/80)
Specific gravity: 1.045 (1.001-1.035)
Hb: 11.9 gm%

7. Assessment:
From the subjective and objective evidence it is confirmed
that the patient is suffering from HYPERTENSION /
UNCONTROLLED DM / PEROPHERAL NEUROPATHY

8. Goals:
Disease Specific:
Near normal glycemia reduce the risk of
microvascular and microvascular disease risk.

9. Assessment of previous therapy: NS
Assessment of current therapy
DRUGS DOSE ROUTE FREQ
UENC
Y
DAY-1 2 3 4
T.ENVAS 5Mg PO O.D + + + +
T.GANATON 50Mg PO B.I.D + + + +
T.METHYLCOBALAMINE 1500Mg PO T.I.D + + + +
INJ.H.INSULATARD 10 UNITS I.V B.I.D + + + +
SYP.CREMAFFIN 1TSP PO T.I.D + + + +
X-MET 500Mg PO H.S + + + +
INJ.H.ACTRAPID 8 UNITS I.V B.I.D + + + +

10. Progress Chart:
• Day 1: No fresh compliant, B.P: 120/80 mm Hg,
Hb: 11.7gm%
• Day 2 : No fresh compliant, B.P: 130/70 mm Hg,
• Day 3 : B.P: 120/80 mm Hg

11. Planning:
• Discharge medications:
• T.ENVAS---O.D
• T.GANATON---B.I.D
• T.METHYLCOBALAMINE----T.I.D
• X-MET---B.I.D
• PREGABILIN---

12. Monitoring parameters:
Insulin: Weight gain, Hypoglycemia.
Enalapril: Headache, Oliguria, Hypokalemia, Fluid and electrolyte
imbalances
Pregabilin: hallucinations,dysphagia,oliguria
X-met: hypoglycemia, cholestatic Jaundice
Paraffin:Anal irritation, vasospasm

13. Patient Counseling:
• Cut down on sugar and sugary foods. Use sugar free, low
sugar.
• Eat regular meals choose high fibre varieties of food: whole
meal bread, cereals.
• Try to cut down on fat particularly saturated fats.
• Try to eat at least five portion of fruits every day.
• Avoid fruits like Mango, Banana, Jack fruits.
• Exercise reduces cardiovascular mortality, improves functional
capacity, and thus is an important lifestyle modification.
• Alcohol and Smoking cessation.