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History of Present Illness

History of Present Illness

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Published by egabe386

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Published by: egabe386 on Jan 21, 2010
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03/31/2013

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HISTORY OF PRESENT ILLNESS
This is a case of Mrs. LM, 48 years old, married, RC and a resident of 14BGumamela Extension, Carmen, Cagayan de Oro City with chief complaints of dizziness.Three weeks prior to admission, patient was admitted at Polymedic General Hospital for four days(4days) with the complaints of dizziness. On the fourth day of admissionpatient insisted for discharge, still with elevated blood sugar level which was notmanaged completely, patient wants to go home because it was her birthday and wantsto celebrate it at home. One week prior to admission, patient complained of dizzinessespecially during ambulation associated with occasional blurring of vision. The day prior to admission, patient reported of ingesting sweets like fruit salad, spaghetti and coca-cola during her birthday and on Christmas and New Year’s Eve, resulted to increase inblood sugar level- thus, prompting this admission.
MEDICAL RECORDS Year 2005
- was the first admission of patient at Madonna Hospital withcomplaints of dizziness and mild headache. She was diagnosed of having DM type II(NIDDM).
2008
- Patient had her check-up at Polymedic General Hospital to check her blood sugar level, it was found out that increases. LM also had complaints of sore throatthat made her too difficult to swallow solid foods and difficulty of breathing, expecting itwas a goiter. Ultrasound order was followed and impression shows no abnormality.Occurrence of round-shaped lesions developed at her upper and lower extremities,situating at interlacing spaces of fingers and toes, characterized as itchy, round-shapedlike skin lesions and reddened. According to LM, lesions get worsted when she ingested“penoy”; a food she loved to eat most, yet, she still continuously ate that food notminding the possible worsening of her lesions.
December 12, 2009
- patient again was confined at Polymedic General Hospitalfor four (4) days. Glimeperide 1mg tablet OD was the drug she maintained to take andapplied Eskinel Ointment to affected areas due to lesions.
January 5, 2010
- latest admission.
 
Heredo-familial Disease: Diabetes Mellitus, Maternal Side.HEALTH TEACHINGS
 
MEDICATION
> Glimeperide (Anti-Diabetic) 1mg tablet, to be taken once a dayafter eating breakfast, ideally at 6am in the morning.
Metformin (Mobic) (Anti-diabetic, Hypoglycemic agent) 15 mgtablet, to be taken once a day at 6am after eating breakfast.
Above drugs stimulates functioning of pancreatic beta cells tosecrete insulin, leading to direct drop in blood glucose.EXERCISE
Encouraged to perform regularly scheduled, moderate exerciseperformed for atleast 30 minutes most days of the week to promotethe utilization of CHO, assists with weight control and improvedcardiovascular fitness. Regular daily exercise was encouragedrather than sporadic exercise. Taught client that walking is a safeand beneficial form of exercise that requires no special equipment(except for proper shoes to protect the foot) and can be performedanywhere. Discussed to patient the benefits of exercising like itseffect of lowering blood glucose and reducing cardiovascular riskfactors. Exercise lowers the blood glucose by increasing the uptakeof glucose by body muscles and by improving insulin utilization, italso improves circulation and muscle tone. Emphasized to patientthat exercise alters blood lipid levels, increasing HDL anddecreasing total cholesterol and triglycerides levels.TREATMENT
OUT-PATIENT (CHECK-UP)
Patient was encouraged to have a follow-up check-upone week after discharge for evaluation of patient’s

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