Chelsea Joy Beleno

BSN 3A

Midterm Requirement 3

Case Presentation
● A 50 years old female teacher visited Services Hospital Lahore with the complaints of
headache, nausea, drowsiness, blurred vision, and fatigue. She was experiencing those
symptoms last 2 months. She was also suffering from diabetes mellitus type 2 since 2
years. She had recently diagnosed with hypertension.

Past Medical History

● Patient was suffering from Diabetes Mellitus Type 2 since 2 years.
● She was using vildose (vildagliptin) 50mg OD since 2 years.

History of Present Illness

● She was complaining of headache, nausea, drowsiness, blurred vision and fatigue.

General Examination
● Weight: 72 kg
● Height: 5 feet 2 inches
● BP: 150/100 mmHg
● Pulse: 88 beats/ min

Lab Findings
● Blood glucose level:
○ Fasting = 140 mg/dl
○ Random= 180 mg/dl

Medication Therapy
● Brands Generics Strength Frequency
● Monitor for side effects of Bisoprolol Fumarate 5mg OD
● Triforge Amlodipine/Valsartan/Hydrochlorothiazide 5/160/12.5mg OD
● Sitamet Sitagliptin + Metformin HCl 50mg +1000mg BD

Focus (F), Data (D), Action (A), and Response (R)

F-DAR for Diabetes Mellitus Type 2
Date/Hour Focus Progress Notes

11/4/2021 Diabetes Mellitus Type 2 D:

● Patients is suffering from diabetes
4:00 pm mellitus type 2 for 2 years

A:
● Patient is taking vildose (vildagliptin)
50mg OD for 2 years
● Sitamet Sitagliptin + Metformin HCl
50mg +1000mg BD

R:
● Patient had been careful since she
was diagnosed

F-DAR for Hypertension

Date/Hour Focus Progress Notes

11/4/2021 Hypertension D:
● Patient had recently diagnosed
4:00 pm with hypertension

A:
● Patient is taking Bisoprolol
Fumarate 5mg OD

R:
● Nurse monitors any for the side
effects of Bisoprolol Fumarate
● Patient had recently did something
to trigger her blood pressure to go
high

F-DAR for Headache

 Date/Hour Focus Progress Notes

11/4/2021 Headache D:
● Patient has been experiencing for
4:00 pm the last 2 months

A:
● Patient went to the hospital to
report the complaint

R:
● Patient will further understand the
cause of this condition

F-DAR for Nausea

Date/Hour Focus Progress Notes

11/4/2021 Nausea D:
● Patient has been experiencing for
4:00 pm the last 2 months

A:
● Patient went to the hospital to
report the complaint

R:
● Patient will further understand the
cause of this condition

F-DAR for Drowsiness

Date/Hour Focus Progress Notes

11/4/2021 Drowsiness D:
● Patient has been experiencing for
4:00 pm the last 2 months
A:
● Patient went to the hospital to
report the complaint

R:
● Patient will further understand the
cause of this condition

F-DAR for Blurred vision

Date/Hour Focus Progress Notes

11/4/2021 Blurred vision D:

● Patient has been experiencing
4:00 pm for the last 2 months

A:
● Patient went to the hospital to
report the complaint

R:
● Patient will further understand
the cause of this condition

F-DAR for Fatigue

Date/Hour Focus Progress Notes

11/4/2021 Fatigue D:
● Patient has been experiencing
4:00 pm for the last 2 months

A:
● Patient went to the hospital to
report the complaint

R:
● Patient will further understand
the cause of this condition