I.

MEDICAL HISTORY
General data
is a y/o woman who works as from who came into for
consultation. She is married, with three children, and came unaccompanied.

Chief Complaint
The patient came in presenting findings of hyperglycemia upon routine physical check-up for work last 2019. No
symptom was presented as main complaint.

History of Present Illness

Around two years and 9 months prior to consult, EN was advised to visit a doctor because of high blood sugar upon
routine physical exam for work. She was then prescribed to drink Metformin 500mg 2x/day which she took for two months until
April 2019 but lost compliance due to no follow-up upon pandemic lockdown. Prior to routine physical exam last 2019, EN has
already reported easy fatigability, polyphagia, and dyspnea when climbing short flight of stairs at work. Around 2020, she reports
feeling nauseous when she eats too much rice which prompted her to start her diet. She still reports intermittently feeling easy
fatigability, dyspnea upon climbing, and nausea prior to the day of consult. Patient reports nocturia, polyphagia, and polydipsia at
night for the past months. She also noticed that she has been losing weight because her clothes started to get loose, which she
attributed to her diet of cutting more rice than she usually consumes. Months prior to consult, she noticed slow resolution of
wounds whenever she had her ingrown taken out during pedicures.

Temporal Profile

Review of Systems
Constitutional: Patient had no fever but had frequent headaches, dizziness, and fatigue. Patient has easy fatigability at
work and reported weight loss.
MSK/Integument: The patient experienced joint pains on her knees. No edema. no skin and hair changes. Nail changes
(ingrown) was reported.
HEENT: Patient reported blurring of vision. The patient did not present with tinnitus or deafness. The patient did not
experience any headaches, dizziness, colds, or hoarseness.
Cardiovascular: The patient was not in cardiac distress
GI: Heartburn was experienced by the patient occasionally. Patient reports polyphagia but controls food intake. The
patient did not present with nausea, diarrhea, rectal bleeding, and gastrointestinal pain.
Endocrine: The patient presented with excessive sweating at night. The patient was not in an agitated state, was not
restless and did not feel down. The patient was also positive for polyuria, excessive thirst, and cold intolerance.
Genitourinary: The patient had normal genitourinary function. There was no report of dysuria, no vaginal discharge, and
all sexual functions were reported to be normal.
Neurological: The patient was alert, coherent, had normal attention and could speak in clear sentences. There was no sign
of loss of consciousness, and the patient could respond and understand the physicians. The patient did not show
seizures and tremors.

Past Medical History

Patient has no history of chronic childhood diseases but has history of getting infected of measles and varicella as a kid.
She got herself checked-up for thyroid disease also because of routine check-up for work but she cannot remember her physician’s
diagnosis and says there was no intervention given. She has no history of TB, asthma, pneumonia, and gastroenteritis. Although
patient reports nausea when eating too much rice and feeling hungry all the time. She reports getting palpitations when surprised,
chest pains when tired, frequent headaches, heartburn, and acid reflux from time to time. She also reported a prior consult for
bradycardia, but patient does not remember the diagnosis and states that no intervention was given. Laboratory findings she passed
as work requirement shows high blood glucose levels, and reports mean BP of 130/90 which she measures as often as she could.
Patient had no liver disease, no prior stroke, no psychiatric condition, no prior surgeries, and had no prior injuries. For prior
hospitalization, she visited the ER twice since the start of the pandemic: one for consult of sudden onset of diarrhea upon first dose
of COVID19 vaccine, and second for high blood pressure due to lack of sleep. She was given Metformin 500mg twice a day last
2019 but only took the medication for two months and was lost due to no follow-up. In the ER, she was Losartan as medication
but again, uncompliant. She takes Vitamin C, and drinks herbal drinks (bayabas, sambong, banaba, eucalyptus) every day.

Immunization History
Patient is completely vaccinated for COVID19, Varicella, MMR, Tdap, BCG, Anti-cholera, Polio and BCG. Last flu
vaccination was in 2019. No vaccination for Hep A, Hep B, and Pneumonia.

Sexual and Obstetric History

Patient had menarche when she was 13. She reports to have had regular cycle with 3-5 days duration of menstruation
when she was younger. Now, she only has menstruation for 3 days and reports low flow of blood. Last menstruation was in
September. Patient is married but not sexually active. She is currently not taking any oral contraceptives and reports no sexual
problems or dysfunction. Patient had three normal labors in the hospital, all at 39 weeks AOG, all without complications.

Nutritional History
Patient reports eating frequently because she feels hungry frequently. She also said she eats moderately because of this.
Ever since she had high blood glucose levels in 2019 and because of her high BP, she only eats moderately and limits intake of
oily and salty foods. Her det includes 2 cups of rice at most per day ever since she started going on a moderate diet.

Family History
EN is married with three children. Her mother died due to hypertension and father died early of unknown causes. All
three children do not have early onset illnesses and are all currently healthy. Patient has 7 siblings, two of which died because of
CV related disease. Two other siblings are diagnosed with hypertension, one of which also has asthma.

Personal, Social and Environmental History

Patient is a high school graduate and has been working as a maintenance worker in the Loyola campus of Ateneo. She
reports using cleaning chemicals at work but insists they are safe to use. She has frequent exercise because her job requires her to
do physical work. She reports walking from the whole UP oval as exercise as well. She also does Zumba during her spare time.
Her hobbies include watching TV during her break and rest time. She has no travel history, no history of illicit drug use, and does
not drink alcoholic beverages. She does not smoke, and no one in her family is a smoker, but admits that many of her coworkers
do smoke cigarettes. She also has no known COVID19 exposure both from work and at home. She currently lives with her 3
children, 1 grandchild, and her husband. Living conditions such as adequate drinking water, sanitation, and access to electricity
said to be adequate.

Stakeholders Analysis

Role Stake/WIFM Stand Intensity Influence Insight or Action

Husband Family member Ally High High Husband is the primary care provider and would
take care of her and would monitor her compliance

Co- Immediate support Ally Medium High Patient would need to tell them to stop smoking
Workers system/ big impact on around her because it increases her risks
social environment

Children Family member Ally High Medium Support system in the intervention and would have
crucial role in her compliance.

II. OBJECTIVE FINDINGS

General Survey
The patient is conscious, coherent, not in cardiorespiratory distress, ambulatory, well-groomed and dressed appropriately

Anthropometric Measurements
Height: 4’11”
Weight: 145 lbs
BMI: 29.3 (overweight)
Waist/Hip Ratio: 41/43 or .95

Vital Signs
HR: 70 (normal)
RR: 20 (normal)
BP: 140/100 (Stage 2 HTN)
Temperature: not taken

Physical Examination
A diabetes focused physical exam was done on the patient.
 General Inspection
à Patient’s gait is remarkable and no apparent joint immobility was observable. Shoes of the patient were ill-fitting.
Dermatologic Assessment
à Patient has mild skin acanthosis nigricans on the neck. Skin on the hands and feet are prominently dry. Feet are
calloused although no ulcerations and other lesions like cracks, and hyperpigmentation were present. Patient also has
ingrown nail, but no other nail dystrophy was observed.
MSK Assessment
à Feet has no gross deformity and contractures. Patient is negative for Charcot foot as well.
Neurologic Assessment
à Patient generally can detect pressure upon 10g monofilament test. But there were instances that she cannot feel the
pressure on her left foot’s little and middle toes.
Vascular Assessment
à Posterior tibialis and dorsalis pedis pulses are present on both feet.
Laboratory Data
No data available.

III. ASSESSMENT
Salient features
Patient is a 53 y/o female visiting the clinic for referral because of high blood glucose level findings upon routine physical
check-up. She complains of easy fatigability, occasional chest pains, frequent headaches, polyuria, polyphagia, nocturia,
polydipsia, slow healing of wounds and weight loss inappropriate to her diet.
Pertinent PE findings include:
(+) hypertensive BP, (+) mild loss of sensation on 3rd and 5th toe of left foot, (+) acanthosis nigricans, (+) calluses on feet,
(+) dry skin

Problem List
BIOMEDICAL PROBLEMS PSYCHOSOCIAL PROBLEMS
High BP Risks at work (smoking, use of hazardous wastes and cleaning products)
High blood glucose level Pandemic as a reason for sedentary lifestyle
Overweight
Polyuria, nocturia, polyphagia, easy fatigability

Primary Impression
Based on the findings, my primary impression would be T2DM with HTN.

RULE IN RULE OUT

TYPE 2 DIABETES MELLITUS >40 y/o No diagnostic tests
- Accounts for around 90% of all cases of diabetes Waist hip ratio >.85 (.95) (FBS, OGTT,
- In T2DM, response to insulin is diminished (insulin Overweight HBA1C) done for
resistance) Hypertensive confirmation yet
- commonly seen in patients older than 40 y/o Acanthosis nigricans
- Most of the patients with T2DM are overweight, obese or Osmotic diuresis: (+) nocturia,
may have high body fat percentage, mainly in the abdominal (+) polyuria, (+) polydipsia
region. Easy fatigability
- Adipose promotes insulin resistance through various Polyphagia
inflammatory mechanisms which is responsible for Weight loss
symptoms seen on those with T2DM. Prolonged healing of wounds

HYPERTENSION 140/100 BP on PE No lab tests (urine

- Hypertension or dyslipidemia increases the risk of T2DM Usual BP of 130/90 on BP self- analysis, CBC, or
which is why it is important to screen and manage patients monitoring (Stage 1) EKG) done for
with T2DM w/ HTN and vice versa. (+) headaches confirmation yet.
Easy fatigability
Chest pain

Differential Diagnoses
Differential RULE IN RULE OUT

Primary Hyperaldosteronism (+) Hypertension (-) OSA

(+) Nocturia Rule out with: ARR, IV Saline
(+) Fatigue Solution Test, and Captopril
(+) Headaches Challenge test
 Type 1 Diabetes (+) nocturia Age (patient is already 53)
(+) polyuria Autoimmune disease (will need tests
(+) FBS to completely rule in/out)
Weight loss
Polydipsia

Metabolic Syndrome (+) hypertension Need lab tests (Triglyceride level,

(+) high blood glucose HDL, LDL, FBS, cholesterol) to
(+) overweight/visceral obesity rule out

Hypothyroidism (+) dry skin (-) enlarged thyroid

(+) easy fatigability (-) muscle aches
(+) slow heartbeat (-) constipation
(+) cold intolerance
(+) weight gain

Diagnostic Plan
Diabetes is confirmed through laboratory diagnosis by way of blood glucose testing. Usually, a patient is tested more
than once. Since his FBS result was taken quite some time ago, it may be prudent to test blood glucose again. The following four
tests can be used to determine blood sugar levels:

Blood Glucose Test Cut-off value diagnostic of diabetes

Fasting Blood Glucose ≥126 mg/dl or 7.0 mmol/L

75 mg Oral Glucose Tolerance Test ≥200 mg/dL or 11 mmol/L

Glycated Hemoglobin (HB1Ac) ≥6.5%

Random Blood Sugar* ≥200 mg/dL

*Must present with diabetic symptoms like polyphagia, weight loss, polyuria, hyperglycemic crisis

Once confirmed to have diabetes, she must also be screened for the presence of diabetic complications immediately as someone
who potentially has T2DM. Currently, the patient does not seem to profess any symptoms indicating acute metabolic
complications. Therefore, we can focus more on the screening for chronic complications, particularly the microvascular ones.
• Retinopathy: use fundoscopy for signs of macular edema, vascular changes, aneurysms, and hemorrhages
• Neuropathy: focused history and PE to check for paresthesia, neuropathic pain with neural distribution, muscle atrophy,
loss of deep-tendon reflexes and protective sense should be conducted
o Rule out any other potential causes before considering diabetes
o This would also include examination of the diabetic foot and the 10g monofilament test
• Nephropathy: check eGFR, do urinalysis
o Diabetes is one of the leading causes of CKD, therefore, kidney function should be assessed through eGFR;
eGFR > 60 mL/min is indicative of CKD. It causes nephrotic syndrome, which typically presents with
proteinuria more than hematuria; albuminuria will cause bipedal edema
• Coronary artery disease: check for symptoms like chest pain, dyspnea, dizziness, or angina equivalents
• Peripheral artery disease: try to look for claudication and poorly healing wounds
• Cerebrovascular complications: look for altered state of consciousness, dizziness, severe headache, slurred speech,
problems with cognition, stroke

Therapeutic Plan
Pharmacologic
• T2DM: When considering appropriate pharmacologic therapy, it is important to determine whether the patient is insulin-
deficient, insulin-resistant, or both. For our patient presenting with T2DM, it is recommended that we give him the first-
line treatment which is Biguanides (Generic name: Metformin) under non-insulin therapies. Its primary mechanism
of action is suppression of hepatic glucose output and enhances insulin sensitivity of muscle and fat. Metformin primarily
lowers fasting glycemia. Metformin is well tolerated, with the most common side effect being gastrointestinal (GI)
complaints, such as diarrhea, nausea, and abdominal discomfort, and a metallic taste. Main benefit of metformin is that
it does not cause hypoglycemia. It can also lead to weight loss, by decreasing plasma triglycerides concentration.
Dosing: Initially, 500 or 850 mg Bid or Tid with meals, gradually increase at intervals of at least 1 week
according to response.
Vitamin B12. Vitamin B12 deficiency is associated with Metformin. This is recommended to be given to
patients taking Metformin and who has risks of peripheral neuropathy.
Dosing: 2.4 µg of vitamin B12 daily
 • HTN: Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, enalapril, benazepril (Lotensin), captopril
and other. These relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.
Dosing: (Enalapril) Initially, 5 mg once daily.
Maintenance: 10-20 mg once daily, up to 40 mg in severe cases, may be given in 2 divided doses inaqdequate.

Non-pharmacologic
1. GLUCOSE MONITORING and COMORBIDITY MANAGEMENT
One of the most important interventions would be to promote Diabetes Self-Management Education and Support. The
patient must know how to take care of herself and be adequately and independently responsive to changes in her condition.
Empowering her to be in control of her condition is an important factor in any intervention given for diabetics since strict
compliance is really important for good results. This will include:
Self-monitored Blood Glucose

BP regulation (Goal: 130/80) Foot and skin care

Prevention and management of hypoglycemia (potentially as an Risk factor modifying activities

adverse effect of insulin administration)

Guidelines for care when sick Management before, during, after exercise

Patient must also come in for regular HbA1c testing every 3-6 months. Knowing the patient’s blood sugar as it changes will be
important in responding with the appropriate interventions needed at the moment.

2. DIET
Cornerstone of DM management is healthy lifestyle and diet. A diet low in saturated fat, low carbohydrates, low
glycemic index, and high in fiber and monounsaturated fats needs to be encouraged. Although each diabetic patient’s diet
should be individualized, EN could first be advised to do portioning of food (example: a palm of protein, a fist of vegetables, a
cupped handful of carbohydrates, a thumb of fat-dense food). Protein amount should also be individualized although some patients
with T2DM can take higher amount of protein, generally they can eat normal amounts of protein. Reducing fat intake reduce
excessive visceral adipose activity, controlling a diabetic’s pro-inflammatory tendencies, which can cause symptoms and impaired
healing later. Her hypertension can also be addressed with reduction in salt intake.

3. EXERCISE AND LIFESTYLE MODIFICATIONS

The major target in T2DM patients, who are obese or overweight, is weight loss. Aerobic exercise for a duration of 200
to 300 minutes per week would be most beneficial for the age and current lifestyle of our patient. Moderate intensity activities like
walking are advised. It is also important to provide the patient with counselling for smoking cessation. Lastly, there could be
psychosocial counselling to help the patient cope with the mental and emotional aspect of the illness.

Patient education
Patients must be educated about the importance of blood glucose management to avoid complications. It is important to
stress the need for lifestyle management, including diet control and physical exercise. Inform them about self-monitoring of blood
glucose and its importance to their quality of life and how patients and their family have the big role and responsibility for diabetes
management. Regular estimation of glucose, glycated hemoglobin, and lipid levels is also needed to be done. There’s also a need
to educate patients about the symptoms of hypoglycemia (such as tachycardia, sweating, confusion) and required action (ingestion
of 15 to 20 gm of carbohydrate) so that they may know when to spot critical symptoms and how to make necessary interventions.
Patient should also be encouraged to stop smoking or avoid social interactions that expose her to such. Emphasize the need for
regular eye check-ups and foot care as well.

Follow-up instructions/Referrals/Prognosis
• Remind patient to follow-up after a week to monitor her response on the medication prescribed. Gradually set follow-up
on a per month basis when the patient is compliant and responsive to medications until target blood glucose and other
necessary laboratory values are observed. Once targets are achieved, follow-up check-ups could be done every 3-6 months
when the patient is compliant to medications.
• The diagnosis and management of T2DM need interdisciplinary perspectives. Patients may need an appropriate referral
to the ophthalmologist (yearly), nephrologist (depending on EFGR results), cardiologist, endocrinologists, nutritionists
and even a diabetic nurse from time to time.
• DM is associated with increased risk for CV diseases. Managing blood pressure, statin use, regular exercise, and smoking
cessation are of great importance in reducing complications and risks. The overall excess mortality in those with T2DM
is ~15% higher. There’s a prevalence of vision-threatening diabetic retinopathy and ESRD among adults with diabetes.
With right prescription and compliance to pharmacologic and nonpharmacologic intervention for hyperglycemia,
lowering LDL cholesterol, and managing blood pressure, complications can be managed adequately, resulting in reduced
morbidity and mortality.