Scribd
Upload
7 views

Presenting complain1

The document details a follow-up visit for a 54-year-old patient named Ahmed, who has been managing type 2 diabetes mellitus for six years with stable glucose control and no new symptoms. He adheres to his medication and dietary recommendations, exercises regularly, and has no significant past medical history or family history of complications. The patient reports good overall health and is not experiencing any concerning symptoms, with blood glucose levels consistently within target range.

Uploaded by

auoop141
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
7 views

Presenting complain1

The document details a follow-up visit for a 54-year-old patient named Ahmed, who has been managing type 2 diabetes mellitus for six years with stable glucose control and no new symptoms. He adheres to his medication and dietary recommendations, exercises regularly, and has no significant past medical history or family history of complications. The patient reports good overall health and is not experiencing any concerning symptoms, with blood glucose levels consistently within target range.

Uploaded by

auoop141
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

Presenting complains: Follow-Up Visit (Type 2 Diabetes Mellitus)

Patient Information:

• Name: Ahmed, Age: 54 years, Marital Status: Married,

• Occupation: retired teacher

Chief Complaint:
The patient returns for a routine follow-up of type 2 diabetes mellitus. He reports no
new or concerning symptoms and has been feeling generally well.

History of Present Illness:

• Diagnosis of Type 2 Diabetes: Diagnosed with type 2 diabetes mellitus 6


years ago. The patient was initially symptomatic with polyuria, polydipsia,
and fatigue but has had stable glucose control since starting treatment.

• Current Status: The patient reports good overall control of his blood sugar
with no hypoglycemic episodes or significant changes in weight. He adheres
to his prescribed diabetes medications and dietary recommendations.

• Symptoms: No new symptoms such as increased thirst, frequent urination,


blurred vision, or fatigue. The patient denies numbness or tingling in
extremities, which was a concern during previous visits. There is no chest
pain, dizziness, or shortness of breath.

• Recent Glucose Levels: The patient reports regularly checking his blood
glucose levels at home, with fasting blood glucose consistently ranging from
5 to 6 mg/dL. The patient also reports post-meal blood glucose values within
target range.

Past Medical History:

• Type 2 Diabetes Mellitus: Diagnosed 6 years ago, with stable control since
initiation of treatment.

• No Other Known Comorbidities: The patient has no history of hypertension,


hyperlipidemia, cardiovascular disease, stroke, chronic kidney disease, or
liver disease. No history of hospitalization or surgeries.

• Medications: Metformin 1000 mg twice daily (no dose adjustments recently)

• Allergies: No known drug allergies or environmental allergies.

Family History:
• Diabetes Mellitus: Positive family history of type 2 diabetes. Father was
diagnosed at age 50 and has been managed with oral medications. Mother
has no diabetes history.

• Cardiovascular Disease: Father had a history of hypertension, but no known


heart disease. No significant family history of stroke or myocardial infarction.

• Other Relevant Family History: No family history of cancer, chronic kidney


disease, or other genetic conditions.

Social History:

• Diet: The patient follows a relatively healthy diet, emphasizing whole grains,
lean proteins, vegetables, and fruits. He avoids sugary snacks and is mindful
of portion sizes, especially carbohydrates. He reports adhering to a diabetic-
friendly meal plan.

• Exercise: The patient has been able to incorporate physical activity into his
routine. He participates in [e.g., 30 minutes of brisk walking, cycling, or
swimming] at least 4 times a week, which has helped with weight
management and energy levels.

• Alcohol Consumption: denies alcohol consumption

• Smoking: The patient is a non-smoker and has never smoked.

• Sleep: The patient reports an adequate sleep pattern, averaging 7-8 hours of
sleep per night. No complaints of sleep apnea or insomnia.

Review of Systems:

• General: No weight loss, no fatigue, and no generalized malaise.

• Endocrine: The patient reports no increased thirst or frequent urination. No


history of hypoglycemia.

• Cardiovascular: No chest pain, palpitations, or shortness of breath.

• Respiratory: No cough or wheezing.

• Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel


habits.

• Neurological: No dizziness, weakness, or numbness. No history of diabetic


neuropathy.
• Musculoskeletal: No joint pain or stiffness.

• Skin: No rashes, wounds, or diabetic ulcers. Skin turgor is normal.

• Urinary: No dysuria, frequency, or hematuria.

ICE: what is your idea regarding to your state? is there anything concern you?, What
are your expectations or goals regarding your treatment moving forward?

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy