Case sheet

Personal history:
Female patient named Mona Mohmmed Hamed 55 years old, a
housewife, divorced 8 years ago, has 6 offspring, youngest aged 21
years, lives in El-gnayn, has no special habits of medical
importance, has a smoker son.

Complaint:
She came to el-shrouk primary health care for the purpose of
following up on diabetes and requesting monthly medication from
the PHC pharmacy.

Present history:
The patient has had type 2 diabetes mellitus for 15 years now, she
had a blood test done, resulted in fasting glucose level was
600mg/dL, the initial symptoms were polyphagia, polydipsia,
polyuria, sudden weight loss and blurred vision. Complications
involved retinal hemorrhage, cerebral stroke, neuropathy
symptomized by tingling in legs and hot flushes at night, and also
hypertension that was diagnosed 5 years ago. Complications of
HTN are not detected yet. No nephropathy.
Medication history:
DM: -insulin therapy 30/70 (bind to insulin receptor to
promote glucose uptake).
-Metformin 850mg (decrease hepatic glucose
production).
Neuropathy: -Thiotacid 600mg (LA is a potent antioxidant with
insulin-mimetic and anti-inflammatory activity.).
HTN: -Atenolol 50mg (selectively bind to beta1 adrenergic
receptors in smooth muscles, blocking positive
inotropic and chronotropic actions of endogenous
catecholamines).

Past history:
Past admission to hospital due to surgery: retinal implant and
cataract surgery. No blood transfusion, no allergy to food or drugs.

Family history: The mother was a diabetic patient.

Socioeconomics: The patient lives in a 3-room apartment, receive
a good water supply and sewage.
Examination:
Height:165 cm
Weight:69.5 kg
BMI:25.5 (slightly overweight)
Blood pressure: 125/80 mmHg (normal)
RR: 16 breaths per min.
Pulse: 73 pbm normal rate regular rhythm, equal in both sides
Edema: non-pitting edema extended to lower third of femur
Feet examination:
Inspection: no ulcers, no deformities, no fungal infection.
Palpation: normally palpated dorsalis pedis and posterior tibialis,
temperature equal on both sides, capillary refill time normal,
normal movement of joints
Neurological assessment: normal responses and sensations (VPT,
ankle reflex, fine touch, pin prick)
No cardiac murmurs.

Screening recommended:
According to the age:
-Colorectal cancer(A), cervical cancer(A), breast cancer(B).
-Hepatitis C(B).
Annually:
-Review cardiovascular risk; statin use and lipid levels.
-Haemoglobin. -12-lead ECG
-Blood lipids, triglycerides, potassium and sodium, creatinine and
eGFR, liver function, uric acid. Urine analysis.
-Fundoscopy.