Family medicine case write up

Patient’s profile

1. Name: Suhaimi Adnan

2. Gender: Male

3. Age: 68 years old

4. Occupation: Retired soldier

5. Address: Kampung Tudung, Merlimau

6. Education: SPM

7. Religion: Islam

8. Date of clerk: 15/7/2019

Reason of attending to Klinik Kesihatan

Mr Suhaimi came to KK today for the appointment of glucose tolerance test.

History of Present Health Status

Mr Suhaimi came for regular follow up 3 weeks ago on 16/6/19 for hypertension and . Routine blood
and urine investigation was done prior to the follow up, and the result shows that there is presence of
glucose in the urine. On further questioning, found that patient had symptoms of polydipsia, polyuria,
polyphagia and nocturia since a month ago. No other active complaints. The doctor then gave him an
appointment on today to screen for Diabetes Mellitus. He took his fasting blood sugar level at 8.30 am
and found to be normal, and then drank the glucose water will again obtain his post-prandial blood
sugar level at 10.30 am. No other macrovascular and microvascular complications.

Systemic Review

1. Respiratory system  No wheezing, breathlessness, chest pain

2. Cardiovascular system  No chest pain, palpitation, cyanosis, pedal edema
3. Central Nervous system  No headache, blurring of vision, photophobia, neck rigidity,
altered consciousness
4. Gastrointestinal system  No vomiting, diarrhoea, epigastric pain
5. Genitourinary system  No dysuria, hematuria. There is increased frequency of micturition
and nocturia.
6. Musculoskeletal system  No immobility, swelling of joints

Past Medical and Surgical History

 Patient was diagnosed with hypertension 2 years ago in 2017. He is currently on medication (Tab.
Amlodipine 5mg OD) and compliant to it. He comes for routine check-up without fail every 3 months
in KK Merlimau. He went for eye check-up and claims that no visual problems. He does not have other
complications such as heart problems, no history of stroke and no renal complications.
As for dyslipidemia, it was also diagnosed 2 years ago in 2017. He is currently on medication (Tab.
Simvastatin 10mg OD) and compliant to it. He comes for routine check-up every 3 months in KK
Merlimau. He does not have any complication such as myocardial infarction, no history of stroke.
Patient had childhood asthma since 7 years old but not on any medication as the last attack was
since 23 years of age. Patient claims he took tablets for asthma last time as there was no nebulisation
last time. There is no history of admission.
Patient had no history of surgery.

Drug history

1) Amlodipine 5mg OD
2) Simvastatin 10mg OD

Family history

His father which is a known diabetic passed away at 70+ years old due to water in the lungs and his
mother passed away due to old age. 1 of his elder sister (2nd in order) have diabetes mellitus,
hypertension and dyslipidimia. 1 of his elder brother (3rd in order) and younger brother (5th in order)
have diabetes and hypertension. Otherwise no other family members have hypertension, diabetes
and dyslipidemia.

Personal history

Patient claims to be taking low salt diet cooked by his wife and he have good appetite. His bowel
habits are normal and increased in frequency of micturition. His sleep is currently disturbed due to
increase in frequency of micturition at night. Patient is a chronic smoker with 30 pack years but quit
smoking 14 years ago after an episode of fever. Patient claims that he have no shortness of breath,
wheezing and chest tightness. He is also a social drinker which mainly consist of beer and no history of
drug abuse.

Socioeconomic history
He stays in a village house with his wife and son. He receive pension from the government and pocket
money from his son. His son is working as a policeman. The house have adequate hygiene and no
factories nearby. Clean air and water source.

Occupational history
Patient work as a soldier in Sarawak for 20+ years. After retiring, he works as a farmer in his village
and sell vegetables to earn his living together with the pension from government.

Summary
Mr Suhaimi, 68 years old, malay male from Kampung Tudung, Merlimau came for appointment of
glucose tolerance test. He is a known case of hypertension and dyslipidemia which is well controlled.
He had symptoms of polydipsia, polyuria, polyphagia and nocturia since a month ago and a strong
family history of Diabetes Mellitus. Currently, he have no active complaints and waiting to do
post-prandial blood sugar level test after taking glucose water.
General Physical Examination

 Patient was sitting, conscious and cooperative. He was well nourished and moderately built.
(Height: 162 cm; Weight: 54kg; BMI: 20.5 Kg/m2)

 Vital signs
o Pulse rate: 80 beats/min; normal volume, normal character, no arterial wall thickening
o Blood pressure: 142/90 mmHg
o Temperature: 37°C
o Respiratory rate: 18 breaths/min

 Head-to-toe examination
o Fingernails: No pallor, no clubbing, no cyanosis
o Palm: No palmar erythema, no pallor
o Eyes: No pallor at lower palpebral conjunctiva, no icterus, no archus seniles
o Mouth: Moderate oral hygiene, no gum bleeding, no pallor
o Neck: No cervical lymphadenopathy, no thyroid swelling
o Legs: No pedal edema

Systemic examination

Cardiovascular system: S1 and S2 heard, No murmurs.

Respiratory system : Normal vesicle breath sounds heard.
No adventitious sounds.

Investigation:

Fasting blood glucose level: 5.8 mmol/L

Discussion:

Mr Suhaimi Adnan is suspected to have Type 2 diabetes mellitus which is prevalent

non-communicable disease (NCD) which is increasing all over the world. It is manifested by a chronic
hyperglycemic state in conjunction with other metabolic derangements. T2DM is primarily due to
insulin resistance as well as deficiency. The insulin resistance state results in increased hepatic glucose
output, reduced utilization of glucose by various organs, increased renal reabsorption of glucose and
reduced incretin hormones production among others. T2DM is an important risk factor for
cardiovascular disease and results in various other complications namely nephropathy, retinopathy,
neuropathy and dermatopathy. Currently there is no known cure but the disease can be controlled
enabling the individual to have an improved quality of life. The main aim of management is directed
at reducing acute and chronic complications (microvascular and macrovascular).
Mr Suhaimi had most of the main symptoms of diabetes mellitus which includes polydipsia,
polyuria, polyphagia and nocturia which high suggestive of him getting diagnosed with Diabetes
Mellitus. Moreover, 1st degree relative of patient had history of diabetes which include his father,
sisters and brothers. Hypertension and dyslipidemia is also one of the risk factors of diabetes mellitus.
Therefore, with all these risk factors and symptoms, Mr Suhaimi is subjected for Oral Glucose
tolerance test to confirm the diagnosis of Diabetes Mellitus. Patient is asked to fast since 10pm the
day before the test and come at 8 am in the morning to take fasting blood sugar level, then a 200ml
solution which contains 75gms of glucose is given. 2 hours later, the post-prandial blood sugar level is
taken. Below are the reference value for OGTT:

IFG- impaired fasting glucose, IGT- impaired glucose tolerance, DM- diabetes mellitus

As for Mr Suhaimi’s case, the fasting blood sugar levels is normal and the post-prandial level is
pending.

After confirming the diagnosis of diabetes mellitus, a detailed history, full physical examination
(including fundoscopy and monofilament test) and baseline investigations must be done to assess the
CVD risk factors and complications of diabetes. Management should be based on the initial
assessment and baseline investigations which includes fasting plasma glucose (FPG), HbA1c, Renal
profile, Lipid profile, Liver function test, Urinalysis for albumin, microalbuminuria (if albuminuria is
absent) and ECG. Diabetes management involves lifestyle modification, medications and patient
education to encourage self-care and empowerment.

The overall aims of the management are to improve quality of life, reduce complications and
prevent premature death. Patient and family members should be counselled by identifying and
addressing concerns which may cause distress thus adversely affecting management. In short term: to
relieve of symptoms and acute complications and in long term for achievement of appropriate
glycaemic levels, reduction of concurrent risk factors and identification and treatment of chronic
complications. Most of the microvascular complications of diabetes are related to the degree and the
length of exposure to hyperglycaemia therefore maintaining patient in euglycemic is important to
reduce the complication of diabetes mellitus.

It is a team approach to educate the patient regarding diabetes mellitus. Dietitian in the
management of diabetes is paramount. Lifestyle changes alone (healthy food and regular exercise
with ensuing weight loss) are sufficient for glycaemic control in the majority of patients with newly
diagnosed T2DM. Recommendation should be individualized to maximize cooperation. Referral to a
dietitian is desirable to ensure detailed education on this important aspect of management. The other
team members must understand the principles of dietary advice to reinforce the dietary
recommendations for the patient. If the blood test result of Mr Suhaimi is within the early stage, diet
modification and exercise is usually advised and further follow up will decide the need of oral
hypoglycemic drugs. Normally, a minimum of 130 g/day CHO should be provided to ensure adequate
intake of fibre, vitamins, and minerals, as well as to prevent ketosis and to provide dietary palatability
and also exercise 30mins every alternate day to aid in the management.

Other than that, once diagnosed with DM, patient is advised for self monitoring of glucose level
by keeping a glucometer at home. Frequency of blood glucose testing depends on the glucose status,
glucose goals and mode of treatment. Normally it is done before and after breakfast and after lunch
and dinner. The value have to be recorded in a small book and bring it along during the follow visit
which will be an interval between 3-6months. Hypoglycemic symptoms should also be emphasized to
the patient and make sure the family members understood the dangerous complication of
hypoglycemia.