History of Present Illness

HISTORY OF PRESENT ILLNESS
This is a case of Mrs. LM, 48 years old, married, RC and a resident of 14B
Gumamela Extension, Carmen, Cagayan de Oro City with chief complaints of dizziness.
Three weeks prior to admission, patient was admitted at Polymedic General Hospital for
four days(4days) with the complaints of dizziness. On the fourth day of admission
patient insisted for discharge, still with elevated blood sugar level which was not
managed completely, patient wants to go home because it was her birthday and wants
to celebrate it at home. One week prior to admission, patient complained of dizziness
especially during ambulation associated with occasional blurring of vision. The day prior
to admission, patient reported of ingesting sweets like fruit salad, spaghetti and coca-
cola during her birthday and on Christmas and New Year’s Eve, resulted to increase in
blood sugar level- thus, prompting this admission.
MEDICAL RECORDS
Year 2005- was the first admission of patient at Madonna Hospital with
complaints of dizziness and mild headache. She was diagnosed of having DM type II
(NIDDM).
2008- Patient had her check-up at Polymedic General Hospital to check her
blood sugar level, it was found out that increases. LM also had complaints of sore throat
that made her too difficult to swallow solid foods and difficulty of breathing, expecting it
was a goiter. Ultrasound order was followed and impression shows no abnormality.
Occurrence of round-shaped lesions developed at her upper and lower extremities,
situating at interlacing spaces of fingers and toes, characterized as itchy, round-shaped
like skin lesions and reddened. According to LM, lesions get worsted when she ingested
“penoy”; a food she loved to eat most, yet, she still continuously ate that food not
minding the possible worsening of her lesions.
December 12, 2009- patient again was confined at Polymedic General Hospital
for four (4) days. Glimeperide 1mg tablet OD was the drug she maintained to take and
applied Eskinel Ointment to affected areas due to lesions.
January 5, 2010- latest admission.

Heredo-familial Disease: Diabetes Mellitus, Maternal Side.
HEALTH TEACHINGS
MEDICATION  > Glimeperide (Anti-Diabetic) 1mg tablet, to be taken once a day
after eating breakfast, ideally at 6am in the morning.
➢ Metformin (Mobic) (Anti-diabetic, Hypoglycemic agent) 15 mg

tablet, to be taken once a day at 6am after eating breakfast.
 Above drugs stimulates functioning of pancreatic beta cells to
secrete insulin, leading to direct drop in blood glucose.
EXERCISE  Encouraged to perform regularly scheduled, moderate exercise

performed for atleast 30 minutes most days of the week to promote
the utilization of CHO, assists with weight control and improved
cardiovascular fitness. Regular daily exercise was encouraged
rather than sporadic exercise. Taught client that walking is a safe
and beneficial form of exercise that requires no special equipment
(except for proper shoes to protect the foot) and can be performed
anywhere. Discussed to patient the benefits of exercising like its
effect of lowering blood glucose and reducing cardiovascular risk
factors. Exercise lowers the blood glucose by increasing the uptake
of glucose by body muscles and by improving insulin utilization, it
also improves circulation and muscle tone. Emphasized to patient
that exercise alters blood lipid levels, increasing HDL and
decreasing total cholesterol and triglycerides levels.
TREATMENT 
OUT-PATIENT (CHECK-UP) Patient was encouraged to have a follow-up check-up

one week after discharge for evaluation of patient’s
condition. Three or four times a week checking of glucose
level may be necessary to monitor its level accurately and
can be managed immediately.
DIET  1400 calories , diabetic diet.
CHO- rice, pasta, bread, apple two inches in diameter, vegetables and
meat.
FATS- legumes, whole grains
FIBER- oats, fruits and green leafy vegetables such as malunggay,

kangkong, camote tops.
 Strict adherence to diet therapy was highly encouraged

although calorie-controlled diets are often confusing and difficult
to comply with because they require patient to measure precise
portion, to eat specific foods and amount at each meal and
snack. Explained too to client that carbohydrate foods have the
greater effect on blood glucose levels because they are more
quickly digested than other foods are converted into glucose
rapidly, thus must be eaten in moderation to avoid postprandial
blood glucose levels. Patient was also educated that using
sweeteners is acceptable but must be used in moderation
amount to avoid potential adverse effects. Too much sweets is
highly avoidable.

History of Present Illness

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HISTORY OF PRESENT ILLNESS

January 5, 2010- latest admission.

➢ Metformin (Mobic) (Anti-diabetic, Hypoglycemic agent) 15 mg

EXERCISE  Encouraged to perform regularly scheduled, moderate exercise

OUT-PATIENT (CHECK-UP) Patient was encouraged to have a follow-up check-up

DIET  1400 calories , diabetic diet.

FATS- legumes, whole grains

FIBER- oats, fruits and green leafy vegetables such as malunggay,

 Strict adherence to diet therapy was highly encouraged

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