Case Presentation On Type 2 Diabebetes Mellitus

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PEER LEARNING CASE PRESENTATION

ON TYPE 2 DIABEBETES MELLITUS ,


SYSTEMIC HYPERTENTION AND OLD
IHD

PRESENTED BY
SINCHANA
2ND PHARM D
• TYPE 2 DIABETES MELLITUS : A Chronic condition that affects the way
the body processes blood sugar with type 2 diabetes , the body either
doesn’t produce enough insulin or it resists insulin.

• SYSTEMIC HYPERTENTION : Systemic hypertension is high blood pressure


in the arteries that carry blood from heart to body tissues
PATIENT DEMOGRAPHIC DETAILS
• NAME : XYZ
• AGE : 75Y
• SEX : MALE
• UNIT : MED. D
• IP.NO : 23-26093
• DOA : 9/09/23
• DOD : 13/09/23
CHIEF COMPLAINTS
• C/O Fever since 1 week
• C/O Easy fatigability
MEDICAL HISTORY :
• K/C/O Type 2 Diabetes Mellitus
• K/C/O Systemic Hypertention
MEDICATION HISTORY :
• Tab Ecosperin (75/10) 0-0-1
PERSONAL HISTORY :
• Diet - Mixed
• Appetite - Adequate
• B/B - Normal and Regular
• Sleep –Good
FAMILY HISTORY :
• Nothing Significant
SOCIAL HISTORY :
• Nothing Significant
PHYSICAL EXAMINATION
• BP : 160/100mmHg
• CVS : S1S2 +
• CNS : Consious and Oriented
• P.R : 70 bpm
• Temp : Febrile
• R.S : B/L NVBS Heard ,no added sounds
• SpO2 : 98%@RA
• R.R :16 cpm
• OTHERS :Soft and Non tender
BIOCHEMICAL INVESTIGATION
• RBS : 226 mg/dl
• SGOT :64.6 U/L
• SGPT : 98.4 U/L
• TC : 3.900 Cells/cumm
• N : 86%
• L : 08%
• Plat :15,000Lakhs/cumm
• ESR : 23mm/hr
SOAP ANALYSIS FOR TYPE 2 DEABETES
MELLITUS
• SUBJECTIVE EVIDENCE :
C/O Fever since 1 week
K/C/O Type 2 DM since 5 years
• OBJECTIVE EVIDENCE :
RBS : 226 mg/dl
S0AP ANALYSIS FOR SYSTEMIC
HYPERTENTION
• SUBJECTIVE EVIDENCE :
C/O Easy Fatigability
K/C/O Systemic Hypertention since 5 years
OBJECTIVE EVIDENCE :
• BP : 160/100mmHg
ASSESSMENT
• From the Subjective and Objective evidence it was diagnosed as TYPE
2 DIABETES MELLITUS AND SYSTEMIC HYPERTENTION.
THERAPEUTIC GOALS
PATIENT SPECIFIC :
• To relieve from symptoms of fever and easy fatigability.
DISEASE SPECIFIC :
• To contron and normalize blood sugar level and blood pressure.
• To improve the health conditions and prevent recurrence.
• To prevent further complications.
ASSESSMENT ON CURRENT
THERAPY :
DRUGII DOSE ROUTE FREQUENCY DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

Inj.Dexona 8 mg IV 1-1-1 + + + + +

Inj.pantoprozole 40mg IV 1-0-0 + + + + +

Inj.optineuron IV 1-0-1 + + + + +
2AMP
Tab P/O 1-0-0 + + + + +
Ramipril+Metaprolol
Inj.H Actrapid IV + + + + +

Tab.Ecospirin 0-0-1 - + + + +

Tab.Cilacar 10mg P/O 1-0-1 - - - - -


PROGRESS CHART :
DAYS INVESTIGATION

DAY 1 BP-160/100mmHg,PR-70bpm,RR16cpm,spo298%@RA

DAY 2 BP-166/88mmHg,PR-66bpm,RR-14cpm,spo2-99%@RA

DAY 3 BP-160/90mmHg,PR-72bpm,RR-14cpm,spo2-100%@RA

DAY 4 BP-160/80mmHg,PR-102bpm,RR-15cpm,spo2-99%@RA

DAY 5 BP-128/64mmHg,PR-90BPM,RR-16cpm,spo2-98%@RA
PLANNING
DISCHARGE MEDICATION
• Cap Ecospirin AV (75/10)mg P/O
• Tab cilacar 10mg P/O
• Tab Optineuron 2Amp IV
• Tab Pantoprozole 40mg P/O
• Insulin H Actrapid SC 10-10-12u
PATIENT COUNSELLING
• DISEASE SPECIFIC FOR TYPE 2 DIABETES MELLITUS
 To maintain normal value of blood pressure
To maintain normal value of random blood sugar
• DISEASE SPECIFIC FOR SYSTEMIC HYPERTENTION

 Reduce salt intake.


Adopt DASH eating plan.
Take regular aerobic exercise.
Maintain a healthy weight.
DRUG SPECIFIC
• TAB PANTOPRAZOLE : Should be taken 1 hour before a
meal ,preferably in morning .
• Inj.Optineuron :Preferably after meals,should not consume nutritional
supplements more than the stated recommended daily dose.
THERAPEUTIC OUTCOME
• Fever reduced
• Easy fatigability
REFERNCE:
• Medscape
• Tata 1 mg
• CIMS
• Dipiro 7 th edition

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