type 2 diabetes case study

1. Diabetic patient aged 56 years
diabetes since12 years
hypertensive, obese ,
dyslipidemic
Complaining of palpitation, progressive
dyspnea,effort intolerance
Pain in the rt calf muscle on walking

2. medications
• Glipemeride 4mg OD/PO
• Metformin 500mg TID/PO
• a
ِ torvastatin 20 mg OD/PO
• Enalapril Hydrochlorothiazide 10/12.5 OD
• ASA 150 mg OD
• Cinnarazine 25mg OD
• Multivitamin Tab OD

3. Clinical data
• Bp 160/100
• Pulse 100 some extrasystole unfrequent
• Random sugar 210mg
• Wt 116 kilos
• Faint pulse on the rt foot Dorsalis pedis
• Bilateral LL soft pitting mild edema

4. LAB
• Hba1c 11
• Urine proteinuria
• Cholesterol 270
• Triglyceride 220
• HDL 35
• LDL 190
• UA 9

5. ECG

6. Do you want to ask patient any
question
• Other Symptoms
• Chest pain
• Self monitoring
• Compliance
• Intermittent claudication

7. DD
• BP, Diabetes and lipid
• IHD
• PVD

8. Plan
• Proposed Investigations
• Cardiac assessment
• Peripheral vascular disease
• Metabolic control, diabetes, lipid
• Diet, improve control, compliance
• Health education , feet

9. Proposed medication
• Oral hypoglycemic
• Insulin
• Hypertension
• Dyslipidemia
• Heart cardiology consultation
• PVD vascular surgery

10. Proposed medication
• Oral hypoglycemic
• Insulin
• Hypertension
• Dyslipidemia
• Heart cardiology consultation
• PVD vascular surgery