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National Colony, Aurangabad, 431001 · Mon - Fri: 9am - 5pm

Report #24 · Office & outpatient

Poorly controlled diabetes

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From the lesson Office & Outpatient

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Clinical note · #24

Office & outpatient

Patient: Mr. X

Age: 65

Presenting Complaint: Poorly controlled diabetes

History of Present Illness (HPI):

The patient presents with elevated blood glucose levels over the past month, indicating poor control of his Type 2 Diabetes Mellitus. He reports increased thirst and fatigue. The patient has been on Glipizide, with a 30 pack-year history of smoking.

Review of Systems (ROS):

  • Cardiovascular: No chest pain or palpitations.
  • Respiratory: No shortness of breath or cough.
  • Endocrine: Increased thirst and fatigue as per HPI.

Past Medical History (PMH):

  • Type 2 Diabetes Mellitus
  • Hypertension
  • COPD

Physical Examination:

  • General: Alert, oriented, in no apparent distress.
  • Cardiovascular: Regular rate and rhythm. No murmurs.
  • Respiratory: Clear breath sounds bilaterally.

Assessment:

The patient's diabetes is poorly controlled, requiring adjustment of medication.

Plan:

  • Discontinue Glipizide and start Metformin
  • Follow-up appointment in one week to monitor blood glucose levels.