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DM CLINIC

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: VINLUAN, Gloria Age/Sex: 63/F Address: 2961 Lorenzo dela Paz, Pandacan, Manila Date of consultation: April 8, 2008 Diagnosis: DM Type 2 HCVD, LVH NSR II B Residents in charge: Dr. Gutierrez/Dimaandal/Areja Clerk-in-Charge: Kalalo/Lingao

CLINICAL ABSTRACT S> This is a case of a 63 year old female who was diagnosed with DM Type 2 in 2006 who returned for a follow-up check up. Fasting Blood Sugar 04/08/08: 145 mg/dL No subjective complaint Medications taken since 2006: Imidapril 5mg OD Metformin 80mg BID ASA 80mg OD Simvastatin 20 mg OD Vitamin B Complex OD Metoprolol ½ tab BID O> Alert, conscious, coherent, not in cardiorespiratory distress, ambulatory Vital signs: BP = 130/50 mmHg CR = 57 bpm

RR = 19 cpm T° = 36.9°C

HEENT: Anicteric sclerae, pink palpebral conjunctiva, no naso-aural discharge, no cervical lymphadenopathy, no tonsillo-pharyngeal congestion Chest and Lungs: symmetrical chest expansion, no retractions, clear breath sounds Heart: Adynamic Precordium, Normal Regular Rhythm Rate, no murmurs Abdomen: flabby, soft, normal abdominal bowel sounds, soft, non tender Extremities: No edema, no cyanosis, full equal pulses Assessment: DM Type 2 HCVD, LVH NSR II B Diabetic diet; Low salt, low fat Continue the following medications: Imidapril 5mg OD Metformin 80mg BID ASA 80mg OD Simvastatin 20 mg OD Vitamin B Complex OD Metoprolol ½ tab BID For follow up after one week

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