Type 2 Diabetes Mellitus

Mr. Bagas, a 48-year-old private employee, complained of weight gain getting down over the
last few months, despite eating a lot. Mr. Bagas complained about frequent urination, so that his
sleep was disturbed. Apart from that Mr. Bagas also often feels thirsty and feels pins and needles
on both feet. The doctor also asked whether there is a family of Mr. Bagas who has had
complaints like him. Mr. Bagas said that his father had the same complaint and was diagnosed
with suffering diabetes. Mr. Bagas's father passed away a few years ago due to a stroke. Mr.
Bagas's work made him sit more and rarely exercise. Doctor suspect Mr. Bagas has type 2
diabetes mellitus the same as his father's.

On physical examination found Mr. Bagas's blood pressure 150/90 mmHg, pulse 80 times /
minute, breathing frequency 16 times / minute, and temperature 36.5C. Body mass index 26 kg /
m2. In the laboratory examination obtained random blood sugar levels 263 mg / dL. Mr. Bagas
carried out further tests examination fasting blood sugar 180 mg/dL, post prandial blood sugar 2
hours 250 mg/dL, HbA1C 7,2%. Mr. Bagas is advised to exercise regularly, adjust his diet
accordingly needs, and regularly consume 500 mg of metformin three times a day. The doctor
also explained secondary preventive measures that can be taken for Mr. Bagas. He responded to
treatment and his blood sugar has been controlled.

SECTION EXAMPLE LANGUAGE

Introduction I’d like to present Mr. Bagas
Patient’s age and occupation a 48 year old private employee
Presenting symptoms and duration Weight gain getting down over last few months
Associated symptoms He also complained about frequent urination,
often feels thirsty, feels pins and needles on
both feet
Past medical history There was no relevant past history
Social history Mr. Bagas's work made him sit more and rarely
exercise
Family history Mr. Bagas said that his father had the same
complaint and was diagnosed with suffering
diabetes. Mr. Bagas's father passed away a few
years ago due to a stroke
Findings on examination On physical examination found Mr. Bagas's
blood pressure 150/90 mmHg, pulse 80 times /
minute, breathing frequency 16 times / minute,
and temperature 36.5C. Body mass index 26 kg
/ m2. In the laboratory examination obtained
random blood sugar levels 263 mg / dL
Investigation results Mr. Bagas carried out further tests examination
fasting blood sugar 180 mg/dL, post prandial
blood sugar 2 hours 250 mg/dL, HbA1C 7,2%.
Diagnosis So we tought he had type 2 Diabetes Mellitus
Treatment We advised him to exercise regularly, adjust
his diet accordingly needs, and regularly
consume 500 mg of metformin three times a
day and also secondary preventive measures
Outcome-what happened He responded to treatment and his blood sugar
has been controlled

Slides:

 Mr. Bagas,48, private employee

 c/o = weight gain getting down, frequent urination, feels thirsty, feels pins and needles on
both feet
 SH= Married, work made him sit more and rarely exercise
 PH= There was no relevant past history
 FH= His father had the same complaint and was diagnosed with suffering diabetes
 OE= Blood sugar test is positive, HbA1C is positive, fasting blood sugar is positive, BP
150/90, pulse 80 times/minute, BMI 26 kg/m2
 IR= Type 2 Diabetes Mellitus