Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of Type 2 Diabetes Mellitus, currently uncontrolled. Reports persistent polyuria, polydipsia, and nocturia. Denies blurry vision, paresthesia, or chest pain. Recent home glucose monitoring reveals significant postprandial and fasting hyperglycemia. Current medication adherence is reported as inconsistent.
Clinical Examination Findings
General: Patient appears alert and oriented, in no acute distress. HEENT: Normocephalic, atraumatic, sclerae anicteric. Cardiovascular: Regular rate and rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally. Extremities: No peripheral edema, pedal pulses 2+ bilaterally, monofilament testing intact, no signs of ulceration or skin breakdown.
Treatment Protocol
Plan: 1. Optimize glycemic control via medication adjustment (titration of oral hypoglycemics/initiation of insulin therapy). 2. Order HbA1c, comprehensive metabolic panel, and lipid profile. 3. Refer to ophthalmology for diabetic retinopathy screening. 4. Emphasize strict adherence to prescribed medication regimen and dietary modifications.