She have thyroid disease 4 years ago but took medication last 2 years Surgery done 2 year ago because her 4 and 5 toe turned purple then she goes went to hospital after 4 to 5 months for surgery She have urgent to drink water add these on medical record which I gave

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Here is a summary of all three additions made to the record:

1. Past Medical History - Hyperthyroidism (updated)

"Hyperthyroidism: Diagnosed 4 years ago. Took medication for the first 2 years. Currently on thiamazole."

2. Past Surgical History (expanded)

Added a second surgical entry: "Surgery approximately 2 years ago for discolouration (purple/cyanotic discolouration) of the 4th and 5th toes on the right foot. The patient first noticed the toe discolouration but delayed presentation; she attended hospital approximately 4 to 5 months after symptom onset, at which point surgical intervention was performed."

3. Medical History / Thirst (updated in two places)

Updated to: "Increased thirst present with urgency to drink water; drinking approximately 2 litres per day." - also reflected in the Case Summary section.

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Here are the three additions made to the medical record:

PAST MEDICAL HISTORY - Hyperthyroidism (updated)

Hyperthyroidism: Diagnosed 4 years ago. Took medication for the first 2 years. Currently on thiamazole.

PAST SURGICAL HISTORY (expanded)

Past Surgical History:

Bilateral inguinal/groin surgery for arterial blockage approximately 2 years ago. The exact procedure is not recalled by the patient.
Surgery approximately 2 years ago for discolouration (purple/cyanotic discolouration) of the 4th and 5th toes. The patient first noticed the toe discolouration but delayed presentation - she attended hospital approximately 4 to 5 months after symptom onset, at which point surgical intervention was performed.

No other surgical history documented.

MEDICAL HISTORY - Thirst (updated)

Increased thirst present with urgency to drink water; drinking approximately 2 litres per day.

These same changes were also reflected in the Case Summary section of the document.

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All three additions are already inside that file:

Hyperthyroidism - diagnosed 4 years ago, on medication for first 2 years
Past Surgical History - surgery 2 years ago for purple 4th and 5th toes, delayed presentation by 4-5 months
Urgency to drink water - added to the thirst entry

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Here is the full updated medical record. The 3 newly added parts are highlighted with ✅:

INTERNAL MEDICINE MEDICAL RECORD

(Internal Medicine / Endocrinology Department - Trung Vuong Hospital, HCMC)

I. ADMINISTRATIVE SECTION

Full name: Chau Thi Bich Diep Gender: Female Date of birth: 16/05/1971 (Age: 55) Address: Ap 1, Xa Vinh Loc, Ho Chi Minh City Ethnicity: Kinh Date and time of admission: 22 June 2026, 07:18 (admitted via Emergency) Date of medical record: 22-23 June 2026 Ward / Room / Bed: Khoa Noi Tiet - Tong Hop / Room 8

II. MEDICAL INQUIRY SECTION

1. Reason for Hospitalization

Fatigue, weakness of arms and legs.

2. Medical History

Onset and Progression:

The patient is a 55-year-old woman with a known background of Type 2 Diabetes Mellitus diagnosed 6 years ago during a routine check-up at Trung Vuong Hospital. She was managed with oral antidiabetic medications and had never been started on insulin. She presented with progressively worsening symptoms of hyperglycaemia, generalised fatigue, increased thirst, and limb weakness over recent months. She also has a known background of hyperthyroidism on thiamazole and hypertension on antihypertensive therapy.

Urine frequency: 3-4 times per day during daytime plus 1 time at night. Urine volume correlates with fluid intake. Urine colour dark, consistent with concentrated urine and mild dehydration.

✅ Increased thirst present with urgency to drink water; drinking approximately 2 litres per day.

She eats 3 meals per day (rice, fish, meat, sweet potato).

Weight loss: Approximately 10 kg over 6 years, unintentional.

Patient mentioned generalised fatigue; weakness involving both arms and legs.

Numbness and tingling on the plantar surface of both feet.

Leg pain on prolonged walking.

Balance is generally normal; however occasional transient episodes of loss of balance reported.

Sweating and shakiness when meals are missed.

Bilateral swelling from mid-lower leg to toes appearing after prolonged ambulation.

Skin: Intermittent itching affecting the arms and whole body.

No blurred vision. No recurrent infections. Normal wound healing. No nausea, vomiting, or abdominal pain.

3. Past Medical History

Type 2 Diabetes Mellitus: Diagnosed 6 years ago during a routine check-up at Trung Vuong Hospital. Managed with oral antidiabetic medications. Never on insulin prior to this admission.

✅ Hyperthyroidism: Diagnosed 4 years ago. Took medication for the first 2 years. Currently on thiamazole.

Hypertension: Known. On antihypertensive therapy. (Irbesartan)

✅ Past Surgical History: (1) Bilateral inguinal/groin surgery for arterial blockage approximately 2 years ago. The exact procedure is not recalled by the patient. (2) Surgery approximately 2 years ago for discolouration (purple/cyanotic discolouration) of the 4th and 5th toes on the right foot. The patient first noticed the toe discolouration but delayed presentation; she attended hospital approximately 4 to 5 months after symptom onset, at which point surgical intervention was performed. No other surgical history documented.

Family history: Sister with Type 2 Diabetes Mellitus. No history of gestational diabetes mellitus (GDM). No history of polycystic ovarian syndrome (PCOS). No history of allergies to food or medications. No history of alcohol or smoking.

4. Clinical Examination

Performed: 22/06/2026, follow-up 23/06/2026

General: Patient conscious, cooperative, alert. GCS 15/15. Weight: 55 kg | BMI: 21.5 kg/m² Temperature: 37.0 °C | HR: 100 bpm | RR: 20/min BP: 130/60 mmHg | SpO2: 98% (room air) 23/06/2026 (follow-up): HR 78-82 bpm, BP 120/60 mmHg, Temperature 37 °C, SpO2 98% - stable and improving.

Skin: Dry and itchy. No acanthosis nigricans. Mucous membranes pink. Cardiovascular: Heart sounds S1/S2 present, regular rhythm. No murmurs documented. Respiratory: Clear to auscultation bilaterally. No crackles or wheeze. No supplemental oxygen required. Abdomen: Soft, non-tender. No hepatosplenomegaly. Neurological: Conscious and oriented. GCS 15. Balance generally normal; occasional transient loss of balance by history consistent with peripheral neuropathy. Bilateral plantar numbness and tingling in a stocking distribution by history. Lower limbs: Bilateral pitting oedema from mid-lower leg to toes. Bilateral inguinal/groin surgical scars from previous vascular surgery.

Diabetic Hand and Foot Assessment:

Test	Result
Prayer's Sign	Normal
Shoulder Range of Motion	Normal
Tabletop Sign	Normal
Dupuytren's Contracture	Negative
Charcot's Foot	Absent

III. CASE SUMMARY

A 55-year-old woman with a known background of Type 2 Diabetes Mellitus (diagnosed 6 years ago at Trung Vuong Hospital, never on insulin), Hyperthyroidism, and Hypertension was admitted on 22 June 2026 via the Emergency Department presenting with fatigue, increased thirst, and weakness of the arms and legs. She reported urine frequency (3-4 times/day plus 1 time nocturia), she drinks 2 litres/day, she doesn't feel hungry alongside and she lost 10 kg of weight over 6 years. She reported bilateral plantar numbness and tingling, leg pain on prolonged walking, and occasional transient loss of balance despite generally normal balance. Hypoglycaemic episodes occur when meals are skipped. She has a history of bilateral inguinal/groin vascular surgery for arterial blockage (exact procedure unknown). She has no history of gestational diabetes or PCOS. Investigations were ordered including fasting blood glucose, HbA1c, thyroid function tests, complete blood count, renal and liver function, and urinalysis to evaluate glycaemic and thyroid status.

Subjective Symptoms:

Fatigue and generalised limb weakness (progressive over months).
✅ She has thirst with urgency to drink water - drinking approximately 2 litres/day.
Urine frequency of 3-4 times during daytime plus nocturia x1.
She eats 3 meals/day, diet unchanged.
Unintentional weight loss of approximately 10 kg over 6 years.
Bilateral plantar numbness and tingling.
Leg pain on prolonged walking.
Occasional transient loss of balance (balance generally normal).
Hypoglycaemic episodes (sweating, shakiness) when meals are skipped.
Bilateral lower limb oedema after prolonged ambulation.
Generalised skin itching.

Objective Signs:

Tachycardia on admission - HR 100 bpm (settling to 78-82 bpm by day 2).
BP 130/60 mmHg with low diastolic of 60 mmHg.
BMI 21.5 kg/m² - normal; significant weight loss by history.
Bilateral pitting oedema from mid-lower leg to toes.
No acanthosis nigricans.
Bilateral inguinal/groin surgical scars from previous vascular surgery.

IV. PROBLEM STATEMENT

Type 2 Diabetes Mellitus - clinically uncontrolled; persistent classical hyperglycaemic symptoms despite oral antidiabetic medication; insulin not yet initiated.
Hyperthyroidism - active disease on thiamazole; tachycardia and weight loss consistent with ongoing thyroid excess contributing to worsening glycaemic control.
Hypertension - known; BP 130/60 mmHg; low diastolic requires monitoring.
Peripheral Diabetic Neuropathy - clinically suspected; bilateral stocking-distribution numbness, leg pain, and occasional transient balance loss.
Past bilateral inguinal vascular surgery - exact procedure unknown; peripheral vascular reassessment indicated.

V. PRELIMINARY DIAGNOSIS AND DIFFERENTIAL DIAGNOSES

Preliminary Diagnosis:

Type 2 Diabetes Mellitus, uncontrolled
Hyperthyroidism (Toxic Thyroid Disease) - known diagnosis on thiamazole. Clinically active based on tachycardia, weight loss, and sweating on presentation. Suspected to be compounding glycaemic deterioration through increased insulin resistance.
Hypertension - known; on antihypertensive therapy. BP 130/60 mmHg on admission; low diastolic monitored.
Peripheral Diabetic Neuropathy - bilateral plantar numbness (stocking distribution), leg pain on walking, and occasional transient balance loss in the context of 6 years of poorly controlled T2DM.

Differential Diagnosis 1: Type 1 DM / LADA

For: Progressive weight loss; failure of oral agents; increasing insulin requirement.
Against: Age 55; gradual 6-year onset; family history of T2DM (sister); no ketoacidosis; no GDM or PCOS history.
Conclusion: T2DM remains the primary working diagnosis. GAD-65 antibodies may be checked at follow-up if clinically indicated.

Differential Diagnosis 2: Hyperthyroidism as Primary Driver of Hyperglycaemia

For: Active hyperthyroidism independently raises blood glucose via hepatic glucose output and insulin resistance; timing of glycaemic deterioration may correlate with thyroid decompensation.
Against: 6-year T2DM diagnosis predates current exacerbation; family history of T2DM; hyperthyroidism is an aggravating factor, not the sole cause.
Conclusion: Both conditions must be treated simultaneously.

VI. PARACLINICAL INVESTIGATIONS PROPOSED

Routine:

Complete Blood Count (CBC)
Biochemistry: Sodium, Potassium, Chloride, Creatinine, eGFR
Fasting blood glucose, HbA1c
Liver function tests (AST, ALT)
Urinalysis

Endocrine / Diagnostic:

TSH, Free T4
Urine ACR - nephropathy screening
Lipid panel
Thyroid ultrasound

Screening:

Dilated fundoscopy - retinopathy
10-g monofilament - neuropathy grading
Ankle-Brachial Index (ABI) - peripheral vascular status given prior inguinal surgery
Abdominal ultrasound

VII. PARACLINICAL INVESTIGATION RESULTS

Results from 22/06/2026. Only abnormal findings reported.

A. Abnormal Glycaemic Findings

HbA1c: 12.6% (Reference: <7%) - ↑↑ Critically High
Fasting Blood Glucose: 251 mg/dL (13.9 mmol/L) (Reference: 80-130 mg/dL) - ↑↑ Critically High

B. Abnormal Thyroid Function

TSH: 0.0027 uIU/mL (Reference: 0.35-4.94) - ↓↓ Suppressed - Active Hyperthyroidism

C. Abnormal Urinalysis

Urine Glucose: 111 mmol/L (Reference: Negative) - ↑↑ Glycosuria
Urine Specific Gravity: 1.032 (Reference: 1.005-1.030) - ↑ Elevated - dehydration/concentration

Ultrasound: normal liver, normal gallbladder, no ascites.

VIII. CURRENT / DEFINITIVE DIAGNOSIS

Definitive Diagnosis:

Type 2 Diabetes Mellitus, uncontrolled - confirmed by critically elevated HbA1c and fasting blood glucose in the clinical context of classical hyperglycaemic symptoms in a patient with a 6-year history of T2DM never previously on insulin. Glycosuria further supports the degree of chronic hyperglycaemia.

Comorbidities: 2. Hyperthyroidism (Toxic Thyroid Disease) - confirmed by suppressed TSH, consistent with clinically active hyperthyroidism. Active disease is a direct contributor to worsening insulin resistance and increased hepatic glucose output, compounding glycaemic failure. 3. Hypertension - known, on antihypertensive therapy. BP 130/60 mmHg on admission. Diastolic 60 mmHg requires monitoring to avoid over-treatment. 4. Peripheral Diabetic Neuropathy - confirmed clinically by bilateral stocking-distribution plantar numbness and tingling, leg pain on walking, and occasional transient loss of balance in the setting of 6 years of poorly controlled T2DM with confirmed chronic hyperglycaemia.

IX. TREATMENT PLAN

Pharmacological Treatment

1. Diabetes Mellitus

Mixtard 30 (Biphasic Human Insulin 30/70) - 16 IU, twice daily. Max: titrate up to dose that achieves fasting glucose 80-130 mg/dL; no fixed ceiling - adjusted per response.
Metformin XR 750 mg - 750 mg, once daily (evening). Max: 2000 mg/day.

2. Hypertension

Irbesartan 150 mg - 150 mg, once daily (morning). Max: 300 mg/day.

3. Hyperthyroidism

Thiamazole (Thyrozol) 5 mg - 10 mg (2 tablets), once daily (morning). Max: 20 mg/day.

4. Peripheral Diabetic Neuropathy

Pregabalin 75 mg - 75 mg, twice daily (morning and evening). Max: 600 mg/day.

5. Rehydration - Admission Day Only

Ringer Lactate - 500 mL IV, once on admission day only.

Non-Pharmacological Treatment

Diet: Diabetic rice diet (DD01-Com). Limit rice to 1/2-3/4 cup per meal across 3 evenly spaced meals. Increase vegetables and lean protein. Avoid refined carbs, added sugars, and excess sweet potato. Sodium <2,300 mg/day. Fluid ~2 L/day. Never skip meals - carry 15 g fast-acting glucose at all times.
Exercise: 150 min/week moderate aerobic activity. Start with 30-min daily flat-surface walks. Add resistance training 2-3x/week when tolerated. Check glucose before and after exercise. Supervised initially due to fall risk.
Patient Education: SMBG fasting 80-130 mg/dL; post-meal <180 mg/dL. Insulin injection technique and site rotation. Hypoglycaemia recognition and 15-15 rule. Sick-day rules. Daily foot inspection; no barefoot walking. All GDSK nurse educator items completed.
Foot and Fall Care: Monofilament testing every visit. Podiatry referral for diabetic footwear. Non-slip footwear at home; clear floor hazards. Physiotherapy for balance training. ABI to assess peripheral vascular status.

X. MONITORING AND FOLLOW-UP

HbA1c - every 3 months until <7.0%, then 6-monthly.
Fasting blood glucose (SMBG) - daily; target 80-130 mg/dL.
Post-meal blood glucose (SMBG) - daily; target <180 mg/dL at 2 hours.
TSH and Free T4 - every 6-8 weeks until euthyroid, then every 3-6 months.
Urine Albumin-to-Creatinine Ratio (ACR) - at first outpatient follow-up visit (not done this admission); target <30 mg/g.
Renal function (Creatinine, eGFR) - annually; target eGFR >60 mL/min.
Lipid panel - annually; target LDL <100 mg/dL.
Dilated fundoscopy - annually for diabetic retinopathy screening.
Foot examination (monofilament) - every clinic visit; annual formal assessment.
Ankle-Brachial Index (ABI) - at first follow-up visit given prior bilateral inguinal vascular surgery; then annually.
Blood pressure - every clinic visit; target <130/80 mmHg.
Pregabalin response - review at 4 weeks; adjust dose based on symptom control.
Body weight and BMI - every visit.
Vaccinations - influenza annually; pneumococcal once; COVID booster per local guidelines.
Endocrinology review - 2 weeks post-discharge, then as directed by specialist.

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