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

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."

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

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. 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.

• 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

INTERNAL MEDICINE MEDICAL RECORD

I. ADMINISTRATIVE SECTION

II. MEDICAL INQUIRY SECTION

1. Reason for Hospitalization

2. Medical History

3. Past Medical History

4. Clinical Examination

III. CASE SUMMARY

• 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.

• 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

1. Type 2 Diabetes Mellitus, uncontrolled
2. 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.
3. Hypertension - known; on antihypertensive therapy. BP 130/60 mmHg on admission; low diastolic monitored.
4. 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.

• 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.

• 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

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

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

• 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

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

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

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

VIII. CURRENT / DEFINITIVE DIAGNOSIS

1. 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.

IX. TREATMENT PLAN

• 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.

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

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

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

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

1. 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.
2. 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.
3. 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.
4. 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.