Here is the fully corrected medical record:
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
BHYT (Health Insurance) Number: GD4797936717703790 26
Date and time of admission: 22 June 2026, 07:18 (admitted via Emergency)
Date of medical record: 22–23 June 2026
Attending Physician: BS. Cao Thi Minh
Ward / Room / Bed: Khoa Noi Tiet - Tong Hop / Room 8
II. MEDICAL INQUIRY SECTION
1. Reason for Hospitalization
Fatigue, weakness of arms and legs, and poor glycaemic control in known Type 2 Diabetes Mellitus not previously on insulin.
2. Medical History (by patient and family)
Onset and Progression:
The patient is a 55-year-old woman with a known background of Type 2 Diabetes Mellitus who presented with progressively worsening symptoms of hyperglycaemia, generalised fatigue, and limb weakness over recent months. She had never been started on insulin. Her oral antidiabetic medications had been insufficient to control her blood glucose, and her symptoms had been progressively worsening over 2 years. She also has a known background of hyperthyroidism on thiamazole and hypertension on antihypertensive therapy.
Polyuria:
3–4 voids per day plus 1 void at night. Urine volume correlates with fluid intake. Urine colour dark, consistent with concentrated urine and mild dehydration.
Polydipsia:
Thirst present; drinking approximately 2 litres per day.
Polyphagia:
3 meals per day (rice, fish, meat, sweet potato).
Weight loss:
Approximately 10 kg over 2 years, unintentional.
Fatigue and weakness:
Generalised; involving both arms and legs.
Peripheral neuropathy symptoms:
- Numbness and tingling on the plantar surface of both feet (stocking distribution).
- Leg pain on prolonged walking.
- Occasional loss of balance.
- Sweating and shakiness when meals are missed (hypoglycaemic episodes).
Oedema:
Bilateral swelling from mid-lower leg to toes appearing after prolonged ambulation.
Skin:
Intermittent itching affecting the arms and whole body; mild dehydration clinically. No acanthosis nigricans.
Negative findings: No blurred vision. No recurrent infections. Normal wound healing. No nausea, vomiting, or abdominal pain. No gestational diabetes history.
Thyroid: Known hyperthyroidism (toxic thyroid disease). On thiamazole prior to this admission. Symptoms of hyperthyroidism may be contributing to the patient's tachycardia, weight loss, and worsening glucose control.
3. Past Medical History
- Type 2 Diabetes Mellitus: Known. Not previously on insulin. Progressive deterioration in glycaemic control prompting this admission.
- Hyperthyroidism (Toxic Thyroid Disease): Known. On thiamazole.
- Hypertension: Known. On antihypertensive therapy.
- Family history: Sister with Type 2 Diabetes Mellitus.
- No history of previous surgeries.
- 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)
- Mild dehydration noted clinically.
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. Ultrasound: normal liver, normal gallbladder, uterus small/atrophic (postmenopausal), no ascites.
Neurological: Conscious and oriented. GCS 15. History of bilateral plantar numbness and tingling (stocking distribution) and episodic loss of balance consistent with peripheral neuropathy.
Lower limbs: Bilateral pitting oedema from mid-lower leg to toes.
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 (not previously on insulin), Hyperthyroidism, and Hypertension was admitted to Trung Vuong Hospital on 22 June 2026 via the Emergency Department. She presented with progressively worsening fatigue and generalised limb weakness over several months, accompanied by the classical triad of diabetic symptoms — polyuria, polydipsia, and polyphagia — alongside unintentional weight loss of approximately 10 kg over 2 years. She reported bilateral plantar numbness and tingling in a stocking distribution, leg pain on walking, occasional loss of balance, and episodes of sweating and shakiness when meals are skipped. Bilateral lower limb oedema appeared after prolonged ambulation. She has a concurrent history of known hyperthyroidism on thiamazole, which may be contributing to her worsening metabolic state. On admission she was tachycardic at 100 bpm with mild dehydration. Investigations were ordered including fasting blood glucose, HbA1c, thyroid function tests, full blood count, renal and liver function, and urinalysis to evaluate glycaemic and thyroid status.
Subjective Symptoms:
- Fatigue and generalised limb weakness (progressive over months).
- Polyuria — 3–4 voids/day plus nocturia x1.
- Polydipsia — approximately 2 litres/day.
- Polyphagia — 3 meals/day, diet unchanged.
- Unintentional weight loss of approximately 10 kg over 2 years.
- Bilateral plantar numbness and tingling (stocking distribution).
- Leg pain on prolonged walking.
- Occasional loss of balance.
- 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 a low diastolic of 60 mmHg.
- BMI 21.5 kg/m² — normal; weight loss noted by history.
- Mild dehydration on examination.
- Bilateral pitting oedema from mid-lower leg to toes.
- No acanthosis nigricans.
- Neuropathic symptoms on history — bilateral stocking distribution.
IV. PROBLEM STATEMENT
- Type 2 Diabetes Mellitus — clinically uncontrolled based on persistent hyperglycaemic symptoms (polyuria, polydipsia, polyphagia, weight loss, fatigue) despite oral antidiabetic medication; insulin not yet initiated.
- Hyperthyroidism — known active disease on thiamazole; tachycardia and weight loss on presentation are consistent with ongoing thyroid excess; may be directly worsening glycaemic control.
- Hypertension — known; BP 130/60 mmHg on admission; low diastolic requires monitoring.
- Peripheral Diabetic Neuropathy — clinically suspected based on bilateral plantar numbness (stocking distribution), leg pain on walking, and episodic loss of balance in the context of longstanding poorly controlled diabetes.
- Fall risk — moderate (Morse Scale 35 points); balance impairment from neuropathy.
- Diabetic nephropathy screening — urine ACR not yet performed; indicated given diabetes duration and neuropathy.
V. PRELIMINARY DIAGNOSIS AND DIFFERENTIAL DIAGNOSES
Preliminary Diagnosis:
Type 2 Diabetes Mellitus, uncontrolled — clinically suspected based on the classical triad of polyuria, polydipsia, and polyphagia with progressive unintentional weight loss of 10 kg over 2 years, fatigue, and generalised limb weakness in a 55-year-old woman with a known diagnosis of T2DM. The failure of oral antidiabetic therapy and progressive symptom burden indicate inadequate glycaemic control. Insulin initiation is clinically indicated.
Hyperthyroidism (Toxic Thyroid Disease) — known diagnosis on thiamazole. Clinically active disease is suspected based on the presence of tachycardia (HR 100 bpm on admission), unintentional weight loss, excessive sweating, and known suppressed thyroid axis. Active hyperthyroidism is a recognised cause of worsening insulin resistance and increased hepatic glucose output, and is likely contributing to the failure of glycaemic control in this patient.
Hypertension — known diagnosis on antihypertensive therapy. BP on admission 130/60 mmHg. The low diastolic pressure (60 mmHg) warrants careful monitoring to avoid over-treatment.
Peripheral Diabetic Neuropathy — clinically suspected based on bilateral plantar numbness and tingling in a stocking distribution, leg pain on prolonged walking, and episodic balance loss in the context of longstanding poorly controlled diabetes. The presence of occasional hypoglycaemia unawareness (sweating and shakiness as primary symptoms rather than neurogenic warning symptoms) further supports autonomic neuropathic involvement.
Differential Diagnosis 1: Type 1 Diabetes Mellitus / Latent Autoimmune Diabetes in Adults (LADA)
Clinical reasoning:
- For: Significant unintentional weight loss over 2 years, progressive failure of oral antidiabetic agents, and no history of response adequate to control symptoms could suggest insulin deficiency from autoimmune beta-cell destruction.
- Against: Age of 55 years at presentation, gradual onset over years rather than acute decompensation, positive first-degree family history of T2DM (sister), absence of ketones clinically, and the pattern of metabolic syndrome risk factors (hypertension, hyperthyroidism as aggravating factor) are more consistent with T2DM. No ketoacidosis features clinically.
- Conclusion: T2DM remains the primary working diagnosis. GAD-65 antibody testing may be considered at follow-up if clinical picture remains atypical after treatment initiation.
Differential Diagnosis 2: Hyperthyroidism as the Primary Driver of Hyperglycaemia
Clinical reasoning:
- For: Known hyperthyroidism, weight loss, tachycardia, sweating, and clinical features of excess thyroid hormone. Hyperthyroidism independently causes hyperglycaemia through increased hepatic glucose production and peripheral insulin resistance. The timing of glycaemic deterioration may correlate with a period of inadequate thyroid control.
- Against: The patient has a longstanding diagnosis of T2DM predating the current exacerbation, with a positive family history. Hyperglycaemia is therefore multifactorial — T2DM is the primary substrate and active hyperthyroidism is a concurrent, treatable aggravating factor rather than the sole cause.
- Conclusion: Both conditions must be diagnosed and treated simultaneously. Thyroid optimisation will improve but not fully resolve glycaemic control.
VI. PARACLINICAL INVESTIGATIONS PROPOSED
Routine:
- Full Blood Count (FBC)
- Biochemistry: Sodium, Potassium, Chloride, Creatinine, eGFR
- Fasting blood glucose
- HbA1c
- Liver function tests (AST, ALT)
- Urinalysis
Endocrine / Diagnostic:
- TSH, Free T4 — to assess thyroid status
- Urine Albumin-to-Creatinine Ratio (ACR) — diabetic nephropathy screening
- Lipid panel (LDL, HDL, Triglycerides, Total Cholesterol)
- Thyroid ultrasound
Screening / Monitoring:
- Dilated fundoscopy — diabetic retinopathy screening
- 10-g monofilament foot examination — peripheral neuropathy grading
- Abdominal ultrasound
- Blood pressure monitoring
VII. PARACLINICAL INVESTIGATION RESULTS
Results from 22/06/2026. Only abnormal findings are reported.
A. Abnormal Glycaemic Findings
| Test | Result | Reference Range | Flag |
|---|
| HbA1c | 12.6% | <7% | ↑↑ Critically High |
| Fasting Blood Glucose | 251 mg/dL (13.9 mmol/L) | 80–130 mg/dL | ↑↑ Critically High |
B. Abnormal Thyroid Function
| Test | Result | Reference Range | Flag |
|---|
| TSH | 0.0027 uIU/mL | 0.35–4.94 | ↓↓ Suppressed — Active Hyperthyroidism |
C. Abnormal Urinalysis
| Parameter | Result | Reference | Flag |
|---|
| Glucose | 111 mmol/L | Negative | ↑↑ Glycosuria |
| Specific Gravity | 1.032 | 1.005–1.030 | ↑ Elevated — dehydration/concentration |
(Full Blood Count, electrolytes, renal function, liver enzymes, and abdominal ultrasound were all within normal limits.)
VIII. CURRENT / DEFINITIVE DIAGNOSIS
Lab Findings Supporting Diagnoses:
- HbA1c 12.6% and Fasting Blood Glucose 251 mg/dL confirm critically uncontrolled Type 2 Diabetes Mellitus, reflecting chronic hyperglycaemia over the preceding 2–3 months. These values indicate a level of glycaemic failure for which insulin initiation is mandatory.
- TSH 0.0027 uIU/mL (suppressed) confirms active hyperthyroidism. This is consistent with the clinical findings of tachycardia and weight loss at presentation. Excess thyroid hormone increases hepatic glucose production and peripheral insulin resistance, directly worsening diabetic control — as clinically suspected.
- Glycosuria 111 mmol/L confirms overflow glycosuria from sustained hyperglycaemia exceeding the renal glucose threshold, consistent with the clinical presentation.
- Urine specific gravity 1.032 confirms urinary concentration from osmotic diuresis secondary to hyperglycaemia and dehydration, consistent with the clinical appearance of mild dehydration on admission.
Confirmed Diagnoses:
- Type 2 Diabetes Mellitus, uncontrolled — confirmed by HbA1c 12.6%, fasting glucose 251 mg/dL, and glycosuria in the clinical context of classical hyperglycaemic symptoms.
- Hyperthyroidism (Toxic Thyroid Disease) — confirmed by TSH 0.0027 uIU/mL; active disease contributing to worsening insulin resistance and glycaemic failure.
- Hypertension — known diagnosis; BP 130/60 mmHg on admission.
- Peripheral Diabetic Neuropathy — clinically confirmed by bilateral stocking-distribution numbness and tingling, leg pain on walking, and episodic balance loss in the setting of confirmed longstanding poorly controlled diabetes.
IX. TREATMENT PLAN
Pharmacological Treatment
1. Diabetes Mellitus — Glycaemic Management
| Drug | Dose | Route | Timing | Titration | Duration |
|---|
| Mixtard 30 (Biphasic Human Insulin 30/70) | Start 16 IU | SC | Morning + Evening, 30 min before meals | Increase by 2 IU every 3 days if fasting glucose remains >130 mg/dL; reduce by 2 IU if fasting glucose <80 mg/dL or hypoglycaemia occurs | Long-term; dose reviewed at every follow-up |
| Metformin XR (Glucophage XR) 750 mg | 750 mg | PO | Evening with meal | No titration needed at this dose; may uptitrate to 1500 mg/day after 4 weeks if tolerated and renal function stable | Long-term; indefinite |
| Sitagliptin (Mebista) 50 mg | 50 mg | PO | Morning | No titration required | Long-term; indefinite |
Note: A GLP-1 receptor agonist should be added after initial glycaemic stabilisation. Prescribe Semaglutide 0.25 mg SC once weekly for 4 weeks, then uptitrate to 0.5 mg SC once weekly for 4 weeks, then to 1.0 mg SC once weekly as the maintenance dose. This is indicated for T2DM with cardiovascular risk factors and also supports the unintentional weight trend. An SGLT2 inhibitor — Empagliflozin 10 mg PO once daily in the morning — should also be considered at the first outpatient follow-up for cardiovascular and renal protection (eGFR 94 mL/min — eligible).
2. Hypertension
| Drug | Dose | Route | Timing | Titration | Duration |
|---|
| Irbesartan (Ibartain MR) 150 mg | 150 mg | PO | Morning | If BP remains >130/80 mmHg at 4-week review, uptitrate to 300 mg once daily. Do not increase if diastolic <60 mmHg. | Long-term; indefinite |
ARB is the preferred antihypertensive in diabetic patients for nephroprotection. Target BP <130/80 mmHg. Current diastolic 60 mmHg — monitor carefully before uptitration.
3. Hyperthyroidism
| Drug | Dose | Route | Timing | Titration | Duration |
|---|
| Thiamazole (Thyrozol) 5 mg | 10 mg (2 tablets) | PO | Morning | Recheck TSH and Free T4 at 6–8 weeks. If TSH remains suppressed, maintain dose or increase to 15–20 mg/day per endocrinology guidance. If TSH normalises, reduce to 5 mg once daily as maintenance. | Minimum 12–18 months; long-term per endocrinology |
Active hyperthyroidism with suppressed TSH is a confirmed contributor to this patient's glycaemic failure. Achieving euthyroid state will improve insulin sensitivity and reduce hepatic glucose output. Endocrinology specialist referral is recommended for long-term thyroid management planning (including consideration of radioiodine therapy or surgery).
4. Peripheral Diabetic Neuropathy — Symptomatic Relief
| Drug | Dose | Route | Timing | Titration | Duration |
|---|
| Pregabalin 75 mg | 75 mg | PO | Twice daily — morning and evening | After 1 week, if tolerated and pain not adequately controlled, uptitrate to 150 mg twice daily. Maximum dose: 300 mg twice daily. Reduce dose if dizziness or sedation occurs. | Long-term; reassess at 3-monthly intervals |
Pregabalin is the first-line agent for painful distal symmetric diabetic polyneuropathy. It addresses the patient's plantar pain, tingling, and balance-affecting discomfort. Primary treatment of neuropathy is through glycaemic optimisation — pregabalin provides symptomatic relief in parallel.
5. Rehydration — Admission Day Only
| Fluid | Volume | Route | Rate | Duration |
|---|
| Ringer Lactate | 500 mL | IV infusion | Over 4–6 hours | Admission day only; discontinue once oral intake is established |
Non-Pharmacological Treatment
1. Medical Nutrition Therapy (MNT):
- Hospital diet: DD01-Com (diabetic rice diet).
- Carbohydrate control: limit rice to 1/2–3/4 cup cooked per meal; distribute evenly across 3 meals.
- Avoid excess sweet potato and all refined starches and sugars.
- Increase non-starchy vegetables at every meal; lean protein at each meal (fish is appropriate).
- Limit sodium to <2,300 mg/day; eliminate sugar-sweetened beverages and added sugars.
- Maintain fluid intake approximately 2 litres per day.
- Never skip meals — patient has documented hypoglycaemic episodes on meal skipping. Carry 15 g fast-acting glucose at all times (15-15 rule).
2. Physical Activity:
- Target: minimum 150 minutes per week of moderate-intensity aerobic activity, spread across at least 3 days/week with no more than 2 consecutive rest days.
- Begin with 30-minute daily low-impact walks on flat surfaces, given leg pain and neuropathy.
- Resistance/strength training 2–3 times per week when tolerated (shown to improve insulin sensitivity).
- Check blood glucose before and after exercise; treat hypoglycaemia promptly with 15 g glucose.
- Avoid prolonged sedentary periods; break sitting every 30 minutes.
- Exercise to be supervised initially given balance impairment from neuropathy — fall risk.
3. Diabetes Self-Management Education (DSMES):
- SMBG technique: fasting target 80–130 mg/dL; 2-hour post-meal target <180 mg/dL. CGM recommended for patients on insulin.
- Insulin injection technique: correct 90° angle, site rotation (abdomen → thigh → upper arm in sequence), proper storage (refrigerator; discard open pen after 28 days at room temperature).
- Hypoglycaemia protocol: recognise sweating and shakiness; treat immediately with 15 g glucose; recheck in 15 minutes; repeat if still <70 mg/dL.
- Sick-day management: never stop insulin when unwell; increase monitoring to every 2–4 hours; contact physician if glucose >300 mg/dL or unable to eat.
- Foot care: daily inspection of both feet (mirror if needed), appropriate closed-toe footwear at all times, no barefoot walking, report any wound, colour change, or loss of sensation immediately.
- Medication adherence: explain that consistent thiamazole use is critical — normalising thyroid function will directly help glucose control.
- All GDSK nurse educator documentation completed: diet, exercise, medication, warning signs, and safety.
4. Foot Care and Fall Prevention:
- Formal 10-g monofilament testing and vibration assessment at every clinic visit.
- Podiatry referral: diabetic footwear prescription and orthotics assessment.
- Fall prevention education: non-slip footwear at home, clear floor of hazards, use handrail on all stairs.
- Physiotherapy referral: balance and proprioceptive gait training given neuropathic balance impairment.
X. MONITORING AND FOLLOW-UP
| Parameter | Target | Frequency |
|---|
| HbA1c | <7.0% | Every 3 months until target reached, then 6-monthly |
| Fasting blood glucose | 80–130 mg/dL | Daily SMBG; CGM recommended (on insulin) |
| 2-hour post-meal glucose | <180 mg/dL | Daily SMBG |
| TSH and Free T4 | TSH 0.35–4.94 | Every 6–8 weeks until euthyroid; then every 3–6 months |
| Urine ACR | <30 mg/g | First outpatient visit (not done this admission) |
| Renal function (Creatinine, eGFR) | eGFR >60 | Annually |
| Lipid panel | LDL <100 mg/dL | Annually |
| Dilated fundoscopy | No retinopathy | Annually |
| Comprehensive foot exam | No ulcer/deformity | Every clinic visit; annual formal monofilament |
| Blood pressure | <130/80 mmHg | Every clinic visit |
| Body weight and BMI | Stable/improving | Every visit |
| Pregabalin response | Pain reduction | Review at 4 weeks; adjust dose |
| Vaccinations | Up to date | Influenza annually; Pneumococcal once; COVID booster per local guidelines |
| Endocrinology review | Euthyroid state | 2 weeks post-discharge; then per specialist |
Attending Physician: BS. Cao Thi Minh
Khoa Noi Tiet - Tong Hop, Trung Vuong Hospital, Ho Chi Minh City
Date: 22–23 June 2026
