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23/06/2026 Polyuria - she urinate 3 to 4 time in day and 1 time in night She told pee normal but depends on the fluids she pee a lot or small She have dark urine color Polydipsia - She feels thirsty and she drink 2 litres a day Polyphagia - She take 3 meals a day and she eat more rice, fish , meats and sweet potatoe And she doesn't feel hungry after eating a meal Weight change - She had a weight loss about 10 kg in 2 yr Fatigue and weakness - She feel tried and she have weak in arms and legs And No blurred vision, no recurrent infection , she have normal wound healing She have itching in arms and sometimes she have whole body itching No gestational diabetes She have no nausea, vomiting, abnormal pain She have sweating and shakiness if she didn't take a meal or miss a meal She have swelling from lower half the leg till toes if the walk long time She have numbness and tingling plantar surface of the foot and she have pain in leg if the walk long time She have loss of balance sometimes She have normal skin with little dehydration and itchy and no acanthosis nigricans She have thyroid disease Family history - her sister have diabetes mellitus She have no history of smoking, alcohol She have normal to little difficult to do daily basis As in medical record she have HbA1c is 12.6% and DMMM is 251 mg/ dl The prayers sign is normal Normal shoulder ROM Tabletop sign is normal Dupuytren's contracture is negative Charcot's foot is absent. From the given internal medicine presentation file medical record format make me a medical record with the information in the image and translated and information I gave now and for treatment and management ( pharmacology and non pharmacological) give me according to the ADA 2026 guidelines

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ADA 2026 Standards of Care diabetes glycemic targets HbA1c treatment algorithm

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INTERNAL MEDICINE CLINICAL PRESENTATION

Patient: Chau Thi Bich Diep | DOB: 16/05/1971 | Age: 55F | Admission: 22/06/2026 Trung Vuong Hospital, Ho Chi Minh City - Khoa Noi Tiet - Tong Hop

I. ADMINISTRATIVE DATA

Field	Details
PID	70131126012722
Admission No.	26/014363
Address	Ap 1, Xa Vinh Loc, HCMC
BHYT No.	GD4797936717703790 26
Ward	Khoa Noi Tiet - Tong Hop, Room 8
Admitting Doctor	BS. Cao Thi Minh
Admitted	22/06/2026 at 07:18 via Emergency

II. CHIEF COMPLAINT

Fatigue, weakness of arms and legs, and poor glycaemic control in known T2DM not previously on insulin.

III. HISTORY OF PRESENT ILLNESS

Polyuria: 3-4 voids/day + 1 at night. Urine volume correlates with fluid intake. Urine colour: dark (suggests dehydration/hyperglycaemic concentration).

Polydipsia: Thirst present; drinking approximately 2 litres/day.

Polyphagia: 3 meals/day (rice, fish, meat, sweet potato). Does not feel satisfied after eating.

Weight loss: Approximately 10 kg over 2 years (unintentional).

Fatigue & weakness: Generalised, involving 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 after prolonged ambulation.

Skin: Intermittent itching (arms + whole body); mild dehydration; no acanthosis nigricans.

Negative findings: No blurred vision, no recurrent infections, normal wound healing, no nausea/vomiting/abdominal pain, no gestational diabetes history.

Thyroid: Known thyroid disease (hyperthyroidism).

IV. PAST MEDICAL HISTORY

Condition	ICD-10
Type 2 Diabetes Mellitus (uncontrolled, not on insulin)	E11.9
Hyperthyroidism (Cuong giap)	E05
Hypertension	I10
Ischaemic Heart Disease	I25.5
Mixed Dyslipidaemia	E78.2

V. FAMILY & SOCIAL HISTORY

Sister: Type 2 Diabetes Mellitus
Smoking: None | Alcohol: None
Diet: Rice-based, 3 meals/day; fish, meat, sweet potato
Function: Normal to mildly limited ADLs; independent in eating, bathing, dressing, ambulation

VI. PHYSICAL EXAMINATION

Vital Signs (Admission 22/06/2026):


Temperature	37.0 °C
Heart Rate	100 bpm
BP	130/60 mmHg
RR	20/min
SpO2	98%
Weight/BMI	55 kg / 21.5 kg/m2
GCS	15/15

23/06/2026 (nursing): HR 78-82, BP 120/60, T 37, SpO2 98% - stable and improving

General: Alert, oriented, no acute distress, mild dehydration Skin: Dry, itchy; no acanthosis nigricans; mucous membranes pink CVS: Regular rhythm; no murmurs documented Resp: Normal pattern; no supplemental O2 Abdomen: Soft; ultrasound normal (no hepatomegaly, no gallstones, no ascites) Neuro: GCS 15; peripheral neuropathy symptoms by history; balance loss occasional Lower limbs: Bilateral pitting oedema mid-leg to toes

Diabetic Hand/Foot Assessment:

Test	Result
Prayer's Sign	Normal
Shoulder ROM	Normal
Tabletop Sign	Normal
Dupuytren's Contracture	Negative
Charcot's Foot	Absent

VII. INVESTIGATIONS

FBC (22/06/2026) - ALL NORMAL: WBC 9.69 | Hgb 14.2 g/dL | HCT 43.6% | PLT 212 | MCV 92 fL

Biochemistry:

Test	Result	Reference	Status
Creatinine	61 umol/L	45-84	Normal
eGFR	94 mL/min/1.73m2	>90	Normal
Na	135 mmol/L	135-145	Normal
K	4.0 mmol/L	3.5-5.1	Normal
Cl	102 mmol/L	98-108	Normal
AST	10 U/L	<35	Normal
ALT	4 U/L	<35	Normal
HbA1c	12.6%	<7%	CRITICALLY HIGH
Fasting BG	251 mg/dL	80-130	CRITICALLY HIGH

Thyroid Function:

Test	Result	Reference	Status
TSH	0.0027 uIU/mL	0.35-4.94	SUPPRESSED - Hyperthyroid
Free T4	1.02 ng/dL	0.70-1.48	Normal (upper range)

Urinalysis: Glucose 111 mmol/L (glycosuria) | Protein: Negative | Ketones: Negative | Blood: Negative | SG: 1.032

Abdominal USS (22/06/2026): No abnormal findings. Liver normal. Gallbladder normal. Uterus: small/atrophic. Conclusion: No current abnormal findings.

VIII. DIAGNOSES

Type 2 Diabetes Mellitus, uncontrolled (E11.9) - HbA1c 12.6%, FBG 251 mg/dL
Hyperthyroidism (E05) - TSH suppressed at 0.0027
Hypertension (I10)
Ischaemic Heart Disease (I25.5)
Mixed Dyslipidaemia (E78.2)
Peripheral Diabetic Neuropathy - symptomatic (plantar numbness, balance loss)
Fall risk: Moderate (35 points) | Pressure injury risk: Low (23 points)

IX. TREATMENT & MANAGEMENT (ADA 2026 Standards of Care)

GLYCAEMIC TARGETS (ADA 2026 - Individualised)

Target	Goal
HbA1c	<7.0% (current 12.6% - aggressive reduction needed)
Fasting glucose	80-130 mg/dL
Post-prandial glucose	<180 mg/dL
Time in Range (TIR 70-180)	>70%
Time Below Range (<70 mg/dL)	<4%
BP	<130/80 mmHg
LDL-C (with IHD)	<70 mg/dL

PHARMACOLOGICAL MANAGEMENT

A. Diabetes - Current Inpatient Regimen:

Drug	Dose	Route	Timing	Rationale
Mixtard 30 (Biphasic rDNA Insulin)	16 IU (increased from 14 IU)	SC	Morning + Evening	ADA 2026: Insulin indicated for HbA1c >10% or symptomatic hyperglycaemia
Glucophage XR (Metformin HCl) 750 mg	750 mg	PO	Evening	ADA 2026: First-line oral agent; safe with eGFR 94
Mebista 50 mg (Sitagliptin)	50 mg	PO	Morning	ADA 2026: DPP-4i adds modest A1c reduction; low hypoglycaemia risk

ADA 2026 Additional Recommendations (not yet prescribed - prioritize after stabilization):

GLP-1 Receptor Agonist (e.g., Semaglutide SC weekly): STRONGLY INDICATED - ADA 2026 recommends GLP-1 RA with proven CV benefit for T2DM + established ASCVD (IHD present); also aids weight management
SGLT2 Inhibitor (e.g., Empagliflozin 10 mg daily): CV and renal protection benefit; consider after discharge given eGFR 94

B. Hypertension:

Irbesartan 150 mg once daily (ARB - ADA 2026 preferred agent for DM + HTN + IHD)
Monitor diastolic closely (current 60 mmHg - avoid over-treatment)

C. Ischaemic Heart Disease / Antiplatelet:

Clopalvix 75 mg (Clopidogrel) once daily - ADA 2026: antiplatelet therapy indicated for established ASCVD

D. Dyslipidaemia:

Sterolow 20 mg (Rosuvastatin) once daily evening
ADA 2026: High-intensity statin recommended for T2DM + ASCVD
Recommendation: Uptitrate to Rosuvastatin 40 mg or add Ezetimibe to achieve LDL <70 mg/dL

E. Hyperthyroidism:

Thyrozol 5 mg (Thiamazole) 10 mg once daily (2 tablets morning)
Critical note: Suppressed TSH (0.0027) worsens glycaemic control by increasing hepatic glucose output and peripheral insulin resistance. Thyroid optimisation is essential for diabetes management. Endocrinology referral recommended.

F. Admission IV Fluid:

Ringer Lactate 500 mL (Ca/K/Na/NaCl): for rehydration and electrolyte correction on admission day

NON-PHARMACOLOGICAL MANAGEMENT (ADA 2026)

A. Medical Nutrition Therapy:

Hospital diet: DD01-Com (diabetic rice diet)
Reduce refined carbohydrates; limit rice to 1/2-3/4 cup per meal; avoid sweet potato excess
Distribute intake evenly across 3 meals; never skip meals (patient has documented hypoglycaemia on meal skip)
Increase non-starchy vegetables; lean protein (fish is appropriate)
Limit sodium <2,300 mg/day; eliminate added sugars
Maintain 2 L fluid intake daily

B. Physical Activity (ADA 2026 - ≥150 min/week moderate aerobic):

Start with 30-minute daily low-impact walks (flat surface, given leg pain)
Seated exercises and resistance training 2-3x/week when tolerated
Monitor BG before and after exercise; treat hypoglycaemia with 15 g fast carbs immediately

C. Diabetes Self-Management Education (DSMES - ADA 2026):

Blood glucose self-monitoring (SMBG): fasting target 80-130 mg/dL
Hypoglycaemia recognition: symptoms = sweating/shaking; treat with 15 g glucose (15-15 rule)
Insulin injection technique, site rotation, proper storage
Foot care: daily inspection, proper footwear, no barefoot walking
Sick-day rules; medication adherence
All nurse educator (GDSK) items documented: diet, exercise, medication, warning signs, safety

D. Monitoring Schedule:

Parameter	Frequency
HbA1c	Every 3 months until target, then 6-monthly
Fasting + post-meal glucose	Daily SMBG; CGM recommended by ADA 2026 for T2DM on insulin
TSH / FT4	Every 3-6 months (TSH critically suppressed)
Renal function (Cr, eGFR, urine ACR)	Annually (ACR not yet done - order at follow-up)
Lipid panel	Annually (3-monthly after statin adjustment)
Dilated fundoscopy	Annually (retinopathy screening)
Comprehensive foot exam	Every visit; annual formal assessment
BP	Every clinic visit
Vaccinations	Influenza annually; Pneumococcal; COVID booster per local guidelines

X. DISCHARGE PLAN

Continue Mixtard 30 (dose titrated to home glucose logs), Metformin XR 750 mg, Sitagliptin 50 mg
Initiate GLP-1 RA (Semaglutide) - ADA 2026 strongly recommends for T2DM + IHD
Continue Irbesartan, Rosuvastatin (consider uptitration to 40 mg), Clopidogrel, Thiamazole
Follow-up: 2 weeks (outpatient Endocrinology); HbA1c recheck at 3 months
Urine ACR: order at next visit
Ophthalmology referral; podiatry/footwear advice; thyroid ultrasound per endocrinology

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Chau Thi Bich Diep Medical Record

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Key Clinical Points to Note:

HbA1c 12.6% is critically elevated - insulin initiation was appropriate and urgent
TSH 0.0027 (severely suppressed hyperthyroidism) is directly worsening glycaemic control and must be optimised in parallel with diabetes management
IHD present - ADA 2026 mandates GLP-1 RA with proven CV benefit (Semaglutide/Liraglutide) as part of the regimen; this has not yet been prescribed and should be added
Peripheral neuropathy is symptomatic - annual foot exam, monofilament testing, and podiatry referral are indicated
Urine microalbumin/ACR has not been checked this admission - order at first follow-up to screen for diabetic nephropathy

Make me a medical record from the internal medicine presentation medical record format and thses 3 are past medication and in polyphagia remove Does not feel satisfied after eating. And remove ICD and give me treatment and management as ADA 2026 guidelines but don't mention it and remove glycemic target and give me medication for the disease of the patient with dose and duration

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