Holistic Primary Care Management of Type 2 Diabetes Mellitus with Controlled Random Blood Glucose and Hyperuricemia in a 59-Year-Old Woman: A Case Report

Abstract

Type 2 diabetes mellitus is a chronic metabolic disease that requires long-term pharmacological treatment, lifestyle modification, and continuous primary care follow-up to prevent vascular and metabolic complications. This case report describes the holistic assessment and management of a 59-year-old woman with a known history of type 2 diabetes mellitus and hypertension who presented to Layang Primary Health Center with intermittent frontal headache, weakness, easy fatigability, and occasional hand cramps for one week. She reported treatment with metformin, glimepiride, and insulin; however, the documented treatment at the visit consisted of metformin 500 mg and glimepiride 2 mg. Physical examination showed a clinically stable patient with blood pressure of 119/62 mmHg, pulse rate of 78 beats/minute, respiratory rate of 21 breaths/minute, temperature of 36.3°C, and body mass index of 27.8 kg/m² calculated from the recorded weight and height. Random blood glucose was 119 mg/dL and serum uric acid was elevated at 8.1 mg/dL. Metformin and glimepiride were documented at the visit, accompanied by education to limit high-sugar foods, sweet drinks, excessive white rice, red meat, and high-purine foods, together with advice to increase water intake and attend monthly follow-up. The case highlights the importance of integrating clinical, dietary, family, and environmental assessment in primary care for diabetes, particularly when glycemic control appears acceptable but comorbid metabolic risks remain present.