DM Case Format

Identification & demographic details:

● Name:

● Age:

● Sex:

● Religion and caste:

● Education:

● Address:

● Occupation (both present and past, duration)

● Nearest health facility:

Family members

Pedigree chart

SES

History of presenting illness:

● K/c/o of DM since __________ years

● Onset: What symptoms were present before diagnosis (eg headache, polydipsia, polyuria,
polyphagia)
● How was it diagnosed & by whom?

● Duration

● Medication(type, dose, dose adjustment, adherence, side effects)

● What was the initial treatment taken and from where?

● Exercise

● Diet modification

● Complications: symptoms, screening

● Was it useful in relieving symptoms?

● Change of practitioners for treatment?

● Change in course of treatment over the years?

● Control of D.M - episodes of uncontrolled hyperglycaemic episodes?

● Symptoms of uncontrolled DM

● Latest measure of F.B.S

● Recurrent infections, UTI, delayed wound healing

History for complications of diabetes
● Diabetic neuropathy- Tingling/ numbness or pain in hands & foot

● Diabetic foot- Ulcers or abscess in foot or callous, cuts

● Diabetic Retinopathy/ Cataract- H/o vision problems

● Hypoglycemic episodes (if on sulphonyl urea or Insulin)- giddiness, sweating, palpitation,

black outs, loss of consciousness
● Any episodes of hospital admission for diabetic complications

● Transient ischemic attack- Sudden headache, transient loss of consciousness

● Cardiovascular complications- Sudden severe chest pain with sweating & radiation,
palpitations, shortness of breath, swelling of foot & face
● Respiratory disease: chronic cough with expectoration, breathlessness: duration,
aggravating/relieving factor, NHYA class
● Vision: using spectacles – near or distinct vision, duration of use

● Hearing problems

● Dentition - Eating or chewing problems

● ADL – 5 base (transferring from bed, toilet, bathing, dressing, eating)

● Bladder & bowel habits: symptoms of BPH

● Locomotor problems

Past history
● Hypertension/ Diabetes/Tuberculosis/UTI/hospitalization/surgical illness

● Stroke, Transient ischemic Attack, Myocardial Infarction, Asthma, COPD

● Long term intake of drugs like NSAIDS

● Tooth extraction- how many

Treatment history:
● Number of drugs taken along with dosing

● Side effects of drugs

● Procurement of drugs – pharmacy shop/government hospital/ private clinic

● Cost of drugs/ months

● Health care facilities availed

● Compliance to treatment – pill count/month

 ● Regularity of treatment (if not regular- reasons)

● Investigations: CBC, FBS, PPBS, HBA1C, LFT, RFT, ECG, thyroid function & others depending
on case

Personal history:
● Diet: Veg/ Mixed/ Vegan

● Saturated fat intake:

● Appetite: Normal/ Increased/ Decreased

● Bowel & bladder: Regular/ Irregular

● Sleep: Adequate/ Increased/ Decreased

● Physical exercise: Regularly/ Infrequently/ No, duration (min/day and days/week)

● Regular health checkup

● Addiction:
o Yes/ No (If yes, then specify Gutkha/ Pan-masala/ Tobacco chewing/ Smoking/
Alcohol/ IV drugs)
o Age of initiation
o Reason for starting
o Daily quantity
o Duration: ___
o Side effects/ disadvantages felt
o Efforts to quit
● If female, ask about menopause and obstetric history

Diet history
● Any dietary restrictions: sugar, salt, fats

● Total calories and proteins

● Intake of salt and fat

Treatment and investigation history: FBS/ PPBS/HbA1c, Total cholesterol, Triglycerides, HDL, LDL,
ECG, Urine albumin and sugar, urea, creatinine, cancer screening, fundoscopy

Epidemiological history:
● age at the onset of symptoms

● duration between onset and diagnosis

● duration between diagnosis and start of treatment

● prevalence of similar disease in the locality

Family history:
● Similar complaints in family members

● H/o cardiac death in family(1st degree relatives)

H/o cardiac disease, HTN, DM in family

Environmental history

Psychosocial history
● Symptoms of depression

● Family support

● Any discrimination or difficulty faced due to the disease

Examination:
● Conscious, cooperative, well-oriented to time, place and person
● Built: well/ fair/ poor
● Nutrition: well/ fair/ malnourished
● Anthropometry: height, weight, BMI, WHR

Vitals:
● Blood pressure (BP): ___________ mm Hg (At various postures)

● Pulse rate (PR): __________ beats/ min

● Respiratory rate (RR): __________ cycles/ min

● Temperature: ___________ degree F

● Pallor: Yes/ No

● Icterus: Yes/ No

● Clubbing: Yes/ No

● Cyanosis: Yes/ No

● Lymphadenopathy: Yes/ No

● Edema: Yes/ No

● Anthropometry:

● Built:

● Nourishment:

● Height: _________m

● Weight: ________kg

● BMI: __________ kg/ m2

 ● Waist hip circumference

Systemic examination:
● Cardiovascular system

● Respiratory system

● Nervous system (especially if there are signs of neuropathy or stroke)

Local Examination:
● Eyes: vision, Fundoscopic examination

● Thyroid

● Skin examination (for acanthosis nigricans and insulin injection sites)

Comprehensive foot examination

a. Inspection
b. Palpation of dorsalis pedis and posterior tibial pulses
c. Presence/absence of patellar and Achilles reflexes
d. Determination of proprioception, vibration, and monofilament sensation

Clinicosocial diagnosis:
A ___________ yr old male/ female _________ suffering from DM under control/ or uncontrolled,
regular or irregular treatment, __________comorbidities. He/she is an elderly person with _______
vision, _______ hearing & ADL score______. Compliance towards diet, medication and lifestyle
modification________

Levels of prevention:

Levels of prevention Which level has failed How it could be

prevented?
primary Health promotion

Specific protection

Secondary Early detection and

prompt treatment

tertiary Disability limitation

rehabilitation
KAP

Disease related Life style modification related

About the disease Causes: eg genetic, stressor, Diet : decrease sugar, oil intake, salty
idiopathic foods, fried fast foods intake

About Course of disease: life long, can't be cured but Increase physical activity, walking
can be controlled by taking drugs for life long atleast 30 mins per day

Compliance to drugs is very important, Side effects of Decrease intake of alcohol & smoking
drugs

Importance of regular visits to doctor & regular blood Decrease body weight
tests & B.P monitoring

Record keeping: prescriptions, OPD cards, Food specially restricted like sweets,
investigations & reports potato, rice for diabetes

Complications: TIA, stroke, vision problem, M.I &

danger signs, kidney & foot problems, Tingling &
numbness, recurrent infection, UTI, SOB, leg swelling,
hypoglycaemia unawareness

Attitude, Practise:

Influence of medico social factors in diagnosis, treatment, and prevention of the disease:

Impact of the disease on socio economic status of

● Family

● Community

● Nation

Medico social diagnosis:

MANAGEMENT:
Primordial prevention:
● Population strategy and high-risk strategy – reduction of risk factors
● Secondary prevention: early detection and treatment
● Tertiary prevention: organizing specialized rehabilitation clinics

Medical:
● Continue drug intake if adequate/ prescribe new drug if not controlled

● Encourage to seek treatment from government hospitals

● Referral if needed
 ● Blood sugar (FBS, PPBS) , HbA 1C if possible, urine albumin & sugar & RFT (serum creatinine,
urea, sodium, potassium), lipid profile, thyroid profile, ECG, chest X ray, (advice depending
the case)
● Cardiologist evaluation ( if needed)

● Ophthalmologist: fundus & other eye problems (if needed)

Non-pharmacological:
● Appreciate good practices

● Dietary advice: Depending upon the diet history, calories deficit, salt intake, oil intake &BMI,
advice multiple small meals a day
● Carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products
should be advised over intake from other carbohydrate sources, especially those that
contain added fats, sugars, or sodium
● Dietary fiber (14 g fiber/1,000 kcal) and to consume foods containing whole grains

● Increased consumption of foods containing long-chain omega-3 fatty acids (EPA and DHA)
and omega-3 linolenic acid (ALA) is recommended
● Regular monitoring of blood sugar

● Avoid smoking & alcohol(If patient chooses to drink alcohol

● Physical activity (ADA 2015 recommendation): at least 150 min/week of moderate-intensity

aerobicphysical activity (50–70% ofmaximum heart rate), spreadover at least 3 days/week
with nomore than 2 consecutive dayswithout exercise.
● If restricted activity : advice yoga& stretching exercises

● Explain side effects of drugs and importance of regular visits to hospital and treatment
adherence
● Explain danger signs: Weakness in limbs (TIA, stoke), sudden chest pain, sudden headache,
shortness of breath, leg swelling, oliguria, hypoglycemic symptoms like sweating/ giddiness
(to carry sugar/ candies in hand), decreased vision
● Muscle strengthening exercise for osteoarthritis (if present)

Diabetes related advice

● Leg & foot care: Methyl cellulose rubber (MCR) chappal, daily night time examination
using mirror, avoid moving on bare foot
● Decrease rice intake, avoid sugar & sweets

● Use of denture for poor dentition

Family level:
● Motivate the patient to take proper diet and drugs
 ● Motivate the patient for periodic checkup

● Family members: to undergo regular screening for hypertension

Community level:
● preventing emergence of risk factors (primordial prevention)

● early diagnosis and prompt treatment

● genetic counselling

● healthy lifestyle

● periodic health checkup

● regular monitoring of weight, BP, and blood sugar

Old age specific Advice:

● Adopt a positive attitude towards ageing (spiritual)

● Fall prevention: careful while going to bathroom & climbing stairs

● Socialise with family, relatives & neighbours

● Social schemes: old age pension scheme, widow pension scheme etc ( if eligible)

● If Osteoarthritis is present: Explain that it is a disease of old age, pain can only be controlled
but not cured completely, pain killer can be harmful and should be taken only on advice by a
doctor, exercises like muscle strengthening will help, to be ambulatory as much as possible,
use walking stick

Failures at the level of prevention: and Interventions given:

Primary prevention
Secondary prevention
Tertiary prevention
 Important points
Etiological Classification of Diabetes Mellitus:
● Type 1 diabetes (absolute insulin deficiency): It is mainly immune mediated or idiopathic
● Type 2 diabetes (relative insulin deficiency)
● Other specific types:
1. Genetic defect of beta cell function
2. Genetic defects in insulin action
3. Diseases of the exocrine pancreas
4. Endocrinopathies
5. Drug or chemical-mediated
6. Infections
7. Uncommon forms of immune mediated diabetes
8. Other genetic syndromes associated with diabetes
● Gestational diabetes mellitus

Malnutrition-related Diabetes Mellitus:

• It is previously known as tropical diabetes, pancreatic diabetes, ketosis-resistant diabetes of the
young
• It is associated with long-term malnutrition
• These patients are thin (BMI <19), young (less than 30 years of age), severely hyperglycemic but do
not have ketonuria and they require high doses of insulin
• There are two types of malnutrition-related diabetes:
1. Fibrocalculous pancreatic disorders (FCPD) (triad of FCPD is diabetes, pancreatic calculi and pain in
abdomen)
2. Protein deficient pancreatic diabetes

Classification of Antidiabetic Drugs and Insulin:

(a) Oral drugs:
• Releasing insulin: Sulfonyrueas (glipizide, gliclazide, glibenclamide) and meglitinides (repaglinide,
nateglinide)
• Other mechanism: Biguinides (metformin), thiazolidinediones (pioglitazone), alpha-glucosidase
inhibitors (acarbose), D2 agonist (bromocriptine)

(b) Parenteral:
• Insulin: Short-acting (regular insulin, semi-lente), intermediate acting (lente and neutral protamine
hegedron (NPH)), long acting (ultralente, protamine zinc insulin)
• GLP-Analogs: Exenatide
• DPP-4 inhibitor: Sitagliptin, vildagliptin
• Amylin analogs: Pramlintide

Warning Signs of Cancer:

• Nonhealing sore
• Lump in breast or blood-stained discharge from the nipple
• Foul smelling discharge from the vagina
• Hoarseness of voice since long time
• Difficulty in swallowing
• Present of lump at any part of the body
• Unusual change in bowel or bladder function
• Unusual bleeding from any part or any orifice of the body
• Change in size and shape of wart or mole