STUDENT GUIDE TO CLINICAL PRECEPTORIAL

Endocrine Module

Session Title: Diabetes mellitus

Session Schedule: October 25, 2016, Wednesday, 1:30-5:30PM

This is a 4-hour learning activity where you will have a clinical encounter with your assigned patient. You
are expected to do complete history taking and focused physical examination, and submit your individual
case write-up. This is followed by a case discussion with your preceptor.

Below is the suggested schedule of this session:

1:30-2:30 PM: History taking and Physical examination

2:30-3:30 PM: Individual case write-up and submit to preceptors

3:30-4:30 PM: Case Discussion (group)

4:30-5:30 PM: Your write-up will be checked

General Objectives
1. To conduct a comprehensive evaluation of DM patient
2. To formulate an appropriate and individualized management plan for a DM patient

Specific Objectives
1. To get a comprehensive medical history
2. To get patients anthropometric measurements including
body mass index
waist circumference
waist to hip ratio
3. To do basic physical examination with emphasis on
identifying common signs related to DM
screening for organ-complications related to DM
4. To provide a comprehensive management program for the patient including
non-pharmacologic plan
pharmacologic treatment
measures to prevent the complications

References:
Harrisons Principles of Internal Medicine 19thed.
UNITE for Diabetes Philippines: Philippine Practice Guidelines on the Diagnosis and Management of
Diabetes- 2014
American Diabetes Association (ADA) Standards of Medical Care in Diabetes 2017
Patient Profile
Male/Female adult with Diabetes Mellitus (DM) or suspected to have DM

Equipment needed (students will be asked to bring the following equipment)

Weighing scale with stadiometer- will be provided by the year level coordinator
BP apparatus
Ophthalmoscope
Tape measure
Stethoscope
128 Hz Tuning fork
Reflex hammer
10 g Monofilament

Patient Outcome
1. Patient understands his/her diagnosis.
Give a complete diagnosis, including co-morbidities if present
Risk factors for DM
Possible complications associated with DM
2. Patient understands the importance or benefits of lifestyle modification in preventing and
managing DM
3. Patient obtains recommendation regarding necessary tests (to rule out co-morbidities) or
referral to OPD if necessary.
4. Patient is given an initial treatment plan for diabetes and other co-morbidities, if present
Nutrition care plan
Exercise program
Target weight loss
Pharmacologic treatment

Interview patient
History
Chief complaint
Medical History
Presence or absence of signs and symptoms of diabetes
Age and characteristics of onset of diabetes
Eating patterns, physical activity habits, nutritional status, weight history
Alcohol consumption, smoking history
Diabetes education history
Review of previous treatment regimens, if any and response to therapy
Current treatment of diabetes, including medications, medication adherence and barriers
thereto, meal plan, physical activity patterns, and readiness for behavior change
Results of glucose monitoring and patients use of data
DKA frequency, severity, and cause
Hypoglycemic episodes
Hypoglycemia awareness
Any severe hypoglycemia: frequency and cause
History of diabetes-related complications
Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of
Foot lesions; autonomic, including sexual dysfunction and gastroparesis)
Macrovascular: CHD, cerebrovascular disease, and PAD
Other: psychosocial problems, dental disease
Any other medical condition
Use of supplements
Review of Systems
Family History
Personal and Social History

Physical Examination (Do a complete physical exam)

Anthropometrics: Weight, height, waist circumference, compute for BMI
Blood pressure determination, including orthostatic measurements when indicated
Fundoscopic examination
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection sites)
Comprehensive foot examination
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation

Diagnosis and Risk factor Assessment

Give a complete diagnosis, including co-morbidities if present
Other possible considerations (rule out kidney disease, etc.)
Explain condition to patient
Possible cause/risk factors for diabetes
Possible complications associated with diabetes

Management plan
Recommend tests or diagnostics (to rule out co-morbidities, assess glycemic control)
Formulate a nutrition care plan and exercise program
Pharmacologic treatment of diabetes
Other lifestyle modification