Brief information about the reference person

Name

Age

Gender

Occupation

Income

Socio-economic status

Address

Nearest health facility

Details of family members

Family tree

Chief complaints
H/o presenting illness

Pertaining to DM

Describe

Onset,

Progression and

Treatment availed in chronological order –

Reasons for delay in seeking services

Failure of early diagnosis, Rx

Places of treatment (When, where, how it was diagnosed, which symptom made him seek
consultation)

health eductn gn – diet/follow-up investing/foot exam/foot care

/ Treatment drugs details, regular? Side effects of drugs?

Reasons for different places of RX, satisfaction with services

Number of consultations

Frequency of follow-up/investigtns

Any referrals?

H/o use of other systems of medicine for treatment

Complications – type? who noticed? How did it manifest? What was he advised?

Microvascular- DM retinopathy, nephropathy,neuropathy

- H/o blurring of vision/progressive loss of vision Acuity/floaters/distortion/double
vision/pain eyes (DM retinopathy)

- H/o decreased urine output/frothing of urine/edema legs/face (DM nephropathy)

- H/o burning sensation/numbness/tingling/sharp pains in lower limbs /foot ulcers

(DM neuro)

- Recurrent vomiting/ urge to pass feces after food intake/recurrent episode of loose stools

(gastroparesis – dm autonomic neuro)

- H/o postural hypotension, early morning erection of penis (autonomic dysfn)

Macrovascular

- H/o weakness in limbs /facial muscles (stroke)

- H/o chestpain ass with sweating/palpitation/syncope/dyspnoea on exertion

(Myo.infarction)

- pain during walking (intermittent claudication pain in lower limbs ( atherosclerosis)

Infections

- recurrent dysuria (UTI)

- h/o skin abcess/skin ulcers

- H/o ear pain/ear discharge (malignant otitis externa)

- H/o tooth pain/foul odour from mouth (dental abcess)

- Persistent cough with expectoration/foul smelling sputum (pneumonia)

 Others - H/o joint pain – ankle , knee (DM charcot joint)

- h/o Hearing loss (csom, nerve def)

- Altered mental status (dm hyperosm.coma)

DKA symptoms - Nausea/vomiting

- Thirst/polyuria
- Abdominal pain
- Shortness of breath

Past history

H/o viral infections, surgeries, major trauma, blood transfusions

H/o autoimmune diseases

H/o prolonged exposure to chemicals

H/o drug intake – diabetogenic drugs/steroids/thiazide diuretics

History of cardiovascular disease

H/o hypertension/heart ds/known kidney ds/ Tb

H/o elevated lipid profile

Personal history

Addictions: smoker/Alcohol/tobacco/drugs

Sleep/appetite

Bowel and bladder habits

Hygiene

Physical activity
Menstrual history

(Women with pcos prone for diabetes)

Marital

status, durtn

child birth

contraception

Antenatal history

History of GDM or delivery of baby >4 kg (9 lb)/recurrent fetal loss

Family History

a) Family type, History of consanguinity

b) Family H/o DM/HTN/Heart ds/kidney ds/paralysis
c) List of morbidities/complications in family
d) Family members screened for HTN/DM
e) Family relationships
f) Emotional support
g) Response of family towards illness, who accompanies to hospital

Social history
Interaction with society
Response of society towards person
Stigma?
Participation in festivals/marriages/social activities
a) Involvement in social groups
Environment
a. Housing – location, K/sp/p
b. Rent/own
c. No of living rooms
d. Overcrowding: P/A
e. Ventilation
f. Lighting
g. Cooking place/utensils/cooking gas
h. Toilet facilities/refuse disposal/ hand washing
i. Methods of waste disposal/ how frequently cleared
j. Drinking water supply – source/frequency/quantity/quality/frequency/storage/boiling
k. Animals/pets
l. Occupational environment (insect if possible)
m. Mosquito/rats
n. Drains/septic tank
o. Outdoor space

Economic conditions
a. Total family income
b. Expenditure on diet/medical care/recreations/eductn
c. Savings/debts
d. Ration card: colour/services
e. Aadhar card
f. Family tensions due to economic conditions
g. Cost incurred
Tangible cost
Consultation fee
Investigtn
Treatment, travel, nutrition – extra care
Intangible cost
Pain, guilt
 Loss of wage/work
Loss of QOL
Stress/tension
Stress on family
Any dropout from
Societal/neighborhood rtn
Interpersonal commtn
Welfare schemes
Food through PDs
Gas/cylinder/stove/kerosene
Oldage pension
Any other details that family is availing

Nutritional history
24 hr recall dietary method
Veg/non-veg
Tabular format for breakfast, lunch, eve snacks and dinner
Total daily calorie intake…….deficient/adequate/excess
Total daily protein intake……. deficient/adequate/excess
Fibre intake (Fruits/veg)
Salt/fried food intake
Refined carbohydrate intake (sugar, starchy foods)
Oil/any mixing of oil
Food beliefs/food taboos
customs
Habit of eating outside

General examination and systemic examination

Anthropometry
Conscious/oriented
Built/nourishment
Ht/ Wt /BMI/waist circumference/WHR
Pulse – rate
- Vessel wall thick (atherosclerosis0
- Radio-femoral delay
- Felt equally in all peripheral pulse (carotid/brachial/radial/fem/popliteal/dorsalis
pedis/post tibial)

BP

Pallor (DM nephro)

Icterus/cyanosis/clubbing/pedal edema/gen LAN

Systemic examination
RS:
Normal/abnormal – vesicular/bronchial
Resonant on Percussion
Vocal resonance/fremitus - normal

CVS
Heart sounds/murmur
Apex

CNS
No focal neurological deficit
Pupil – rtn to light
Consciousness

Abdomen
P/A – soft
No organomegaly
No renal bruit (atherosclerosis –of renal vessels)..keep steth above umbilicus
Special senses
Hearing- (tuning fork – 520- rinne test/weber test)
Vision – visual acuity/cataract/fundoscopy (snellen chart)

Examn of both knee jts

Swelling/warmth/Tender/edema

Foot examn
Foot sensations – monofilament
position sense/vibration sense/crude touch/fine touch
ankle jerk – present/brisk/absent
ulcer/wasting of muscles
Check web space
Breast examtn

(Physical Findings of DKA

Tachycardia

Dehydration/hypotension

Tachypnea/Kussmaul respirations/respiratory distress

Abdominal tenderness (may resemble acute pancreatitis or surgical abdomen)

Lethargy/obtundation/cerebral edema/possibly coma)

Clinico-social diagnosis
First mention clinical diagnosis
Summarize all positive and negative clinico-social aspects explaining the influence of family
Social and environmental factors on the cause
Course
Treatment of disease

Lab investigations
Already done and planned future
Investigtns done before start of treatment/after
Last ECG date?

Urine examn
Glucose
Albumin
Pus cells
RBC ketones

Blood examn
Plasma glucose – fasting /pp
HbA1c
Urea/cr/Na/k
Lipid profile
Fundus examn

Resting ECG

Comprehensive management plan

Levels of prevention Primary Secondary Tertiary
Health promotion and Early diagnosis and Disability limitation
specific protection treatment and rehabilitation
Individual
Family
Community

Individual
How will u titrate the dose
Treatment at different stages

Kit to be carried

- Steth
- Snellen chart
- Monofilament ( for testing diabetic neuropathy)
- Thermometer
- Knee hammer
- Tuning fork
- ophthalmoscope