Socio-Demographic History:

Name: 

Age:

Sex:

Religion:

Marital status: 

Education:                              

Occupation:

Address: 

Native /Migrant:                                  

Informant:

Date of Admission:

Chief Complaints:

Mention the complaints and the duration for which the patient has come to the OPD or hospitalized. 

In case the patient has come for routine follow up and does not have any complaints, mention accordingly.

Present History: 

In a known DM patient, ask

1. Age of onset and Characteristics of onset:

Whether the patient was diagnosed when signs and symptoms of diabetes were seen; 

or when complications occurred; 

or as a result of laboratory tests done for screening; 

or during investigations for pre-anaesthesia fitness etc.

2. What medications is he/she taking? 

Ask the patient to show the medications he/she is taking?

3. Is he/she taking medications as advised?  

Ask how many tablets are consumed in a day and the time when they are consumed. 

4. Does the patient take medications on his own or is there a family member who reminds them/or takes out the medicines and gives them to consume.

Ask for presenting symptoms  suggestive of complications of diabetes

1. Fever, Cough (diabetics are susceptible to TB).

2. Vision related problems - Blurred, double, or distorted vision or difficulty reading, Floaters or spots in  vision.

3. Tingling sensation or numbness, loss of sensation in hands and feet.

4. Any ulcer or wound on the foot that has not healed.

5. Any fatigue and claudication pain in leg.

6. Dental problems

7. Recent polyuria, polydipsia, nocturia, or weight loss (symptoms suggestive of of hyperglycemia)

8. Any episodes of hypoglycemia - If so, when, how often, and how does the patient treat these episodes

For the presenting complaints, ask If the patient has sought medical advice for these complaints and details of treatment.

9. When were investigations done?

10. When was the fundoscopy done?

Past History: 

1. Did the patient have any similar complaints in the past? (for a patient presenting with hypoglycaemia or ketoacidosis)

2. Did the  patient have  any major illness in the past?

   • Hypertension

   • Chronic renal disease

   • Heart disease - CAD

   • Has the patient had a stroke or transient ischemic attack

3. Did the patient have  any surgery in the past?

4. Did the patient ever get hospitalised?

5. Did the patient have tuberculosis anytime in the past? If yes, ask

   • Time of illness (how many years back he was diagnosed).

   • Type of TB - pulmonary or extrapulmonary.

6. Is the patient on dialysis

7. Is the patient on lipid  lowering agents

Personal History: 

1. History of addiction - History of consumption of tobacco, alcohol or drug abuse, with details

2. History of allergies 

3. History of adverse drug reactions

4. Bladder/ bowel complaints

5. Sleep 

6. Appetite 

7. Physical exercise

Family History: 

1. Is there any family member having diabetes.

2. Find out if there is exposure to a TB case at the place of work or at home.

Menstrual History: 

1. Record the age at Menarche/Menopause:

2. Date of last menstrual period:

3. Menstrual Cycle: Duration ______________, Regularity _______________________, Pain during menses __________________ , 

4. Flow - less/moderate/heavy

Family Planning: 

Mention the methods being used.

Past Obstetric History: 

Gravida _____ Para ________Abortion _______Live birth _________ Stillbirth ________

History of gestational diabetes.

Immunization History: 

Socioeconomic History: 

1. Obtain details of 

   • No. of persons living in family.

   • Age and sex wise distribution of family. 

   • Head of the family.

   • Relationship of the family members to the head of the family.

   • No. of earning family members and total income.

   • Education and occupation of the Head of the family.

2. Draw the family tree with the above information

3. State the type of family

4. Calculate and state the socio-economic class using either B.G. Prasad or Modified Kuppuswamy classification.

If using Kuppuswamy classification calculate  

• Educational status of head of family and state education score.

• Occupation of head of family and state occupation score.

• Monthly combined income of family and state income score.

• Give the total score.

• State classification as per Modified Kuppuswamy classification.                       

If using BG Prasad classification, 

• Calculate per capita income per month.

• State the socio-economic class as per BG Prasad’s classification.

Environmental history:

1. Locality: Urban slum / Urban Non slum/ Rural

2. Housing: Type of house i.e. kaccha / pukka /semi pukka, area of house, etc.

3. No. of rooms:               Overcrowding: Yes / No

4. Lighting & Ventilation: Adequate / Inadequate

5. Water supply:Continuous/ Intermittent

6. Waste disposal:

   • Garbage stacked before disposal (Bin/Plastic bag)

   • Disposal of garbage

7. Latrine:

   • Common/ separate

   • Indian/ western

   • Bathroom separate/Common

8. Sullage: Piped/ unpiped

9. Pets: If pets kept, type and vaccination status of pets

10. Complaints of pests (Mosquitoes/ Cockroaches/ Fleas / Ants / Lizards / Rodents)

11. Sanitation: Drainage facility. Open drains near the house.

Socio-cultural factors

1. Decision making by husband or other family members regarding health seeking behaviour and treatment.

2. Ignorance about disease and availability of facilities.

3. Religious and other spiritual beliefs 

4. Stress at home and workplace

Dietary History: 

1. Vegetarian or non-vegetarian diet.

2. Frequency of meals.

3. Foods consumed regularly.

4. Foods avoided.

5. Total calories and proteins consumed using a 24 hour recall method on a typical day.

6. State the deficit or excess calories and proteins consumed.

General examination:

1. Consciousness / Orientation 

2. Built / Posture / Gait

3. Weight

4. Height

5. Calculate BMI

6. Waist circumference and hip circumference

7. Temperature

8. Pulse

9. BP

10. Respiratory Rate

11. Pallor / icterus / cyanosis / clubbing / oedema / lymphadenopathy

12. Other relevant findings

    • Skin - acanthosis nigricans , insulin injection marks

    • Thyroid gland

    • Foot examination 

      • • Inspection

        • Palpation of dorsalis pedis and posterior tibial 

• Patellar and Achilles reflexes - present or absent

• Determine proprioception, vibration, and monofilament sensation

Systemic Examination:

Cardiovascular system:

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

Respiratory system:

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

Alimentary system:

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

Central Nervous system:

1. Sensory System

2. Motor System

Case Summary:

Differential Diagnosis: 

Provisional Diagnosis:

Proposed Investigations: 

1. FPG, PPPG, HbA1C

2. LDL,HDL, Cholesterol, Triglycerides

3. Sr. Creatinine

4. Urine Albumin and sugar

5. TSH

Pharmacological Management:

Non-Pharmacological Management:

1. Dietary advice:

2. Physical Activity:

3. Environmental:

4. Follow-up

   1. • Physician follow up

      • Investigation follow up

5. Self Care Practice

   1. • Self monitoring

      • Recognising Hypoglycaemia

      • Foot Care

      • Abstain from addictions if any

      • Adherence Counselling

6. Screening of  family members