In a recent postgraduate assessment the candidate at one of the assessment stations was given the task of taking a history from a 54 year old patient who had been diabetic for more than a decade in order to assess what complications of this disease the patient has already developed, was in the process of developing at present or was likely to be in danger of developing in the future. An assessor, with a key, was observing. Additional information was that the patient was on insulin and metformin. He wore glasses for distant vision which he was using at the time of the examination. The scenario did not say that any questions would be asked. The time given to the candidate was 6 minutes. Remember at some stations you are being observed only though you do have the right to offer an explanation.
The usual preliminary greetings, introduction of the doctor and patient, asking permission, and if the patient really had diabetes took longer than 30 seconds because questions which could have been avoided were repeated and the information already given in the scenario was also enquired about again.
What complications should one be looking for?
Divide the complications into those already present at the time of the diagnosis and progression of the disease since then.
It might be a good idea to ask about the current status.
- Is your blood sugar controlled in the fasting state and after lunch or dinner? Have you had your HbA1 test done?
- What is the problem about your disease that is bothering you at present?
If the patient identifies a problem like exertional chest pain, breathlessness, swollen feet, cramps and pain in the limbs, non-healing ulcers, visual problems then question along those lines first.
- Do you find it difficult to comply with your diet? Do you understand about your diet? Is food craving a problem? Are you losing weight or gaining weight?
Remember that diabetes is a metabolic disease. Inadequate manipulation of the diet and failure to comply with calorie control leads to poor control of the diabetes and progression of the disease. Weight management is very important.
- Why are you on metformin and insulin?
- What was your initial treatment?
- If insulin was added then was it because your blood sugar was uncontrolled with a full dose of metformin or some complication developed?
- What was the complication that developed?
- What kind of insulin was added?
- Was the insulin given before meals or once or twice a day or with no relationship to meals?
- Initially you were on insulin was the metformin added because the dose of insulin was too large?
The patient developed diabetes around the age of 44 years. He is most likely to have Type 2 non-insulin dependent diabetes, specially if he was overweight at the time of diagnosis. Metformin would be a good choice along with calorie control and exercise. If the diabetes is not controlled within a reasonable time say 6-9 months with repeated diet counselling then adding another drug will be feasible. Insulin, specially short acting pre-meal insulin, will increase hunger and food craving and make weight control a problem. An intermediate insulin might have been given before breakfast to control post lunch blood sugar or two doses used to control post lunch and post dinner and fasting blood sugar levels. A long acting insulin like glargine could be used to keep the basal sugar level under control. Remember do not use up all your time on these questions!!!
The patient has not volunteered any problems. It might be worthwhile starting with his eyes. In 10 years time visual problems specially cataract and retinopathy will have started. Keep glaucoma in mind.
- Are your glasses for distant vision or reading or do you use two sets of glasses?
- Has your focal number gone up recently or do you need to go repeatedly to your doctor because the spectacles become ineffective? (Myopic shift in cataract)
- Problem with night driving, glare from headlights, difficulty in reading road signs, haloes round lights, progressive dimness of vision poor perception of colour: associated with cataract.
- Painful red eye: glaucoma in diabetes and in cataract protein lysis associated glaucoma.
- Double vision: 3rd nerve palsy, abducens nerve palsy.
- When did you have your eye checked with a computer or have your retina examined?
- Have you ever had episodes of blindness which cleared up suddenly or have blindness on bending down or standing up from a sitting or squatting position?
Renal complications are very common in diabetes and this patient is entering the age as of prostate hypertrophy as well.
- Ask about urinary frequency especially at night, hesitancy, incontinence of urine, dysuria and fever associated with urinary symptoms.
- Ask about swelling of the feet and foaming urine or blood in the urine.
- Ask if the doctor has checked the patient for anemia and/or renal function. Asking if the patient has had an ultrasound of the kidneys is not the right answer as it is very unlikely to give much help unless the kidneys are sclerosed and then it is too late
Ask about hypertension. Has it been checked? Does it remain high? Is it being treated? If so with which which drugs? Is the patient on an ACE or ARB class of drug?
Ask about the heart.
- Acute myocardial infarction?
- Recent angiography or stenting?
- Exertional breathlessness?
- Breathlessness on lying flat?
- Tiredness and listlessness?
Ask about the central nervous system and the peripheral nervous system.
- Tingling, feeling of heat, painful cramps in the commonly in the feet accompanied by numbness should be enquired about.
- Loss of sensation in the hands will lead to frequent injury to the fingers i.e cutting with a knife for those involved with cooking or burns, with a needle in tailors and seamstresses etc.
- Not being able to feel the floor so stumbling and falling.
- Slippers flying off the feet.
- Missing to note injuries on the feet specially on the soles.
- Ulcers that needed longer than 2 weeks to heal or required antibiotics for treatment.
- Episode of weakness of a limb or one side of the body which was temporary or permanent.
- Double vision.
- Episode of loss of consciousness or coma.
Remember peripheral ischemia so do ask about intermittent claudication and painful black toes.
In 6 minutes time you may be able to get all this in if you are quick and sensible; know what you are talking about and are prepared to answer why you are asking all these questions. A family history is not required.