Diabetes is a common illness with various presentations and complications. Therefore, many students will get a diabetic patient for their long case. In such situations it is very important to ask all the relevant symptoms and complications of the disease from the patient. The following format will help as a basic guide for a detailed history.
- Identification
- Name
- Age
- young age à more likely type 1 diabetes
- old à type 2 diabetes
- occupation à sedentary life style, drug compliance
- Presenting Complaint
- Polyuria, polydypsia, pholyphagia
- Lethargy, weakness, loss of weight
- Infection
- Complications
- microvasular
- macrovascular
- History of presenting complaint
- When was he/she is diagnosed to be diabetic
- What were the symptoms he/she had
- What were the treatments given
- Adherence to treatments
- Problems with treatment/ side effects
- Was he/she advised regarding hypoglycemic attacks
- Was he/she advised about diet control
- Was he/she referred to eye clinic
- was he/she advised regarding foot care
- How many hospital admissions since then, for what illness, what was done
- Macrovascular complications
- Ischemic heart disease
- Perepheral vascular disease
- Strokes/Transient ischemic attacks
- Microvascular complications
- Visual disturbances
- frothy urine, oliguria, red colored urine
- Nuropathies
- eripheral nuropathy - Loss of sensation, abnormal sensation, tingling of feet
- Mononuropathies - Symptoms of carpel tunnel syndrome/tarsal tunnel syndrome
- Autonomic nuropathy - impotence, gustatory sweating, urinary retension, incontenance, constipation, diarrhea, dizziness, recurrent nausea and vomiting
- Nuroglycopenic symptoms - impaired interlectual activity, diminished psychomotor skills, severe agitation, confusion, coma, epileptiform seizures
- Immunological complications
- Recurrent infections
- Urinary tract infections
- Balanitis
- pruritus vulvae
- Past Medical History
- strokes
- Ischemic heart disease
- Dyslipidemias
- Fits
- Bronchial asthma
- Strokes
- Past Surgical History
- Drug History
- antidiabetic drugs, side effects, compliance
- Allergic History
- Drug, food, laster allergies
- Family History
- Diabetes, premature heart diseases, Strokes, young deaths in first degree relatives
- Social History
- Educated up to
- Occupation
- Lives with
- Income
- Exercise
- Alcohol intake
- Smoking
- Nearest hospital
- Dietary history
- Regularity of meals
- Quality of content
- Fatty greasy food
- Fruit and vegetable content
- Sugar and sugary foods
- Salt
Thank you so much
ReplyDelete