DIABETES MELLITUS CASE PROFORMA

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

History of present illness :

Chief complaints Onset Duration Description of symptoms

(sudden/gradual)

Treatment before admission : Y/N

If yes, nature of treatment (in brief):
If treatment discontinued, reasons
Past history (as relavant)
H/O previous illness /hospitalisation for similar complaints:
Time of illness : nature : hospitalisation :

Family history for Non communicable diseases

General examination:
Built:
Height:
Weight:
Nourishment:
Temperature:
Pulse:
Blood pressure:
Respiration:
Anemia/clubbing/cyanosis/jaundice/lymphadenopathy/edema

Systemic examination
RS:
CNS:
CVS:
Abdomen:
OTHER RELAVANT SYSTEM
Examination pertinent to diabetes

Eyes : Foot :

Skin : Ulcer/Infection :

BMI (Body Mass Index ) : Waist – Hip Circumference Ratio :

Others

EPIDEMIOLOGICAL DIAGNOSIS

LAB INVESTIGATIONS:

Investigations Required Done (method used) Report

Urine:
sugar
Albumin
Microscopy
Protein
Ketone bodies

BLOOD :

FBS
GTT
Lipid profile
Glycosylated Hb

CLINICAL DIAGNOSIS:
Criteria for
Diagnosis:

Symptoms –

Lab findings –
Classification:
Insulin dependent diabetes mellitus IDDM (type 1)
Non –insulin dependent diabetes mellitus IDDM ( type 2)
Impaired glucose tolerance IGT
Malnutrition –related diabetes mellitus MRDM
Gestational diabetes mellitus GDM
Others , specify

MEDICO SOCIAL DISCUSSION

Identification Of Factors Responsible For /Influencing The Person

Condition
Biological risk factors
Age , sex
Ethnicity /inheritance
Metabolic –insulin deficiency (absolute/relative)
Genetic markers
Nutritional
Physical –inactivity
Biological- infection of pancreas
Migration
Immune mechanism
Maternal diabetes
Syndrome X
Others

Fnvironmental factors Social factors

(physical, biological ,psychological) Economic conditions
Marital status
occupational environment Religious practices
stress and strain Lack of education
Urbanisation
chemical agents affecting pancreas Alcohol intake
Unemployment
Incorrect knowledge ,attitude
/practices
Mal nutrition
Habit and lifestyle
Social stigma
Non availability & utilisation of health
services

Levels of prevention:
Levels of Which level has How could have
prevention failed been prevented ?
Primary Health promotion

Specific protection
Secondary Early detection

prompt treatment
Tertiary Diasability
limitation

Rehabilitation

Assessment of knowledge ,attitude, and practice towards the disease

particulars knowledge attitudes practice

Cause
Treatment
Prevention
Health services
others

Influence of medico social factors in diagnosis , treatment and prevention of the

disease impact of the disease on socio economic status of

Family :
Community :
Nation :

Medico social diagnosis

MANAGEMENT

GENERAL MEASURES :
Primordial prevention :
Population strategy
High risk strategy _
Secondary prevention :
Early detection and treatment

Tertiary prevention :
Organising specialised diabetic rehabilitation clinics
Treatment plan
diet
Exercise
Drugs
Diabetes knowledge

Diet :
What to eat :
What not to eat ( prohibited foods ) :
When to eat :
How much to eat (amount of food ) :
Liberally (desired):
Moderate :
Restriction :
Proportion of nutrients in diet :
Carbohydrates : %
Fat : %
Proteins : %

EXERCISE
Type and frequency :

DRUGS :
Drugs :

Dosage :

Frequency :

Diabetes education and knowledge :

Does the patient require reference to higher center
If yes , reasons

ADVICE

((Preventive ,promotive and curative)

patient

adherence to diet , exercise

follow drug regimen
periodic examination and follow up

family

motivate the patient to take proper diet and drugs

motivate the patient for periodic check up
family members – to undergo screening for diabetes

community
early diagnosis and prompt treatment
genetic councelling
healthy lifestyle;
regular monitoring of weight , BP, blood sugar