usmle step 2 cs diabetes follow up
DIABETIC NPH
Duration
insulin and other drugs
hb A1c
Blurry vision (when was the last eye exam? is there any abnormality)
bloating(r/o gastroparesis)(do u have any pain,dyspepsia,nausea)
Emotion
Energy
Erection (r/o depression)
(erevtile dysfunction-LIMP PENIS
Libido
Injury
Meds
Present medical condition(DM,HTN,Stroke,heart problem)
Prostate exam
Erection at all?
Nocturnal
Incontinence
Stress,depression
Trauma /Foot ulcer
I nfection(skin,cough,URI,foot)
Numbness/tingling,weakness
Perfect control of blood sugar
Home glucose device
Hypoglycemic episodes (availability of juice &candy)
NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain the physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.
In this case the DDx depends on the patient’s HPI and whether he/she has any other complains other than the request for refill prescription. For example if the patient is complaining of “Chest pain”
then you must do DDx for Chest pain, or if the patient is having
problem with erection then you must do differential diagnosis for Erectile dysfunction and…
Diabetes Mellitus & Hypertension Counseling –> MEDOWS
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HISTORY
HPI:
56 yo M present for diabetes follow up.
-25 year history of dm,treated with insulin.
-compliant medication
- monitors blood glucose twice a week, readings between 120-145mg/dL.
-last HbA1c 6 months ago was 7%.
-occasional episodes of palpitations and diapheresis, occuring after mnissing meals and resolving with drinking orange juice.
-tingling and numbness in fett all the time,especially at night ,worse over past 2 months.
-loss of erection x 2 years;absence of eazrly morning erection.
-no weight or appetite changes
-no special diet.
ROS: negative except as above
allergies: NKDA
medication: lovastatin,NPH insulin ,aspirin ,atenolol
PMH: hyperchoelsterolemia diagnosed with 2 years ago ,MI 1 years ago.
PSH: none
SH: no smoking ,drinks whiskey on weekend s(CAGE 0/4),no illicit drugs.works as a clerk.he is married and lives with his wife
FH: father died of a stoke at age 60.
Physical examination :
pt is in no distress.
VS: WNL
HEENT :PEERLA,no fundoscopic abnormalities.
Neck: nocarotid bruits,no JVD
chest: clear breath sounds bilaterally
Heart: apical impulses not displaced ;RRR,normal S1/S2;no murmurs,rubs or gallops.
abdomen : soft nondistended ,nontender positive BS,no bruits no organomegaly.
exteremities : no edema no skin breadown 2+dorsalis pedis pulses.
Neuro : motor : sterenght 5/5 in bilateral lower extremities. DTR: symmetric 2+ knee jerks ,absent ankle jerks and negative babinski bilaterally. sensation: decreased pinprick ,soft touch, vibratory and position sense in bilateral lower extremities.
differentioal diagnosis:
diagnosis 1 insulin-induced hypoglycemia
hx findings:
episodes of palpitations and disphoresis that resolves with drinking orange juice
tight hypoglycemic control
diagnosis 2: diabetic peripheral neuropathy
hx findings:
hx of DM
constant numbeness aned tingling in her feet
PE findings: absent ankle reflex
diagnosis 3 : organic erectile dys function
hx findings:
loss of erection for 2 years with absence of early morning erection
hx of dm
hx of alcohol user
taking lovastatinm adn atenolol
diagnostic workup:
genital exam
serum glucose ,HbA1c
UA,urine microalbuminea,BUN/Cr
doppler US -penis
nerve conduction study
Duration
insulin and other drugs
hb A1c
Blurry vision (when was the last eye exam? is there any abnormality)
bloating(r/o gastroparesis)(do u have any pain,dyspepsia,nausea)
Emotion
Energy
Erection (r/o depression)
(erevtile dysfunction-LIMP PENIS
Libido
Injury
Meds
Present medical condition(DM,HTN,Stroke,heart problem)
Prostate exam
Erection at all?
Nocturnal
Incontinence
Stress,depression
Trauma /Foot ulcer
I nfection(skin,cough,URI,foot)
Numbness/tingling,weakness
Perfect control of blood sugar
Home glucose device
Hypoglycemic episodes (availability of juice &candy)
PHYSICAL EXAMINATION for Diabetes Follow Up mnemonic
- Eye examination: Funduscopic exam
- Neck exam: Carotid auscultation
- Cardiovascular exam: Palpation, auscultation
- Pulmonary exam: Auscultation
- Abdominal exam: Auscultation, palpation, percussion
- Extremities: Inspect feet for infection or ulcers, Check peripheral pulses
- Neurologic exam: Motor, Sensation, DTRs, Babinski Reflex
DIFFERENTIAL DIANGOSIS “DDx” for Diabetes Follow Up mnemonic
DIAGNOSTIC WORK UP for Diabetes Follow Up mnemonic
- Genital Exam (If patient complains of Erectile dysfunction )
- Serum Glucose
- HbA1c
- Urinalysis
- Urine Microalbumin (to check Kidney function)
- BUN/Cr (to check Kidney function)
- CBC
COUNSELING for Diabetes Follow Up mnemonic
- Medication (Regularity/Compliance)
- Exercise (For obese/secondary life style)
- Diet modification (Less Salty & Fatty food)
- Ophthalmoscopic exam (EVERY Year “annually”)
- Weight management
- Sugar check up daily
- HELLO,MR MILLER,MY NAME IS DR.CHONG . IM UR PHYSICIAN IN THE OFFICE TODAY
- IM HERE TO DO SOME PHYSICAL EXAMINATION N ASK U SOME QUESTION IS THAT OK?
- R U COMFORTABLE IN THIS ROOMMAY I PUT THIS DRAPED ON UR LAPED
- DO U MIND IF I SIT DOWN N TWRITE WHILE WE TALK?
- MR MILLER CAN U PLS TELL ME HOW CAN I HELP U TODAY
- U R HERE FOR Diabetes FOLLOW UP.
- Ok I will do everything to help u
- OK .CAN U TELL ME WHEN WERE U DX OF DM
- WHEN DID U FIRST NOTICE SYMPTOMS OF DM
- WHAT TYPE OF MED R U TALKING
- WHEN DID U START TAKING this medication
- R U TAKING IT REGULARYLY
- HOW MUCH DID U TAKE
- HOW Do U USE THE MEDS,DID U INJECT it or take it ORALLY?
- HW MNY TIMES PER DAY?
- R U EXPOERIENCING ANY SE FROM THE MEDS?
- WHEN WAS UR LAST CHECK UP?
- WAT WAS THE RESULT OF UR CHECkUP?
- DID U MONITOR BLOOD GLUOCSE AT HOME?
- HOW R U FEELING TODAY?
- DO U HAVE ANY OTHER MEDICAL CONDITION?
- R U URINATING MORE OFTEN THAN USUAL?
- HAVE U HAd AN INCREASE IN APETITE?
- R U DRFINKING MORE WATER THAN USUAL?
- DID U EX?
- R U ON A DIET?
- HAVE U SEEN ur EYE DR IN THE LAST 6 MO
- R U MNGING ON UR WEIGHT
- WHEN WAS UR LAST TIME U HAVE UR HBA1C CHECK
- WHEN WAS UR LAST time u have ur FEET CHECK
- DO U HAVE ANY DISCOmFORT IN UR FEET
- DID U HAVE ANY CHEST PAIN
- DID U EVER FEEL LIKE UR HEART IS RACING
- DID U HAVE ANY DIFFICULTY BREATHING
- DID U HAVE A COUGH
- DID U FEEL ANY weakness or NUMBNESS IN UR LEG OR JOINTS
- DID U HAVE A Headache
- DID U FEEL DIZZY
- MAY I ASK U SOME QUESTION ABOUT UR HEALTH IN GENERAL
- RU ALLERGY TO ANY MEDS
- R U TAKING ANY OTHER MEDS BSIDES INSULIN
- HAVE U HAD ANY INFECTION
- HAVE U EXPEROIECNING ANY DIARRHEA,NAUSEA,pain in belly,CHANGES IN BOWEL MVMT,CHANGES WITH UR URINATION,SWEATING,WAKE UP FROM NIGHT,RECENT TRAUMA
- HAVE U EVER BEEN HOSP[ITALIZED
- MAY I ASK U SOME QUESTION ABOUT UR PAST MEDICAL HISTORY
- DO U HAVE ANY OTHER MEDICAL CONDITION
- MAY I ASK U ABIT OF UR QUESTION ABOUT UR FAIMLI HX
- R UR PARENT ALIVE AND WELL
- DOES ANYONE ELSE IN UR FAMILY HAVE DM
- HAVE U EVER HAD SURGERY
- MAY I ASK U SOME PERSONAL QUESTION,I CAN ASSURE EVERYTHING WE DISCUSS IS COMPLETELY CONFIDENT
- R U SEXUALLY ACTIVE
- R U USING PROTECTION
- HAVE U HAD ANY STD
- DO U SMOKE,
- Do u use ALCOHOL, RECREATIONAL DRUGS.
- WHOM DO U LIVE WITH
- WHAT DO U DO for WORK,
- R U MARRIED,
-----
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HISTORY
HPI:
56 yo M present for diabetes follow up.
-25 year history of dm,treated with insulin.
-compliant medication
- monitors blood glucose twice a week, readings between 120-145mg/dL.
-last HbA1c 6 months ago was 7%.
-occasional episodes of palpitations and diapheresis, occuring after mnissing meals and resolving with drinking orange juice.
-tingling and numbness in fett all the time,especially at night ,worse over past 2 months.
-loss of erection x 2 years;absence of eazrly morning erection.
-no weight or appetite changes
-no special diet.
ROS: negative except as above
allergies: NKDA
medication: lovastatin,NPH insulin ,aspirin ,atenolol
PMH: hyperchoelsterolemia diagnosed with 2 years ago ,MI 1 years ago.
PSH: none
SH: no smoking ,drinks whiskey on weekend s(CAGE 0/4),no illicit drugs.works as a clerk.he is married and lives with his wife
FH: father died of a stoke at age 60.
Physical examination :
pt is in no distress.
VS: WNL
HEENT :PEERLA,no fundoscopic abnormalities.
Neck: nocarotid bruits,no JVD
chest: clear breath sounds bilaterally
Heart: apical impulses not displaced ;RRR,normal S1/S2;no murmurs,rubs or gallops.
abdomen : soft nondistended ,nontender positive BS,no bruits no organomegaly.
exteremities : no edema no skin breadown 2+dorsalis pedis pulses.
Neuro : motor : sterenght 5/5 in bilateral lower extremities. DTR: symmetric 2+ knee jerks ,absent ankle jerks and negative babinski bilaterally. sensation: decreased pinprick ,soft touch, vibratory and position sense in bilateral lower extremities.
differentioal diagnosis:
diagnosis 1 insulin-induced hypoglycemia
hx findings:
episodes of palpitations and disphoresis that resolves with drinking orange juice
tight hypoglycemic control
diagnosis 2: diabetic peripheral neuropathy
hx findings:
hx of DM
constant numbeness aned tingling in her feet
PE findings: absent ankle reflex
diagnosis 3 : organic erectile dys function
hx findings:
loss of erection for 2 years with absence of early morning erection
hx of dm
hx of alcohol user
taking lovastatinm adn atenolol
diagnostic workup:
genital exam
serum glucose ,HbA1c
UA,urine microalbuminea,BUN/Cr
doppler US -penis
nerve conduction study
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