Approach to a Case of Diabetes Mellitus
NATIONAL JOURNAL OF HOMOEOPATHY 1998 May / Jun VOL VII NO 3.
Dr Nishit Kumar F. Shah

A patient who has diabetes is a challenge to the primary care physician, who has to perform the triple task of assessing, planning management as well as educating the patient in the short time generally available to the doctor, while under a barrage of questions and interruptions from the patient.
Well-worded questions as well as pertinent examination, preferably simultaneously, may allow the doctor sufficient time to impart knowledge to the patient, so essential to treating diabetes

History Taking:
The order of the questions may be modified according to personal preference and on a case-to-case basis.
When was the first time your sugars were found on the higher side? Have you ever been checked for sugars before?
The duration of diabetes is the most important indicator of chances of complications of diabetes. Since patients may have their own idea of what levels of sugars are high enough to mean diabetes and what levels do not constitute diabetes, it is necessary to question the patient on preceding values, if any, especially gestational diabetes and transient hyperglycaemia during stress.

Very high sugars at diagnosis may add years to the actual duration whereas normal values documented in the past puts a ceiling to the duration.
Have any of your relatives developed diabetes so far? Patients tend to ignore relatives who have developed diabetes after them, but who were born before them eg parents. Patients also neglect to mention relatives who stay away [eg married sisters] as they seem to think that diabetes is contagious.

Familial diabetes tends to be similar in the severity [or mildness] especially of control and tendency for complications, like nephropathy and cardiovascular symptoms.
The prevalence of diabetes in a particular family can be used to discuss transmission rates, means of early detection in those not yet affected and preventive measures eg control of obesity and change in lifestyles.

What has been your highest weight in the past?
What is the current trend?
Obese diabetes generally responds better to OHA on long term basis rather than non-obese. Ex-obese are much better off than obese.
Rapid weight loss even in an obese diabetic may be an indication for insulin therapy [temporary] as well as a search for some intercurrent illness.

What has been the highest sugar value in your life so far?
Past glucose values above 300 mg/dl increases the chances of secondary failure of oral anti diabetic drugs and the need for insulin in the future.
However, if these high levels were during medical stress, then one would expect similar levels during illness in the future.

When did you last get the sugars checked?
The frequency of testing which is 2-3 months if stable, but more often if levels are high or unstable or on large amounts of medication, can be emphasized at this point.

What anti-diabetics are you taking at present?
Anything else in the past?
It is essential to know why a certain drug was discarded. May be it was declared ineffective before maximal doses were reached. May be it was abandoned due to reaction ie hypoglycemia rather than a side effect. Explanation to the patient may allow the doctor to restart the same drug.

Have you ever received insulin in the past?
Chances of allergies and resistance due to anti-insulin antibodies are higher with past exposure to crude insulin.
A patient who has received insulin in the past may be more willing to accept it.
Most importantly fears of insulin therapy always being permanent may be dispelled by this question.

Which other medications are you taking?
A detailed drug history may led to uncovering details of present or past hypertension, ischemic heart disease or cardiovascular disease, the diagnosis of which itself might need review.

Have you ever experienced symptoms of low sugar?
Patients with hypoglycemia unawareness need to be picked out. Symptoms of hypoglycemia either as alarm signals or as dangerous should be discussed as well as a means of treatment. The presentation may change with time and with the degree of control.

How long can you tolerate hunger?
This question identifies patients taking greater chances with meal timings.

Which is your major meal?
The question may initiate a discussion on diet, so be prepared. It is not expected of a doctor to be an expert in this field and an early referral to a dietician is ideal. Paucity of time may entail handing over a printed sheet of Do's and Don'ts with sick day rules and a model diet of say 1200 calories.
Since a doctor who doesn't advise about food is not a good doctor, it is wiser to give some verbal advice eg the need for an evening snack, making the dinner lighter, and the safety of sweeteners in moderate doses [upto 12 tablets/day]

How often do you wake up form sleep to pass urine?
This is better questioning than how often do you pass urine in the night. The feeling of restfulness on awakening can assess adequacy of sleep.
Since nocturia may not be due to glucosuria, the patient needs to be questioned about dysuria ie a difficulty in passing urine. The ability to interrupt the stream and restart again at will is a good index of adequate autonomic control.Pruritis vulvae / Balanitis may be brought up at this point.

How are the motions?
Constipation is common in diabetics, best treated by bulk laxatives.

Any problems with your feet or hands?
If the answer is negative, direct questioning is necessary. Preferred terms are tingling, numbness, catches [people use the word cramps to describe paraesthesias], burning soles, pains in legs on walking, cool extremities, inability to lift hand above head [for frozen shoulders]

Any problems in climbing stairs?
Dyspnoea, palpitation, chest pain may mean ischemic heart disease whereas leg pains may be due to peripheral vascular disease.

When did you last get your eyes checked?
Patients may have got their vision checked by an optician, rather than a complete evaluation of the fundus with dilated pupils by an ophthalmologist.
In order to motivate the patient for their yearly check up it makes sense to explain it in simple terms like Diabetes affects the eyes before it affects sight. Once it affects sight it may be too late.
Patients with diabetes retinopathy or with proteinuria may need more frequent check up.

Any cold, cough fever? Past infections? Last dental checks up?
Intercurrent infections may be the cause of poor control. TB/UTI may recur during phases of poor control.

Any impending surgery?
Plan of action/ tightness of control will be decided accordingly.

Examination:
In the standard examination of the patient the following points are important in a diabetic.

1. Weight
2. Height - calculate Body Mass Index, BMI, which is weight in kgs divided by square of height in metres. A BMI below 25 is desirable in women, and in men below. 27 is acceptable
3. Blood pressure supine and standing, with attention change in the pulse rate too. Patients with a history of postural giddiness may not necessarily have postural hypotension.
4. Cataract
5. Dentition - yearly examination necessary
6. Goitre
7. Frozen shoulders checked by placing the hand on the shoulder and abducting the arm to 90 degrees.
8. Acanthosis Nigricans - darkening and increasing of the skin over the nape of the neck indicates hyperinsulinism, ie insulin resistance. There may be skin tags too.
9. Skin spots - brown discoloration of the skin indicating vasculopathy.
10. Pedal pulsations
11. Feet especially for ulceration. Foot care especially inspection with a mirror needs to be taught to the patient.
12. Pain sensation by a pinprick for neuropathy
13. Vibration by 128 Hz tuning fork for the ankles and great toes if possible

1. Any patient ill enough to need hospitalization, e.g. vomiting, semi conscious, needs hospitalisation and insulin
2. Moderate to heavy ketonuria
3. First degree relative who is an IDDM
4. Personal history of auto-immune disease, e.g. myxoedema, pernicious anemia
5. Rapid/ abrupt onset
6. Severe symptoms, eg Nocturia [due to glycosuria] 3-4 times, weight loss
7. Fasting glucose above 300 ml/dl
8. Diabetes with infection
9. Diabetes with significant complications

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