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COMPREHENSIVE HISTORY-TAKING MEDICAL RECORD

Diabetes Mellitus & Associated Diseases

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SECTION 1: BIODATA

Always record biodata FIRST before asking any history. It anchors the clinical picture.

CLINICAL NOTE — Occupation matters in DM: Shift workers have disrupted glycaemic patterns; sedentary workers have worse insulin resistance; professional drivers face hypoglycaemia risk (licensing implications).

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SECTION 2: CHIEF COMPLAINT (CC)

Ask in the patient's own words — do not suggest answers or use medical terminology.

• "What brought you here today?"
• "What is the main problem that is bothering you?"

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SECTION 3: HISTORY OF PRESENTING ILLNESS (HPI)

Use SOCRATES for EACH complaint. For DM, always probe for hyperglycaemic symptoms, acute decompensation, and complication clues.

3A. SOCRATES Framework

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3B. Cardinal Symptoms of Hyperglycaemia — Ask ALL

Polyuria (Excessive Urination)

• "How many times do you urinate during the day?"
• "Do you wake up at night to urinate? How many times?" (Nocturia)
• "How much urine do you pass each time — a small amount or a lot?"
• "Is your urine pale, dark, or does it look foamy?"
• "Have you noticed ants being attracted to where you urinate?" (Glycosuria — classical bedside clue)

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Polydipsia (Excessive Thirst)

• "Do you feel very thirsty more than usual?"
• "How much water or fluids do you drink in a day?"
• "Is the thirst there all the time, or does drinking relieve it only briefly?"

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Polyphagia (Excessive Hunger)

• "Is your appetite increased, decreased, or normal?"
• "Do you feel hungry soon after eating a full meal?"

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Weight Changes

• "Have you lost or gained weight recently without trying?"
• "How much weight have you lost/gained, and over what period of time?"

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Fatigue and Weakness

• "Do you feel tired all the time?"
• "Does the tiredness come on even without activity, or only after effort?"
• "Do you feel weak in your arms or legs?"

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Blurred Vision

• "Has your vision changed recently?"
• "Is the blurring in one eye or both?"
• "Is it constant or does it fluctuate with your blood sugar levels?"
• "Have you seen floaters, flashes of light, or had sudden loss of vision?"

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Recurrent Infections and Poor Wound Healing

• "Do you get infections frequently — skin, genital, or urinary?"
• "Have you noticed itching around the genitals or white discharge?" (Candidiasis)
• "Do wounds, cuts, or sores take a long time to heal?"
• "Do you have any sores or ulcers not healing, especially on the feet?"

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3C. Onset and Type Classification Clues

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3D. Acute Decompensation — Screen for ALL Three

CRITICAL ALERT — Always ask these questions directly. Missing DKA or HHS is a clinical emergency.

• "Have you had nausea, vomiting, or abdominal pain with very high blood sugar?"
• "Have you had episodes of sweating, shakiness, heart racing, or confusion — especially if you missed a meal?"
• "Have you ever been hospitalised for very high blood sugar or a diabetic coma?"

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SECTION 4: COMPLICATIONS SCREENING — SYSTEMATIC REVIEW BY ORGAN

Tell the patient: "I am now going to ask about different parts of your body to make sure everything is being checked carefully."

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4A. EYES — Diabetic Retinopathy

• "Has a doctor ever looked at the back of your eyes with a special instrument?" (Fundoscopy / dilated eye exam)
• "Have you had any changes in your vision — blurring, dark spots, or sudden loss of sight?"
• "Have you seen floaters, cobweb-like shapes, or flashes of light?"
• "Have you had any eye injections (anti-VEGF) or laser treatment for your eyes?"
• "Have you ever been told you have diabetic eye disease or glaucoma?"

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4B. KIDNEYS — Diabetic Nephropathy

• "Have you noticed your urine becoming foamy or frothy?" (Proteinuria)
• "Do you have swelling in your legs, ankles, or around your eyes in the morning?" (Nephrotic oedema)
• "Have you ever been told your kidneys are not working properly?"
• "Do you know your kidney function test results — creatinine or eGFR?"
• "Have you ever been on dialysis or been referred to a kidney specialist?"

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4C. PERIPHERAL NERVOUS SYSTEM — Sensorimotor Neuropathy

• "Do you have numbness, tingling, or a burning sensation in your feet or hands?"
• "Does it feel like you are walking on cotton wool or sand?"
• "Is the pain or tingling worse at night?"
• "Have you lost feeling in your feet — for example, unable to feel hot or cold water?"
• "Have you had falls because of loss of balance or unsteadiness?"
• "Do you have any foot ulcers, wounds, or sores that are not healing?"
• "Have you ever had an amputation?"

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4D. AUTONOMIC NERVOUS SYSTEM — Autonomic Neuropathy

• "Do you feel dizzy or lightheaded when you stand up quickly?" (Postural / orthostatic hypotension)
• "Do you feel full very quickly after eating only a small meal?" (Gastroparesis)
• "Do you have nausea, vomiting, or bloating after eating?"
• "Do you have problems with your bowels — constipation or diarrhoea that comes and goes?" (Autonomic gut dysmotility)
• "Do you sweat abnormally — too much or not at all?"
• "Do you have difficulty controlling your bladder or do you need to strain to pass urine?" (Neurogenic bladder)
• "[Male patients — ask sensitively and privately]: Do you have difficulty getting or maintaining an erection?" (Erectile dysfunction — earliest autonomic symptom in men)

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4E. HEART AND LARGE BLOOD VESSELS — Macrovascular Disease

NOTE: Diabetic patients may have SILENT myocardial infarction — chest pain may be absent due to cardiac autonomic neuropathy. Always ask about atypical symptoms.

• "Do you have chest pain or tightness — especially on walking, climbing stairs, or at rest?"
• "Do you feel short of breath with activity or when lying flat?" (Orthopnoea — heart failure)
• "Do you have swelling in both ankles?" (Biventricular failure)
• "Have you had a heart attack or been told your heart arteries are blocked?"
• "Have you had any stroke or sudden weakness / numbness on one side of your body?"
• "Do you get pain in your calves when walking that goes away with rest?" (Intermittent claudication = Peripheral Arterial Disease)
• "Do you have palpitations or feel your heart racing or skipping?"

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4F. FEET — Diabetic Foot Disease

• "Do you check your feet every day?"
• "What type of footwear do you use? Do they fit well?"
• "Do you have any calluses, corns, or hard skin on your feet?"
• "Have you had any cuts, blisters, or sores on your feet that you did not feel?" (Loss of protective sensation)
• "Have you been told your foot bones have changed shape?" (Charcot's arthropathy)

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4G. MUSCULOSKELETAL — Diabetic Rheumatological Conditions

From Firestein & Kelley's Rheumatology: Diabetic cheiroarthropathy, Dupuytren's, trigger finger, carpal tunnel, adhesive capsulitis, and Charcot arthropathy are all strongly DM-associated.

• "Do you have stiffness in your fingers or cannot fully close/open your hands?"
• "Do you have difficulty getting your palm flat on a table?"
• "Do any of your fingers catch, snap, or lock when you bend them?"
• "Do you have pain or tingling in your hands at night?" (Carpal Tunnel)
• "Do you have pain or stiffness in your shoulder that limits lifting your arm?"

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4H. SKIN

• "Do you have dry, itchy, or discoloured skin?"
• "Do you have any non-healing wounds or sores?"
• "Have you noticed darker velvety skin at the back of your neck or in the armpits?" (Acanthosis nigricans — insulin resistance)

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SECTION 5: GLYCAEMIC CONTROL HISTORY

This section establishes current control, monitoring practice, and hypoglycaemia risk — essential for every DM encounter.

• "When were you first told you have diabetes? Who made the diagnosis?"
• "What type of diabetes do you have — Type 1, Type 2, or were you not told?"
• "What was your most recent HbA1c result? When was it done? Is it improving or worsening?"
• "Do you check your blood sugar at home with a glucometer? How often?"
• "What are your typical fasting blood sugar readings in the morning?"
• "What are your blood sugar readings after meals?"
• "Do you use a continuous glucose monitor (CGM)? What is your time-in-range?"

Hypoglycaemia Assessment

• "Have you had episodes of low blood sugar (hypoglycaemia)?"
• "How often do these episodes happen?"
• "What are your warning signs — sweating, shaking, heart racing, confusion?"
• "Have you lost your warning signs for low blood sugar?" (Hypoglycaemia unawareness — HIGH RISK)
• "Have you ever needed help from another person, or called emergency services?"

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SECTION 6: PAST MEDICAL HISTORY (PMH)

Ask systematically — these comorbidities are both DM complications AND DM accelerators.

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SECTION 7: DRUG HISTORY & ALLERGIES

For each drug: Name → Dose → Frequency → Route → Compliance → Duration.

7A. Diabetes Medications

• "Do you take your diabetes medications every day? Do you ever miss doses?"
• "For insulin: Do you rotate injection sites? Are there any lumpy areas?" (Lipohypertrophy)

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7B. Other Medications (Comorbidities)

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7C. Drugs That WORSEN Glycaemic Control

Always check for these — they are a common and frequently overlooked cause of poor glycaemic control.

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7D. Allergies

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SECTION 8: FAMILY HISTORY (FH)

A strong family history of T2DM confers 2–4× increased risk. First-degree relatives with T1DM increase risk ~15-fold.

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SECTION 9: SOCIAL HISTORY (SH)

9A. Smoking

• "Do you smoke or have you ever smoked?"
• "How many cigarettes per day? For how many years?"
• Pack-years = (cigarettes/day ÷ 20) × years smoked
• "If stopped — when did you stop?"

Smoking DOUBLES cardiovascular risk in DM. It also impairs wound healing, worsens neuropathy, and accelerates nephropathy. Smoking cessation is a core DM management goal.

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9B. Alcohol

• "Do you drink alcohol? What type? How much per week?"
• "Do you ever drink on an empty stomach?"

Alcohol can mask hypoglycaemia symptoms AND cause delayed hypoglycaemia up to 24 hours after drinking — especially on insulin or sulfonylurea. Educate all patients.

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9C. Diet

• "What do you usually eat in a day from morning to night?" (24-hour dietary recall)
• "Do you eat regular meals, or do you skip meals?"
• "How much rice, bread, sugar, or sweet drinks do you consume daily?"
• "Are you following a special diabetic diet?"
• "Do you count carbohydrates or follow a meal plan?"

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9D. Physical Activity

• "How active are you on a daily basis?"
• "Do you do any structured exercise? What type, how often, and for how long?"

Target: 150 min/week moderate aerobic exercise + resistance training 2–3×/week. Exercise reduces HbA1c by ~0.6% independently.

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9E. Socioeconomic Status & Adherence Capacity

• "Do you have any difficulty affording your medications or test strips?"
• "Who cooks your meals at home?"
• "Do you live alone or with family?"
• "Do you understand how to use your glucometer and insulin device?"

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SECTION 10: DIABETES CLASSIFICATION — CLINICIAN ASSESSMENT

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SECTION 11: PHYSICAL EXAMINATION — GUIDE & FINDINGS

11A. General Assessment

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11B. Vital Signs

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11C. Eyes, ENT, Oral Cavity

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11D. Cardiovascular

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11E. Abdomen

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11F. Neurological — Peripheral Neuropathy Screening

Diabetic neuropathy is a diagnosis of exclusion — always rule out B12 deficiency, hypothyroidism, uraemia, CIDP, and vasculitic neuropathy.

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11G. Foot Examination — 5-Minute Minimum

ALWAYS remove shoes and socks. Check the feet at EVERY DM visit. Foot disease is the most preventable major complication of DM.

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11H. Musculoskeletal — Diabetic-Specific Signs

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11I. Skin Examination

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SECTION 12: INVESTIGATIONS — RESULTS RECORD

ADA Diagnostic Criteria — Any ONE of the following:

• FPG ≥7.0 mmol/L
• 2-hr OGTT ≥11.1 mmol/L
• Random PG ≥11.1 mmol/L + symptoms
• HbA1c ≥48 mmol/mol (≥6.5%)

Asymptomatic patients require TWO abnormal tests on DIFFERENT days to confirm diagnosis.

12A. Glycaemic

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12B. Autoimmune (Type 1 / LADA Classification)

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12C. Metabolic Panel

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12D. Cardiovascular

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12E. Ophthalmology

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12F. Coexisting Autoimmune (T1DM Screening)

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SECTION 13: RISK STRATIFICATION SUMMARY

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SECTION 14: ACTIVE PROBLEM LIST

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SECTION 15: MANAGEMENT PLAN FRAMEWORK

15A. Patient Education

• Disease understanding — what is DM and what causes complications
• Sick-day rules — never stop insulin when ill
• Hypoglycaemia recognition and treatment — carry fast-acting glucose (15g rule)
• Foot care — daily inspection, proper footwear, nail care, when to seek help
• SMBG technique
• Medication adherence counselling

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15B. Lifestyle Modification

• Diet: Reduced refined carbohydrates; Mediterranean or DASH diet pattern; caloric restriction if obese
• Exercise: 150 min/week moderate aerobic activity + resistance training 2–3×/week (reduces HbA1c ~0.6%)
• Weight loss: 5–10% body weight reduction significantly improves glycaemic control, BP, and lipid profile
• Smoking cessation — pharmacotherapy (varenicline) if needed
• Alcohol reduction counselling

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15C. Pharmacotherapy — T2DM Step-Up Approach

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15D. Treating Comorbidities

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15E. Complication-Specific Treatment

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15F. Follow-Up Schedule

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SECTION 16: BEDSIDE QUICK-REFERENCE CHECKLIST

History Checklist

• Biodata complete (name, age, sex, occupation, address, informant)
• Chief complaint in patient's own words with duration
• SOCRATES applied to each complaint
• Polyuria, polydipsia, polyphagia, weight loss asked
• Blurred vision, recurrent infections, poor wound healing asked
• DKA symptoms (nausea/vomiting/fruity breath) screened
• HHS symptoms (confusion/extreme thirst/very high BG) screened
• Hypoglycaemia episodes and unawareness assessed
• Eyes complications screened (retinopathy, laser treatment)
• Kidney complications screened (foamy urine, oedema, eGFR)
• Peripheral neuropathy screened (numbness, burning, cotton-wool sensation)
• Autonomic neuropathy screened (postural dizziness, gastroparesis, ED, neurogenic bladder)
• Cardiovascular history (chest pain, dyspnoea, claudication, palpitations)
• Foot history (ulcers, amputation, footwear)
• MSK history (stiff fingers, trigger finger, shoulder pain)
• Glycaemic control history (HbA1c trend, SMBG, hypoglycaemia)
• Past medical history (HTN, dyslipidaemia, CVD, CKD, thyroid, PCOS)
• All diabetes medications recorded with dose, frequency, compliance
• Drugs that worsen glucose checked (steroids, antipsychotics, thiazides, beta-blockers)
• Allergies recorded
• Family history (DM, CVD, CKD, obesity, MODY)
• Smoking status and pack-years calculated
• Alcohol history with hypoglycaemia education noted
• Diet (24-hour recall), exercise, adherence capacity assessed

Examination Checklist

• Height, weight, BMI, waist circumference recorded
• Blood pressure both arms; orthostatic BP measured
• Capillary blood glucose measured
• Fundoscopy attempted or referral arranged
• Oral cavity (Candidiasis) and thyroid examined
• All peripheral pulses palpated (femoral, popliteal, posterior tibial, dorsalis pedis)
• Abdomen: liver size, renal angle, injection sites
• Neurological: monofilament, tuning fork, pin-prick, ankle jerks, proprioception, Romberg's
• Shoes and socks removed; feet fully inspected
• MSK: prayer sign, tabletop, Dupuytren's, trigger finger, Tinel's, Phalen's, shoulder ROM
• Skin: acanthosis nigricans, necrobiosis lipoidica, dermopathy, xanthomas, vitiligo

Investigations Checklist

• HbA1c requested / result recorded
• FPG or random BG with result
• Urine ACR (nephropathy screening)
• eGFR / creatinine / urea
• Fasting lipid profile
• FBC (rules out anaemia affecting HbA1c)
• LFTs (NAFLD screening, medication monitoring)
• TSH
• B12 (on metformin)
• ECG
• Anti-GAD / C-peptide (if type classification unclear)
• Dilated fundoscopy referral made if not done within past year

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SECTION 17: CLINICAL ASSESSMENT & SIGNATURE

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