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1) Diabetes counselling- Patient with high HbA1c or FBS report

Why did you get these tests done?

Is this the first time? If already known diabetic - then ask CHaMP and DICE

CHaMP- Caregiver (Doctor)- When was your last visit to a doctor?

Hospitalization- were you ever admitted to hospital because of this? (only if


Medication- Are you taking any medicines for diabetes? If yes- DICE- Dosage,
Indication (already known), Compliance (Do you take your medicines regularly? If
not, why?), Effects (good and bad both)- are your symptoms controlled? Do you
feel or have any side effects.

Procedures/ Investigations- What are the investigations done in the past? blood
tests, foot and eye care, kidney tests etc

History for diabetes - a) Symptoms of diabetes b)Direct complications- DKA

and hypoglycemia c) Indirect Complications- HENS GRIP

a) Symptoms- Do you pee more? Do you wake up more than usual at night to pee?
feel more thirsty? weight loss? b) DKA- vomiting, abdominal pain, faster
breathing, very thirsty, tired , ever been admitted to hospital with these symptoms?

Hypoglycemia- feel weak and drowsy, sweating and trembling, dizzy, confused


 Heart- chest pain, SOB, high blood pressure, high cholesterol, any heart
 Eyes- blurring of vision
 Nerves- foot sores/ulcers, numbness
 Stroke- weakness, difficulty in speaking, swallowing
 Gastrointestinal- constipation, indigestion, bloating
 Renal- ankle swelling, any kidney disease, any problems with bladder
habits? (already asked)
 Impotence- any problems in your sexual life?
 PVD- pain in calves while walking, skin changes such as loss of hair,
shiny skin


Past med hx- any other health issue in the past

Family hx- diabetes- V IMPORTANT



Gynae- If female, ask for PCOS symptoms- irregular habits, weight changes,
abnormal hair growth; and h/o GDM

Lifestyle- V Important- dietary habits, exercise, Obesity (do you know your BMI?)

Occupation- sedentary?

Social/ Stress

Diabetes Counselling

How much do you know about diabetes? How much would you like to know?

Diabetes is a long term illness and occurs when a person's body does not make
enough insulin or doesn't use insulin in right way. Insulin helps your cells to use
blood sugar for energy and this leads to increase in sugar in your blood. Over time,
high blood sugar can damage your blood vessels, eyes, nerves and kidneys. It
needs lifelong care and I will be with you at every step. Let us make a plan
together. How does that sound?

Counseling will depend on patient's report :

 Presence of classic symptoms of DM PLUS random blood glucose >= 11.1

mmol/L (200mg/dl)
 On at least 2 separate occasions:
o FPG>= 7 mmol/L (126mg/dl) OR
o 2h 75g OGTT>=11.1 mmol/L (200mg/dl) OR
o RPG>=11.1 mmol/L (200 mg/dl) OR
o HbA1c >=6.5%

So if a patient has come for first time with high blood sugar with no symptoms-
Repeat the test

If its high 2nd time or if patient has symptoms- Initiate lifestyle modifications


A- HbA1c- every 3 months-it helps show how well your blood sugar has been
controlled during previous 3 months. Our goal is less than 7%

Blood pressure Pay close attention to your blood pressure and cholesterol
levels. This will reduce the complications such as heart disease
and stroke. Keep your BP at 130/80.


Weight Now let us talk about lifestyle modifications. Following a

healthy lifestyle can help in lowering blood sugar level and
Exercise reduce risk of heart disease and stroke. We can make an
exercise plan for you and I will refer you to a dietitian

Diet who can advice you about healthy food choices for you.


Smoking- (only if pt smokes)- Smoking has many bad effects including causing
high blood sugar. Have you thought about quitting?

Yes- I am really happy to hear that. We will make a plan for that in next meeting

No- Let me know whenever you feel ready to quit but I will like to tell you about
effects of smoking on your health in next appointment.

Alcohol- Limit your weekly intake of alcohol to less than 9 drinks in women and
14 in men
Medicine compliance/ Monitoring- One of the best ways to reduce damage to
your body by high blood sugar is to control your blood sugar levels. You can do
that by above methods and by taking your medicine regularly in the right way.
Regular blood sugar checks can help you see how eating affects your blood sugar
and also how healthy lifestyle and medicines are affecting it and if you need to
change your dose of medicine.

Do you have any questions till now? Let us talk about what more we need to do

Foot Care- Check your feet daily and I will also check your feet on every visit for
any ulcers, numbness or skin changes

Renal- Diabetes can affect your kidneys so we will your urine for any protein
every year.

Eye care-You should also see your eye doctor every year or earlier if you have any

Education- I know it is lot of information to take in so I will give you some

information material about diabetes, go through them and if you have any further
questions we can discuss that in next appointment.

I will also advise you: (depending on patient's concerns. e.g if a patient is a truck
driver, driving care is important or if patient has come for ED then addressing that
concern is important)

Vaccines- Influenza, Pneumococcal

Sexual concerns- if ED

Driving care- explain symptoms of hypoglycemia, neuropathy

2) Erectile Dysfunction

Confidentiality - very very important

OCD- since when you have noticed this issue? Did it happen suddenly
(psychogenic) or gradually (organic)

-Is it always there or comes and goes i.e depends on circumstances or partner?

-Is this the first time this issue has happened? When was the last time you had
normal erection?

Specific questions- PEERS

Penetration- Do you have erection sufficient to penetrate? After penetration, were

you able to maintain erection?

Erection at night/ early morning/ with self stimulation?

Ejaculation- When you have erection, how often do you ejaculate?

Relationship- How is your relationship with the partner?

Sexual desire- How would you rate your sexual desire?


I- Iatrogenic- Did you have any surgery or exposure to radiation in your pelvic

M-Mechanical- Peyronie's disease- Do you have any pain on erection? When you
have an erection, is your penis straight?

P-Psychological- How is your mood? Do you feel anxious about something?

P-Prostate- symptoms of prostatitis and BPH- fever, FUND SHED

O-Occlussive Vascular- ask risk factors for CVS + CVS blocks- "shychodifals"-
smoking, hypertension, high cholesterol, diabetes

CVS blocks- pain chest, SOB, pain in legs, skin changes in legs, heart racing
T-Trauma- any injury to pelvic area or penis or spine, long distance cycling

E-Endocrine- DM, Thyroid, Pituitary ( increase in prolactin), Hypogonadism

(decrease in testosterone)- weight changes, discharge from nipples, headache,
blurring of vision

N-Neurogenic- CNS, DM, Neuropathy, Stroke, Parkinson's- any numbness/

weakness/ difficulty in walking

C-Chemical- Medicines- Do you take any medicines? Do you use any street drugs?

E-Extra factors- ask Sexual history- complete- How many partners did you have in
past? Do you practice safe sex? any penile d/c? Have you ever been tested for


SAD - already asked

GLOSS- asked

Counselling for ED

Thankyou for answering my questions and I am glad that you came here to discuss
about your concerns. I will examine you and send you for some investigations to
check your blood sugar, cholesterol. From what you have told me, you have a
condition called Erectile dysfunction.

Erectile dysfunction is when a man is unable to get and/or keep an erection that
allows sexual activity with penetration.1 It is not a disease, but a symptom of some
other problem, either physical, psychological or a mixture of both. There are many
diseases that interfere with how the penis functions by either reducing blood flow
or affecting the nerves such as diabetes, hypertension, high cholesterol.

Some of the causes of occasional erectile dysfunction include excessive intake of

alcohol, anxiety and tiredness. One of the most common causes of erectile
dysfunction in middle-aged men is lack of sleep.

Usually there will not be a specific treatment that will lead to the cure of erectile
dysfunction. However, there are treatments that will allow erections to happen and
can enable sexual activity to take place. The main types of treatment for erectile
dysfunction are:

Tablet medicines (Viagra®, Cialis® and Levitra®) Taking a tablet for erectile
dysfunction is non-invasive and allows a more spontaneous approach to sexual
activity. You should take it 30 to 60 minutes before you need it.

Vacuum device is a pump placed over the penis to create blood flow. It draws
blood into specific tissues of the penis, as would happen in a normal erection.

Injection treatments increase blood flow when they are injected into the penis,
causing an erection. A possible side-effect is priapism (a painful erection lasting
for hours) that if not managed can damage the penis.

Prescription medicines may need changing in consultation with your doctor, if they
are the cause.

Penile prosthetic implants are usually used as a last resort if all other treatments
have not worked.

Following a healthy lifestyle i.e. Regular exercise , a healthy diet, losing weight,
giving up smoking and alcohol intake in moderation will reduce the risk of obesity,
diabetes, high blood pressure and high cholesterol, therefore making erectile
dysfunction less likely.

Medicines causing ED

B blockers, water pills, cimetidine

3) Fatigue


Is it related to particular time of day?

What are the activities you are unable to do? e.g getting up from chair, combing
your hair (PMR), opening jars, turning keys (RA)

How has it affected your life? (missed work, not able to do household work)


Muscle/Joint disease- PMR, Chronic fatigue syndrome, MG, RA- muscle
weakness, visual disturbance, joint pains, numbness


 DM- h/o Diabetes or gestational diabetes, increased urination, increased

thirst, increase appetite, weight changes
 Thyroid- weight gain, constipation, skin dryness,
 Cushing's- weight gain, use of steroids, skin marks on abdomen

Depression- How is your mood? Do you still enjoy the activities you used to enjoy
before?- If positive ask MI PASS ECG and h/o abuse

Infections- UTI/Pyelonephritis/ Infectious mononucleosis/ Pneumonia- from top to

bottom- fever,N/V/D, cough, sore throat, loss of appetite, abdominal pain/flank
pain, dysuria, burning, changes in color of skin/urine

Anemia- pale, dizziness, SOB, heart racing, bleeding from any site

Abuse- asked in depression

Diuretics- Do you take any water pills? (Thiazides, loop- hypokalemia, K sparing-
Hyperkalemia)- muscle cramps, constipation, heart racing

Uremia- any kidney disease/ face swelling/ ankle swelling/ oliguria

Neoplasm- weight loss/ night sweats/ lumps or bumps in body

Liver disease- Hepatitis- yellowness of eyes/ skin, h/o travel

OSA- how's your sleep? has anyone told you that you snore at night? Do you wake
up gasping for air?

Pregnancy- when was your LMP? Is it possible you can be pregnant? Are you

Substance abuse- caffeine/ alcohol/ drugs


SAD- already asked GLOSS- already asked

Investigations- depending on hx

M- CRP, ESR, RA factor

E- FBS, HbA1c, T3, T4, TSH, Thyroid Abs


I- CBC with diff, urine R/E, cytology and culture, CXR

A- CBC, S. ferritin, iron studies, peripheral smear, Hb electrophoresis

D- S electrolytes

U- BUN, creatinine, lipid profile, urine R/E, urine protein, albumin

N- occult blood in stool, colonoscopy, UGIE, MRI/CT

L- AST, ALT, Bilirubin, ALP

O- sleep studies

P- B-hcG

S- urine toxicology


Intro/ consent

wash hands

Vitals- comment on them- Ms______ your BP is ____ which is normal/high/low

and your HR/temp is ______ which is ______

General appearance- Pt is sitting comfortable/ in distress

Hands- Pulse, dry skin, clubbing, cyanosis

Face- puffiness/ swelling, loss of outer eyebrows, moon facies

Eyes- pallor/jaundice
Mouth- hydration status, ulcers, macroglossia, sore throat(enlarged tonsils/LNs)

Neck- LNs, Thyroid

Chest- breath sounds/ heart sounds

Abdomen- striae/ discoloration/ tenderness (suprapubic/ RUQ), CVA tenderness,


Neuro- Motor, sensory, reflexes

MSK- quickly look for joint swelling/pain, skin rash

Some extra points

Polymyalgia Rheumatica-

- age>= 50 years, B/L shoulder aching and abnormal ESR/CRP (must be present)

-pain and stiffness of shoulder and pelvic girdles, no muscle weakness

- Absence of RA factor, normal CK

-fever/ weight loss/ fatigue

-gel phenomenon- stiffness after prolonged inactivity

-Rx- start prednisone 15-20 mg PO OD, taper slowly over 2 year period and
monitor with ESR/CRP

- follow for symptoms of GCA- new headache/scalp tenderness, temporal artery

tenderness, ESR>50,sudden painless loss of vision, pain in chewing- if suspected
start prednisone 1,g/kg in divided doses for 4 weeks then taper as symptoms
resolve, consider low dose ASA

-GCA with vision loss- High dose IV glucocorticoids- e.g IV methylprednisolone

1000 mg daily for 3 days followed by oral glucocorticoids.

-GCA- yearly CXR and abdominal USG for screening of thoracic aortic aneurysm
and abd aorta

Nephrotic - HELP- Hypertension, edema, Lipid increased, Proteinuria

Nephritic- PHAROH- proteinuria, hypertension, Azotemia, RBC casts, Oliguria,


Hypokalemia- A SIC WALT


Shallow Respirations

Irritability/ Intestinal- N/V, Ileus

Confusion, drowsiness

Weakness, fatigue

Arrythmias- Tachycardia/ Brady cardia/ irregular rhythm


Thready pulse

Hyperkalemia- MURDER

Muscle cramps/weakness/ fatigue

Urine- oliguria

Resp distress

ECG changes- Broad QRS, Tall tented T wave, prolonged PR, arrhythmias

Reflexes- spastic paralysis