Skip to main content

Rationale

Diabetes mellitus is, after obesity, the most common endocrinologic problem seen in primary care practice. All physicians must identify those at risk and institute appropriate management to ameliorate the potentially fatal complications of this disease.

Prerequisites

Basic courses in physiology, pathology, and pharmacology, and introductory required course in physical diagnosis

Specific Learning Objectives

  1. Knowledge: Students should be able to define and describe:
    1. presenting symptoms and signs of type 1 and type 2 diabetes mellitus
    2. presenting symptoms and signs of diabetic ketoacidosis and nonketotic hyperglycemic coma
    3. major causes of morbidity and mortality in type 1 and type 2 diabetes mellitus (e.g., coronary artery disease, peripheral vascular disease, hypoglycemia, diabetic ketoacidosis, nonketotic hyperglycemic coma, retinopathy, neuropathy, nephropathy, foot disorders)
    4. pathogenesis, genetics, and epidemiology of type 1 and type 2 diabetes mellitus
    5. diagnostic criteria for type 1 and type 2 diabetes mellitus, based on a history, physical examination, and laboratory testing
    6. key laboratory tests needed to diagnose type 1 and type 2 diabetes mellitus, diabetic ketoacidosis, nonketotic hyperglycemic coma, and hypoglycemic coma including:
      1. serum glucose
      2. electrolytes
      3. blood urea nitrogen
      4. creatinine, ketones (serum)
      5. arterial blood gas
      6. glycosylated hemoglobin or fructoseamine
      7. urine glucose, ketones, albumin/protein
    7. goals of treatment of diabetes mellitus (i.e, preventing complications, maintaining acceptable levels of glycemic control, and achieving weight reduction, if obese)
    8. key indications for diet therapy, oral hypoglycemic agents, and insulin therapy in diabetes mellitus
    9. management strategies for diabetic ketoacidosis and nonketotic hyperglycemic states, including the similarities and differences in fluid and electrolyte replacement
    10. the American Diabetes Association (ADA) dietary recommendations for type 1 and type 2 diabetes mellitus
    11. the Somogyi effect and the dawn phenomenon, and the implications of each in diabetes management
    12. describe steps in the critical pathway for patients with diabetes mellitus
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, including:
      1.  weight gain or loss, polyuria, polydypsia, polyphagia, weakness, fatigue, blurred vision, recent skin or other infection, vulvovaginitis/balanitis, abdominal pain, medication history (e.g., corticosteroids, medication compliance), family history of diabetes mellitus, and social history (e.g., cigarette use)
      2. disease complications (e.g., cardiac symptoms, autonomic postural hypotension, gastroparesis, diarrhea, constipation, urinary retention, impotence, lower extremity pain, numbness)
      3. diet history (i.e., total caloric intake, intake of sugar-containing foods, intake of saturated fat and cholesterol, physical activity level, alcohol intake, timing of meals in type I diabetes)
    2. physical exam skills: Students should be able to perform, a physical examination on patients with type 1 or type 2 diabetes mellitus to establish the diagnosis and severity of disease focusing on altered mental status, stupor, coma, Kussmaul respirations, fruity breath, signs of autonomic insufficiency and/or volume depletion, skin examination for diabetic dermopathy, furuncles, carbuncles, candidiasis, and necrobiosis lipoidica diabeticorum, cataracts, retinopathy, glaucoma, peripheral pulses, peripheral neuropathy, corns and calluses, dermatophytosis, ulceration
    3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings, to diagnose type 1 versus type 2 diabetes
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1.  laboratory and diagnostic tests should include, when appropriate:
        • serum glucose, electrolytes, blood urea nitrogen, creatinine, ketones, arterial blood gas, glycosylated hemoglobin or fructoseamine
        • urine glucose, ketones, albumin, creatinine clearance
        • CBC with differential
        • EKG
    5. communication skills: Students should be able to:
      1.  explain the results of the evaluation to the patient
    6. basic and advanced procedure skills: Students should be able to:
      1. insert a peripheral venous catheter and obtain an arterial blood gas, after explaining each procedure to the patient
      2. perform fingerstick capillary blood glucose determination
      3. assist in the insertion of a central venous catheter
    7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including:
      1. writing appropriate fluid and insulin orders and outline critical steps for the treatment of diabetic ketoacidosis and nonketotic hyperglycemic coma
      2. counseling a patient regarding basic features of ADA diabetic diet recommendations
      3. instructing a patient in home blood glucose monitoring
      4. counseling a patient on behavior changes (e.g., smoking, poor glycemic control, hypertension, hyperlipidemia and infection) to avoid the complications of diabetes
      5. determining when to institute diet therapy, oral hypoglycemic agents, and insulin therapy
      6. calculating an appropriate insulin dose for a diabetic patient
      7. determining when to involve an endocrinologist in the care of a diabetic patient
      8. determining when to involve an expert in foot care and the proper fitting of specially designed weight bearing shoes
      9. accessing and utilizing appropriate information systems and resources to help delineate issues related to diabetes
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. appreciate the impact of diabetes mellitus on the individual and the family
    2. consider the individual’s social, socioeconomic, and cultural background when designing nutritional recommendations and making referrals