DOORWAY INFORMATION
Opening Scenario
The mother of Louise Johnson, a 10-year-old female child, comes to the office because she is concerned that her daughter was recently diagnosed with diabetes.
Examinee Tasks
1. Take a focused history.
2. Explain your clinical impression and workup plan to the mother.
3. Write the patient note after leaving the room.
Checklist/SP Sheet
Patient Description
The patient’s mother offers the history; her daughter is at school.
Notes for the SP
None.
Challenging Questions to Ask
■ “Doctor, I have no history of diabetes in my family. Why is this happening to my daughter?”
■ “Will my child ever be able to eat sweets again?”
Sample Examinee Response
“Your daughter probably had a genetic tendency to develop diabetes. Then certain unknown environmental factors led her to get full-blown diabetes. Your daughter may have either type 1 or type 2 diabetes. In type 1 diabetes, the immune system attacks the pancreas and destroys the cells that are responsible for making insulin. Since insulin regulates and maintains blood sugar, an insulin deficiency will lead to high levels of blood sugar. On the other hand, if your child is overweight and is not physically active, she may have type 2 diabetes, which is a combination of insulin deficiency and resistance to the action of insulin resulting from being overweight. In either case, it is not necessary to have a family history of diabetes. With regard to sweets being the cause of your daughter’s diabetes, this is a myth. In fact, your daughter can still eat sweets, but in moderation. She will need to see a dietitian to develop healthy meal plans as well as to learn to recognize which foods contain carbohydrates and how much.”
Examinee Checklist
Building the Doctor-Patient Relationship
Entrance
□ Examinee knocked on the door before entering.
□ Examinee introduced self by name.
□ Examinee identified his/her role or position.
□ Examinee correctly used patient’s name.
□ Examinee made eye contact with the SP.
Reflective Listening
□ Examinee asked an open-ended question and actively listened to the response.
□ Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
□ Examinee summarized the SP’s concerns, often using the SP’s own words.
Information Gathering
□ Examinee elicited data efficiently and accurately.
Connecting with the Patient
□ Examinee recognized SP’s emotions and responded with PEARLS.
Physical Examination
None.
Closure
□ Examinee discussed initial diagnostic impressions.
□ Examinee discussed initial management plans:
□ Further examination.
□ Follow-up tests.
□ Examinee asked if the SP had any other questions or concerns.
Sample Closure
Mrs. Johnson, I can understand how you have felt since your daughter was diagnosed with diabetes. Diabetes may alter the dynamics of the entire family and affects everyone, so your life is going to be a little different now. We can manage this disease very well through a combination of insulin, a balanced diet, and regular exercise. First of all, you should understand the disease and know how to manage it. You will need to attend diabetes classes with your daughter. Second, everyone in your family, including your daughter, should learn to recognize signs of low glucose levels, such as confusion, disorientation, or fainting, and should know how to provide appropriate care. Your daughter should always carry a snack or juices as an “emergency kit.” Her teachers and friends should also be aware of her disease. I hope you understood what we discussed today. Do you have any additional questions or concerns?
History
HPI: The source of the information is the patient's mother. The mother of a 10 yo F states that her child was diagnosed with DM 1 month ago, when she presented with excessive thirst and frequent urination. The parents were shocked after the diagnosis was made. The child seems concerned but not irritable or depressed. She is active, plays tennis, and is currently on a diet prescribed by a dietitian. She is on insulin injections and regularly monitors her blood glucose levels at home. Her compliance is good; she checks her blood glucose before each meal and at bedtime. Fasting glucose levels are usually 80 to the low 100s and in the high 100s before meals. She has not had any episodes of hypoglycemia. She has lost 9 lbs in the past 3 months, but her weight is stable now at about 180 lbs. She denies any weakness, fatigue, tingling over the limbs, visual symptoms, or rash/itch at the injection sites. She has not yet started menstruating.
ROS: Negative.
Allergies: NKDA.
Medications: Insulin.
PMH: None.
PSH: None.
Birth history: Normal.
Developmental history: Normal.
FH: No family history of diabetes.
Physical Examination
None.
Differential Diagnosis
CASE DISCUSSION
Patient Note Differential Diagnoses
■ Diabetes mellitus (DM): Although most cases of DM in the pediatric population are type 1, the increasing prevalence of obesity and physical inactivity in the urban population has led to a growing incidence of type 2 DM among children. In every suspected case of DM, it is mandatory to rule out other causes.
■ Secondary causes of diabetes (hyperglycemia): DM can be secondary to other factors or medical conditions, such as drugs (eg, thiazide diuretics, glucocorticoids), Cushing’s syndrome, pancreatitis, cystic fibrosis, hemochromatosis, and acromegaly.
Diagnostic Workup
■ Insulin and C-peptide levels: When combined, can be a useful tool in identifying type 1 DM.
■ Islet cell antibodies: This finding will support the diagnosis of type 1 DM.
■ HbA1c: Used to diagnose DM and to monitor treatment. HbA1c estimates blood glucose control during the preceding 2-3 months. Elevated levels suggest existing DM as well as lack of control of blood glucose levels within the past 2-3 months.
■ Electrolytes, glucose: To assess for hypernatremia, which may be seen in DM, as well as for glycemic control in conjunction with HbA1c. A random glucose test ≥ 200 mg/dL can help make the diagnosis of DM.
■ UA, urine microalbumin: To screen for diabetic nephropathy.
■ 24-hour urine free cortisol: To rule out coexisting Cushing’s syndrome.