A sample PBL Scenario to start and direct learning on Diabetes mellitus for Medical undergraduate (MBBS) students in India

1. PROBLEM BASED
LEARNING
Diabetes Mellitus
Dr. Mandar Baviskar
Associate Professor Community Medicine
Dr. BVP RMC, PIMS(DU), Loni

2. CASE
Mr. Dinkar Kumar is a 49 year old Hindu businessman belonging to
upper middle class and resident of Loni presented with complaints of
■ Excessive thirst since 2 months
■ Increased frequency of micturition since 2 months
■ Tiredness since 2 months
HOPI: The symptoms were first noticed when he was on business tour 2
months back.

3. ■ Personal History:
The patient smokes 4 cigarettes per day and drinks 120 ml liquor at least 3 days a
week. The patient exercises irregularly and reports business stress. Sleep-reduced
■ Family History:
The patient’s father has Diabetes since 14 years and is on oral medications for same.
■ Dietary History:
Mixed diet (Intake 3000 kcal, Requirement: 2400 kcal, Excess: 600 kcal)
■ Environmental History: Not significant
■ General Examination: BMI- 32 m2/kg, Pulse- 74/min, BP-130/80mmHg,
■ Systemic examination: NAD

4. Questions:
■ What is the probable diagnosis? Why?
■ How will you confirm?
■ What investigations will you advise this patient?
■ What preventive measures will you take?
■ Name some government schemes and programs that can help the patient

5. Ask for
■ Frequent urination
■ Excessive thirst
■ Excessive hunger
■ Weight loss
■ Delayed wound healing
■ Tiredness
■ Itching especially in genital areas
■ Tingling numbness
■ Visual disturbances
■ Family history
■ History suggestive of hypoglycemia, DKA, HHS, Coronary Heart disease
■ H/o complications like Pedal edema, nocturia, facial puffiness, angina, claudication,
sensory impairment, disturbed gait in dark, sexual dysfunction

6. Look at
■ BMI, Waist Circumference, Waist/Hip
ratio
■ Blood pressure measurement
■ Abdomen examination
■ Thyroid examination
■ Skin examination
■ Fundus Examination
■ Dental Examination
■ Foot examination: Inspection,
peripheral pulses, Ankle brachial
index, ankle & knee jerks,
Proprioception, vibration and
monofilament sensation

7. Typically Diabetes Presents as
■ An Adult of either sex in 3rd Decade of Life or older
■ Positive family history
■ Overweight/obese
■ Symptoms of Hyperglycemia ( polyuria, polydipsia, polyphagia, weight loss)
■ Signs of Insulin Resistance (acanthosis nigricans, skin tags)
■ But Mostly Diagnosis is incidental (80%)
OPPORTUNISTIC SCREENING IS IMPORTANT

8. ■ Probable Diagnosis: Type 2 Diabetes Mellitus
■ Why?
– Polyuria,
– Polydipsia,
– Family History(++),
– Obesity,
– Smoking,
– Alcohol consumption
– Stress

9. Diagnostic Criteria
■ Diabetes Mellitus
– Fasting Plasma Glucose >= 126mg/dl
– Casual Plasma Glucose>=200mg/dl
– 2 hour plasma glucose>=200mg/dl on OGTT
– HbA1c >6.5%
■ Impaired Fasting Glucose
– Fasting plasma glucose >=110 <126mg/dl (>=100 ADA)
■ Impaired Glucose Tolerance
– 2 hr post load plasma glucose >=140 & <=199mg/dl

10. 3 patients have undergone OGTT give
their diagnosis
Mr. A Fasting Plasma Glucose 120
md/dl
At 2 hours 209 mg/dl
Urine glucose +++
Mr. B Fasting 96md/dl
2 hour 186 mg/dl
Urine Glucose is absent
Mr. C Fasting 114 mg/dl
2 hour 136 mg/dl
Diabetes Mellitus
Impaired
Glucose
Tolerance
Impaired Fasting
Glucose

11. Homework
■ Distinguishing features of
– Type 1 DM,
– Type 2 DM,
– MODY, Monogenic
– Early onset DM,
– Fibrocalcinous DM,
– Latent Autoimmune Diabetes of Adults
■ What is ASCVD?
■ What is metabolic syndrome?

12. Investigations to advice
■ Index Visit: Blood Glucose (Fasting, PP)
– HbA1c
– Fasting Lipid Profile
– LFT, RFT
– Retinal examination
– Foot examination
– ECG, CXR, ECHO, TSH
■ Once in 3 months : HbA1c, Fasting, PP
■ Once in 6 months: Lipid Profile
■ Annual Check up: Baseline tests repeated

13. Screening

14. Primary Prevention
■ For NCDs primary prevention involves
■ Population Based Strategy: Small change in lifestyle of entire population translates
to large change in mortality and morbidity.
■ High Risk Strategy: Risk mitigation in High risk individuals

15. Secondary Prevention
■ Get blood glucose checked regularly
■ Take the correct dose of diabetes pills or insulin
■ Take diabetes pills or insulin at the right time
■ Eat the correct food portions
■ Eat meals/snacks on time
■ Keep food records
■ Treat low blood glucose with just the recommended amount of carbohydrate
■ Carry quick acting sugar to treat low blood glucose
■ Come in for clinic appointments
■ Exercise

16. Tertiary
Prevention
■ Regular follow up and testing for
complications
■ Foot care

17. Health Programs
■ NPCDCS
■ India Hypertension Control Initiative

18. THANK YOU