Diabetes Mellitus

When a Diabetes Mellitus examination is requested, begin with this worksheet. For each diabetic complication manifested by the veteran, complete appropriate additional worksheets.

Chronic complications from diabetes include vascular and nonvascular complications. Vascular complications include microvascular (eye disease, neuropathy, nephropathy) and macrovascular complications (coronary artery disease, peripheral vascular disease, cerebrovascular disease). Nonvascular complications include gastroparesis, sexual dysfunction, and skin changes.

Reference: Harrison's Principles of Internal Medicine, 2001, page 2119.

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

As pertains to Diabetes Mellitus or its complications, comment on:

1. Age of onset.
2. Frequency of ketoacidosis or hypoglycemic reactions.
3. Hospitalizations per year for ketoacidosis or hypoglycemic reactions.
4. Restricted diet.
5. Weight loss or gain since last exam.
6. Describe any restriction of activities on account of the diabetes (e.g., avoiding strenuous activity to prevent hypoglycemic reactions).
7. Treatment - oral hypoglycemic, insulin (frequency of injections).
8. Frequency of visits to diabetic care provider.
9. Other symptoms, such as anal pruritus, loss of strength.
10. Visual problems.
       Refer to examination worksheet: Eye examination, if indicated.
11. Vascular (including hypertension, if appropriate) or cardiac symptoms.
       Refer to examination worksheet(s): Hypertension, Heart, Arteries, Veins, and Misc., etc., if indicated.
12. Neurologic symptoms.
       Refer to examination worksheets(s): Peripheral Nerves, etc., if indicated.
13. Bladder or bowel functional impairments.
       Refer to examination worksheets(s): Genitourinary, Rectum and Anus exam, etc., if indicated.

C. Physical Examination (Objective Findings):

Assess for chronic complications of diabetes mellitus. Complete appropriate additional worksheets.

1. Cardiovascular examination to include blood pressure and status of peripheral arteries, presence of peripheral edema.
2. Neurologic examination.
3. Eye examination.
4. Skin examination.
5. Examination of extremities, including feet.

D. Diagnostic and Clinical Tests:

Provide:

1. Fasting blood sugars, or other laboratory evaluation if necessary to establish the diagnosis.
2. Blood sugars.
3. Evaluation for kidney function including: urinalysis with urine for microalbumenuria; blood urea nitrogen (BUN) and creatinine (Cr).
4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. State whether the veteran has diabetes mellitus. Indicate type.
2. Specifically list each identified complication of the veteran's diabetes. Indicate these conditions as "complications of the veteran's diabetes". If the veteran has peripheral edema, indicate whether it is a consequence of diabetic kidney disease or other non-diabetic related etiology.
3. For each identified complication of the veteran's diabetes, provide a brief rationale for your conclusion. You may base your rationale on such things as the duration of the veteran's diabetes, whether the veteran's diabetes has been poorly controlled, the onset of the condition that you deem to be a complication of the veteran's diabetes in relation to the onset of the veteran's diabetes, the severity of the complication, or anything else you consider relevant.
4. Where the veteran has visual impairment, cardiovascular disease (including hypertension), kidney disease, neurologic disease, amputations, or any other disabilities which, in your opinion, are not complications of the veteran's diabetes, please state so and provide a supporting rationale as to the basis for your conclusion.
5. Where the veteran has a condition that is worsened or increased by the veteran's diabetes but is not a diabetic complication, discuss the relationship between the condition and the veteran's diabetes. In particular, discuss what the degree of disability is of the condition over and above the degree of disability that existed prior to aggravation/worsening by the diabetes. Provide your rationale. Indicate if this is not possible to do without resorting to speculation.

Signature:

Date: