 Hello all, in this video we are going to see what to write in recommendations for clinical social case of diabetes mellitus. Before going to the recommendations in a clinical social case, we should understand what is the major difference between a clinical case and the clinical social case. There are three key differences rather additions to the clinical case that is we add social aspects of the disease that is we include environmental history, social history in order to make it as a clinical social case. Secondly, we try to identify the cause of the disease and try to suggest the prevention control measures for the particular disease. Thirdly, we give recommendations not only to the individuals but also to the family and the community. Here is the list of clinical social cases which will be kept in community medicine practicals. Here I have given 10 cases, 99% of the times you will get one among these cases. This list can be divided into five pairs that is the non-communicable pair, diabetes mellitus and hypertension, MCH maternal and child health, MCH pair that is anti-natal case and post-natal case, the pediatric pair ARI and ADD or diarrhea, the chronic illness pair tuberculosis and leprosy then the miscellaneous pair DINGU or any fever for evaluation or HIV. These cases the availability of the cases from anti-natal care to HIV is very will be less during exams. The chance of students getting diabetes mellitus and hypertension is more that is almost about half of the times you will either get a case of diabetes mellitus or hypertension or a case of some other clinical social case who has in addition to this disease they have diabetes mellitus and hypertension. So before writing the recommendations of clinical social case we should have this in mind that we are going to give recommendations not only to the individual but also to the family and the community level. Then the other things which we should keep in mind is the levels of prevention that is primary prevention, secondary prevention and tertiary prevention. In primary prevention we have population strategy and high risk strategy and in primary prevention the modes of the interventions are health education and specific protection or health promotion and specific protection. Secondary prevention the modes of interventions are early diagnosis and prompt treatment or adequate treatment and in tertiary prevention we have disability limitation and rehabilitation. In specific to diabetes mellitus we are going to deal in this presentation. So here we have to write recommendations in this headings that is at individual level we have to give recommendations for the relief of symptoms, diet, exercise, self-care, adherence to the medication, general information, monitoring of disease and family level and community level recommendations. At individual level the first is the relief of the symptoms. If suppose he has got some complaint for getting admitted in the hospital then we should treat that symptom first. For example, Parasthitia or any wound or any fever, superadidine infections or any signs of complications then we have to give medicines to control the symptoms. Then second is treating the comorbidities and any drug interactions if the patient has. Then the third thing is we should check for the blood sugar control using the blood sugar and HBEa1c and this blood sugar monitoring is a separate heading in individual level recommendation which will be dealt later. Diet is very important in case of diabetes mellitus patient. Based on the literacy level of the patient we can explain some of these basic concepts otherwise we have to keep this in mind and recommend to the patient in a way that the patient can understand easily. So first thing is the patient should take a low glycemic index food and also a low calorie food. We all know calorie is just the energy which a food can yield but glycemic index is the ability of the food to how fastly increase the blood sugar level that is called as the glycemic index. Some food like potato will have low calorie but has high glycemic index that is if 100 gram of rice yield about 350 kilo calories the rate at which it increases the blood sugar will be very less but 100 grams of potato will yield only 60 kilo calories but it increased the blood sugar level very fast. So high glycemic index should be avoided such as sweets, bread, rice, potato have high glycemic index and we should recommend the low calorie foods then whole grains can be preferred fruits with edible skin has low glycemic index and high fiber content when compared to the fruit juices. We have to recommend the patient to eat in a small quantities at frequent interval. Small frequent meal is a key factor in case of diet recommendation for a diabetes mellitus patient and reduce the consumption of the oil especially the oil which has more saturated fats and reduction of fried foods and bakery items and the patient should aim for at least 5 servings of vegetables and fruits per day. Alcohol should be avoided the concept of empty calories is each gram of alcohol liberates about 4 kilo calories as equal to your carbohydrate or a protein. Then for a diabetics patient no fasting is advisable and no feasting is advisable. Then the third important thing in diabetes mellitus recommendation is the exercise. We have to advice the patient based on the BMI of the patient to make a weight loss or weight maintenance based on the BMI. Then we have to recommend aerobic exercise like walking, cycling and swimming. The basic difference between aerobic exercise and anaerobic exercise is aerobic exercise does not hold your breath. It makes you breathe more while doing that exercise that is good for diabetes mellitus patients and this brisk exercise should be a target of about 30 to 45 minutes per day in most of the days of the week. Then other types of exercise which can be recommended is body building like weight lifting, yoga, meditation, first stress relief, upper body exercise in case knee pain is there. Then the fourth important thing in case of diabetes mellitus recommendation is the self care that is the personal hygiene. The patient has to take a daily bath, should wear clean cloths and trim their nails in order to avoid the ingrown nails then they should avoid injuries. For the food care they should examine their feet every day for cracks, swellings, callosities, redness, increased temperature or ingrown nail or loss of sensation. They should keep their interdigital spaces dry by using the towel and dusting powder if necessary. Use of mirror or a person can help. So in this image we can see that hygiene always keep your feet clean, dry the feet especially in between the fingers. Then we have to check for cracks, swellings, callosities, redness, increased temperature, ingrown nails with our naked eyes. If possible we have to use a mirror or we can ask a person for help. We should always seek help of the medical care professional. The fifth important point in case of the recommendation of diabetes mellitus is the adherence to the medication. Diabetes mellitus patients have to take the medicines at time and adequate medicine not to change their dosage without the doctor's advice if they are on insulin. They should correctly follow the procedure and dosage. Then the general information which they should know is about the symptoms of the hypoglycemia that is sweating, gidiness, headache, fainting and lekkosuria and complications of the diabetes mellitus. They should carry sweets and snacks in order to avoid the symptoms of hypoglycemia. Then they should carry a card always with the details of the patient name, address phone number and about the disease and the prescribed medicine. And they should avoid tobacco usage in any form. The last most important individual recommendation for diabetes mellitus is monitoring the diabetes mellitus investigations. Every day patient has to do a foot examination without the help of a mirror and without a person. Home glucose monitoring can be advised weekly and every month fasting and postprandial should be taken, BP measurement, weight measurement should be taken every month, then every three months HBA1C should be taken, every six months HBA1C if sugar levels are under control and every year they should do electrocardiogram, lipid profile, serum creatin, urine microalbuminuria and fundus examination in order to foresee the microvascular and macrovascular complications of the diabetes mellitus. In the family level we should insist on the importance of the diet, exercise, proper follow-up in controlling blood sugar and preventing further complications. Importance of diet monitoring as it is better to avoid more sweet and oily foods in the diet of the patient, screening to be done for other family members. So the diet, exercise and proper follow-up should be insisted for the patient among the family members. Then the next is the community level recommendation. We should do a health education about the risk factors of the diabetes mellitus among the community and these health, these community level recommendations should target the high risk groups that is people over the age of 45 years, obese people, family history of diabetes mellitus, history of gestational diabetes, pre-diabetes, hypertensive patients, female with baby weighing more than 3.5 kg, females with excess weight gain in pregnancy. All these has to be considered as the high risk groups. Lifestyle modifications including primordial prevention among adolescents that is the removal of the risk factors among the adolescents. Then importance of adherence to the medications, diet, exercise and food care for those who are diagnosed with diabetes mellitus. So before we end the presentation, we are going to see the commonly asked questions while presenting a clinical social case pro forma of diabetes mellitus. What is diabetes mellitus? So the key points about diabetes mellitus is diabetes mellitus is a state of chronic hyperglycemia caused by defective production or action of insulin which on a long term result in number of complications which includes cardiovascular, renal, neurological, ocular and others such as intercurrent infections. So the key words here is the diabetes mellitus is a heterogeneous group of diseases. Now the next question is what is the classification of the diabetes mellitus? We should know this table to answer classification of diabetes mellitus. WHO classifies diabetes mellitus into three types that is diabetes mellitus, impaired glucose tolerance and gestational diabetes mellitus. Among diabetes mellitus, type 1 diabetes mellitus are insulin dependent, here there is insulin deficiency. Type 2 are non-insulin dependent diabetes mellitus where insulin resistance is the most common cause. When malnutrition related diabetes mellitus, then other types include secondary to pancreatic, hormonal, drug induced, genetic and other abnormalities. Then the next question is what are the screening tests used for diabetes mellitus? Here urine for sugar, blood sugar test will be the answer. Then what is impaired glucose tolerance and what is impaired fasting glucose? So to answer this we should know this table and we can forget about this millimoles which is not commonly used in our settings. Fasting plasma glucose is more than 126 then we say diabetes. If the 2 hour plasma glucose is more than 200 then we say diabetes. Impaired glucose tolerance is the fasting plasma glucose less than 126 and under 2 hour plasma glucose is between 140 to 200 milligrams. Impaired fasting glucose is if the 2 hour plasma glucose is less than 140 milligrams but the fasting blood sugar is between 110 to 125 then we call it as impaired fasting glucose and this is impaired glucose tolerance. When 2 hour is more then we call it as impaired glucose tolerance. When fasting is more then we call it as impaired fasting glucose. Then what is HBA1C? HBA1C is glycosylated hemoglobin it gives a value it gives a idea of long term glucose control. It reflects the mean glucose level during the red cell lifetime. What is syndromax? Syndromax is characterized by hyperglycemia, hyperinsulinemia, dyslipidemia and hypertension called as metabolic syndrome. What are the complications of the diabetes mellitus? When we are answering complications of diabetes mellitus we have to answer by dividing it into microvascular and macrovascular complications. Microvascular complications include which involve eye, kidney and nerves causing retinopathy, nephropathy and neuropathy respectively. In macrovascular complications the organs affected our brain, heart and the extremities which causes stroke or transient ischemic attack and heart attacks and peripheral vascular disease respectively. And what are all the common oral hyperglycemic agents? This for this answer we have metformin from the bigoenates. Then among insulin secretogogs in sulfonylureas we have glubonchlamide glipeside, glyclozide glimepride and glinates. We have rippaglinate and natiglinox, thiocylidazones, pyoclidazone, sodium glucose co-transport to inhibitors, alpha-glucosidase inhibitors, ecargos, glucagon like peptide 1 receptor agonist, dipeptidyl peptidase 4 inhibitors, so out of which these insulin secretogogs causes the risk of hyperglycemia. So we should know the advantages and at least one disadvantages of these drugs. What are all the host factors leading to diabetes militias? Age, gender, genetic factors, genetic markers especially with the type 1 we have HLA, DR3 and D4 which is powerfully associated with type 1 diabetes militias, HLA V8 and HLA V15 are also associated with type 1 diabetes militias. And obesity, maternal diabetes are all the host factors that can lead to diabetes militias. What are all the environmental factors that lead to diabetes militias? Sedentary lifestyle with lack of exercise, diet with saturated fat intake unless dietary fiber intake, modern nutrition in the childhood, excessive alcohol intake, viral infections, chemical agents and stress are all the environmental factors that can lead to diabetes militias. In this question number 12, 13, 14 and all we have discussed in the individual level recommendations. Then what are all the high risk groups for screening diabetes militias? People with sedentary lifestyle, obesity, who are on oral contraceptives, smoking, high blood pressure, elevated cholesterol and triglyceride levels. What are all the treatment available for gestational diabetes militias? The answer here is the insulin and oral hypoglycemic agents are contraindicated in gestational diabetes militias. What is hypoglycemic index? As I told earlier, glycemic index is an index for the food material. The ability of the food material to fastly raise the blood sugar is called as glycemic index, irrelevant of the calorie that is glycemic index. Some foods like potato will have less calorie but high glycemic index that is it raises the blood sugar level very fast when consumed. There are some food items like rice, wheat and herb will have high calorie but the rate at which it increases the blood sugar level will be very less hence the glycemic index is also less. So that's all about recommendations for clinical social case of diabetes militias. Thanks for watching this video.