01/11/2025
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🩺 OSCE Case 46: Newly Diagnosed Type 2 Diabetes Mellitus
Stem:
A 50-year-old man presents to the GP clinic. He has recently been diagnosed with type 2 diabetes. He also has hypertension and is obese. The examiner asks: “Take a history, order relevant laboratory tests, and outline your management.”
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1. Focused History 🟩
☑ Diabetes symptoms
Polyuria, polydipsia, weight changes
Blurred vision, recurrent infections (skin, UTI, thrush)
Fatigue
☑ Complications (micro & macrovascular)
Neuropathy: tingling, numbness, burning in feet
Nephropathy: swelling, frothy urine
Retinopathy: vision changes
Cardiovascular: chest pain, claudication, stroke/TIA history
☑ Past medical history
Hypertension, hyperlipidemia, cardiovascular disease
Medications (antihypertensives, statins)
Family history of diabetes, heart disease
☑ Social history
Diet, exercise
Smoking, alcohol use
Occupation and impact on lifestyle
Weight history
☑ Psychological
Mood, depression, coping with diagnosis
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2. Examination 🟩
☑ General: BMI, waist circumference, BP
☑ Fundoscopy (if trained, otherwise refer)
☑ Cardiovascular exam (pulses, murmurs, BP in both arms)
☑ Feet exam: neuropathy (monofilament test), pulses, ulcers
☑ Signs of metabolic syndrome (acanthosis nigricans, central obesity)
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3. Investigations 🟩
☑ Bloods
HbA1c (diagnosis & monitoring)
Fasting glucose (if needed)
Lipid profile
Renal function (U&E, eGFR)
LFTs (before statin)
☑ Urine
Albumin:creatinine ratio (microalbuminuria)
☑ Others
ECG (baseline CV assessment)
Retinal photography (annual screening)
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4. Differential Diagnosis 🟩
☑ Type 2 diabetes mellitus (confirmed)
☑ Type 1 diabetes (less likely at age 50, but check if atypical)
☑ Secondary diabetes (steroids, pancreatic disease)
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5. Management Plan 🟦
☑ Lifestyle modification (first-line)
Diet: reduce refined carbs, increase fiber, fruits/vegetables, portion control
Exercise: 150 min/week aerobic + resistance training
Weight loss program (BMI >30 → dietitian referral, consider bariatric surgery if severe)
Smoking cessation, reduce alcohol
☑ Pharmacological
Metformin (first-line, unless contraindicated: renal impairment, severe GI issues)
If not controlled: add sulfonylurea (gliclazide), DPP-4 inhibitor, SGLT2 inhibitor, or GLP-1 agonist (esp. if obese/heart failure risk)
Hypertension: target
