Greeting
Good day, esteemed Professor Doctor …,
I would now like to present the patient Erika Baumann to you.
She is 61 years old, 178 cm tall and weighs about 73 kg. The body mass index (BMI) is 23 (normal range).
Current history
The patient with known type 2 diabetes mellitus presented about an hour ago with sudden onset dizziness, asthenia, reduced visual acuity and palpitations.
In addition, she reported paresthesias of the extremities, restlessness, hyperhidrosis, lip pallor as well as confusion.
The patient also reported intense hunger.
She also reports limited memory of the event.
The symptoms occurred after physical exertion and improved markedly in the ambulance after oral glucose administration (three glucose tablets).
There is no evidence of emesis, no cranial trauma, tremor, pareses or plegias, no loss of consciousness, no convulsions and no substance abuse.
The patient stated that yesterday evening at around 21:00 she injected 20 units of insulin glargine (Toujeo®).
She added that her last meal was yesterday evening.
Course of events:
The patient reported that she celebrated her birthday yesterday, consumed three glasses of red wine and went to bed late. As a gift her son gave her a bike tour, since she regularly cycles on weekends.
This morning the alarm did go off, but she overslept and went straight to the meeting point. Therefore she only had a coffee and no breakfast. The tour started at 9:00.
About half an hour after the start of the tour she felt unwell and complained of nausea, but initially continued cycling. Afterwards she had to take a break; a friend gave her a glass of cola, which temporarily made her feel better.
After about two hours the symptoms occurred.
Autonomic history
The autonomic history is unremarkable, except for stress-related insomnia after the death of her husband and a low-carbohydrate diet with a resulting weight loss of about 4–5 kg in the last two months. For some time she has had constipation, which has recently improved due to lifestyle changes.
Past medical history
The following past medical conditions are known from the history:
For three and a quarter years there has been diabetes mellitus type 2, which was diagnosed in the context of recurrent mycoses.
Initial therapy was with metformin; due to persistently elevated HbA1c values, insulin therapy was subsequently initiated.
Because of irregular blood glucose monitoring, the current metabolic status cannot be reliably assessed.
There is no evidence of diabetic nephropathy, retinopathy, neuropathy or trophic changes. Cardiovascular diseases are not known.
No previous inpatient admissions; episodes of hypoglycemia in the past are not documented.
Almost four years ago there was an intertriginous candidiasis on the right and a tinea pedis interdigitalis between the fourth and fifth toe on the left.
About a year ago the patient reported occasional palpitations. A cardiology consultation with a Holter ECG, which showed no pathological findings, was performed.
A hypercholesterolemia is also known.
There is osteoarthritis of the right upper ankle, which is being treated conservatively.
Two years ago during a stay in Spain after an insect bite there was a phlebitis of the right lower leg vein with local swelling, redness and pain. Initial therapy with amoxicillin was stopped due to an urticarial reaction; subsequent treatment was with azithromycin.
Previous surgeries
About 25 years ago the patient sustained a fracture of the right upper ankle after a fall from approximately three meters. This was surgically treated with screw osteosynthesis . The implants were removed about one year postoperatively. Several years later pain recurred; osteoarthritis of the ankle was diagnosed as a possible complication.
Note: When a statement can be objectively confirmed by a medical examination – for example by visible scars – the indicative is appropriate. (No physical examination takes place in the Fachsprachprüfung.)
Gynecology
The patient has given birth three times. The first two births were spontaneous, the third by Cesarean section due to macrosomia.
She has been in postmenopause for seven years and occasionally reports vasomotor symptoms in the form of hot flashes.
Medications:
Metformin 500 mg 1-0-1
Acetylsalicylic acid 81 mg 1-0-0
Atorvastatin 20 mg in the evening
Diclofenac (Voltaren® Dolo) 25 mg as needed
Insulin glargine (Toujeo®) 20 units in the evening
———
Clotrimazole-ointment (Canesten®) topical
Note: When a statement can be objectively confirmed by a physician’s observation – for example based on a prescription – the indicative is appropriate.
Allergies
There are allergies to amoxicillin with urticarial reaction to crustaceans with angioedema in the face as well as to wasp stings with anaphylaxis, which previously required inpatient treatment and subsequently a desensitization was performed as baseline therapy.
Exposures
The patient has been a non-smoker for almost 4 years. Previously she had smoked for over 35 years about half a pack per day, corresponding to approximately 17.5 pack-years .
Alcohol consumption is about one glass of beer per week. There is no indication of drug abuse.
Social history
The patient has been widowed for one year, works as a clerk in the housing office and has three children (a 22-year-old daughter, a 19-year-old son and a 15-year-old son). The daughter suffers from an obsessive-compulsive disorder with hand eczema and is being treated with sertraline and topical external preparations.
Family history
The patient’s mother is 79 years old, suffers from dementia and lives in a nursing home. For two days she has been hospitalized due to an injury of the right hip joint after a fall on the stairs.
The father died 15 years ago at the age of 65 from a pancreatic carcinoma.
Suspected and differential diagnosis
In my assessment, the anamnestical information in the context of known diabetes mellitus speaks primarily for hypoglycemia. Supporting this are symptoms of activation of the sympathoadrenal system such as hyperhidrosis, palpitations and pallor as well as neuroglycopenic symptoms such as dizziness, concentration disorders, confusion and paresthesias.
Triggers that should be considered include fasting, physical activity and insulin administration.
The marked improvement after glucose administration strongly supports hypoglycemia.
There are no relevant symptoms indicating a cardiac cause such as chest pain, tightness or dyspnea. Moreover, in that case no improvement would be expected from glucose administration. Nevertheless, initial diagnostic measures such as an ECG are indicated.
There were no neurological deficits, making a stroke or a transient ischemic attack less likely.
There are no indications of a psychiatric disorder.
The patient denies drug use; with appropriate suspicion a toxicological urine test should be considered
Diagnostic workup
As a first measure the blood glucose should be determined. Inpatient admission is indicated here in order to closely monitor blood glucose values and, if necessary, adjust therapy. In addition, structured diabetes education during the inpatient stay is of crucial importance.
physical examination
After the history a structured physical examination should be performed. This begins with the collection of vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation and temperature), followed by a thorough physical examination. In the presence of hypoglycemia symptoms of activation of the sympathoadrenal system such as hyperhidrosis, palpitations and pallor as well as neuroglycopenic symptoms such as dizziness, concentration disorders, confusion and paresthesias may occur. Subsequently, a targeted examination to exclude possible complications should take place, beginning with inspection.
Attention should be paid to typical skin changes such as acanthosis nigricans and nail changes. Signs of mycotic infections, especially interdigital or nail mycoses as well as intertriginous mycoses (e.g. under the breast in women), should also be recorded. Additionally, skin findings such as pallor, cyanosis, edema, trophic disorders or ulcers (with information on location, size, borders, secretion and odor) should be assessed to evaluate peripheral circulation .
If edema is present, it should be checked whether it is pitting.
Auscultation can reveal possible pathological flow sounds, such as heart murmurs in terms of valvular insufficiencies or stenoses.
A diabetic foot examination as well as a fundoscopy are also required.
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Additional knowledge |
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Microangiopathy (Microvascular) |
Macroangiopathy (Macrovascular) |
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Diabetic retinopathy → damage to the retinal vessels → microaneurysms, hemorrhages, exudates, risk of blindness. |
Coronary artery disease (CAD) → angina pectoris, myocardial infarction. |
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Diabetic nephropathy → glomerular damage → proteinuria, microalbuminuria, later renal insufficiency. |
Cerebrovascular disease → TIA, ischemic stroke. |
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Diabetic neuropathy → damage to the small vessels of the peripheral nerves → sensory disturbances, pain, autonomic symptoms. |
Peripheral arterial occlusive disease (PAOD) → claudication intermittens, ulcers, amputations. |
Laboratory tests
For further evaluation a complete blood count, fasting blood sugar (FBS), HbA1c, a lipid profile (total cholesterol, LDL, HDL, triglycerides), renal function parameters (creatinine, urea, GFR), a blood gas analysis to assess the acid-base balance, electrolytes as well as a urinalysis including a proteinuria test should be performed.
Electrocardiogram
The patient has several risk factors for cardiovascular disease, therefore an ECG should be performed to detect possible arrhythmias, signs of ischemia or myocardial strain.
An ECG is performed by placing electrodes on the skin of the chest, arms and legs to record the electrical activity of the heart.
Consultations
Internal medicine, nephrology, ophthalmology, nutritional medicine / diabetology
Treatment:
• Definition
• Blood glucose concentration < 60 mg/dl: patient may be symptomatic or not.
• Blood glucose concentration < 40 mg/dl: patient is usually symptomatic.
• Blood glucose concentration < 20 mg/dl: may be associated with seizures and coma.
• Symptoms and clinical signs
• blurred vision
• Sweaty palms, generalized hyperhidrosis
• Tremor
• Increased appetite
• Confusion, anxiety
• Perioral tingling and numbness
• Some patients become aggressive and judge inappropriately. (Delirium)
• Nocturnal hypoglycemia: nightmares, restless sleep, profuse sweating, morning headache, “hangover” in the morning.
• Treatment
• Intake of 10–20 g rapidly absorbable carbohydrates
• Repeat after 15–20 minutes if the glucose concentration remains < 60 mg/dl or the patient is still symptomatic.
• Examples of foods with approx. 15 g of carbohydrates:
• Orange juice, grapefruit juice or apple juice; regular (not diet) soda → ½ glass
• Grape juice → ⅓ glass
• Sugar → 1 tablespoon or 3 sugar cubes
• Candies → 5 pieces
• Glucose tablets → 4 tablets
• For unconscious patients:
• Glucagon 1 mg subcutaneously, intramuscularly or intravenously (response time approx. 6 minutes)
• Glucose 25 g intravenously (50 ml of a 50% dextrose solution; response time approx. 3 minutes)
Measures to reduce cardiovascular risk factors in patients with diabetes mellitus:
• Weight reduction in overweight (Not applicable here.)
• Regular physical activity (walking training, at least 3×/week) (Not applicable here.)
• Smoking cessation (if necessary nicotine replacement therapy or behavioral therapy) (Not applicable here.)
• Structured diabetes education in a diabetes center
• Diabetes mellitus:
Self-monitoring of blood glucose is an important tool of self-management for patients.
FBS < 130 mg/dl
HbA1c < 7 %
• Arterial hypertension:
Target value: < 130/80 mmHg or < 120/80 mmHg
• Hypercholesterolemia:
LDL target < 70 mg/dl in high cardiovascular risk
• Consistent foot care:
Daily inspection, avoidance of pressure points and infections
Medication therapy:
• As the patient has a high risk for cardiovascular events, the use of acetylsalicylic acid (ASA, Aspirin) for platelet aggregation inhibition should be considered. (The patient is already taking it.)
• In most patients, monotherapy with metformin should be started after diagnosis. If metformin is contraindicated or poorly tolerated, an alternative antidiabetic approved for monotherapy can be used.
• Metformin
• Mechanism of action:
Metformin lowers blood glucose by reducing hepatic glucose production and indirectly improving insulin resistance. It does not cause weight gain or hypoglycemia. Additionally, it has beneficial effects on plasma lipid levels.
• Side effects:
Gastrointestinal complaints such as diarrhea, bloating, loss of appetite, abdominal pain, nausea or a metallic taste frequently occur at the start. These side effects usually decrease over time. Therefore therapy should be started at a low dose and increased slowly.
• The risk of lactic acidosis increases especially with renal insufficiency, liver insufficiency, increased alcohol consumption and when using iodinated contrast agents.
• Metformin is contraindicated with eGFR < 30 ml/min.
• Long-term monitoring:
During long-term therapy, every 2–3 years the VitaminB12level should be checked.
• Daily maximum dose: 1500 mg/day
• According to the AACE guidelines (American Association of Clinical Endocrinologists), initiation of insulin therapy should be strongly considered if the HbA1c value is > 10 %.
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Drug class / example |
Mechanism |
Indications (FDA) |
Side effects |
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Insulin |
Replaces or supplements endogenous insulin |
Monotherapy; can be combined with any oral antidiabetic |
Hypoglycemia, weight gain, local skin reactions |
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DPP4 inhibitors Sitagliptin, Linagliptin |
Inhibits DPP4 → increases endogenous incretins, ↑ insulin secretion, ↓ glucagon secretion |
Monotherapy or combination (metformin, SFU, TZD, insulin) |
Headache, nasopharyngitis, hypoglycemia (esp. with SFU), rash (rare) |
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GLP1 receptor agonists (incretin mimetics) Exenatide, Ozempic, Liraglutide, (s.c./oral) |
Stimulates insulin secretion, delays gastric emptying, reduces glucagon secretion, promotes satiety |
Monotherapy or combination (metformin, sulfonylureas (SFU), thiazolidinediones (TZD), insulin) |
GI complaints (nausea, vomiting, diarrhea), hypoglycemia (esp. with SFU), weight loss, reports of pancreatitis, upper respiratory tract infections |
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Thiazolidinediones (glitazones) Rosiglitazone, Pioglitazone |
Enhance insulin action in the periphery, ↑ glucose uptake in muscle/adipose tissue, ↓ hepatic glucose production |
Monotherapy or combination (SFU, TZD, insulin) |
Anemia, fluid retention, edema, weight gain, macular edema, fractures (esp. women) |
• Types of insulin
• Rapid-acting insulin analogues (e.g. Lispro, Aspart, Glulisine): onset of action after 10–20 min, duration 2–4 h. → Use at meals.
• Intermediate-acting insulins:
NPH insulin (Neutral Protamine Hagedorn): onset after 1–2 h, duration 12–18 h. → Mostly for basal coverage.
• Long-acting insulin analogues (basal insulins):
Glargine, Detemir, Degludec: onset 1–2 h, duration up to 24–42 h. → steady basal coverage, once daily.
• Insulin is injected subcutaneously (under the skin, into the adipose tissue).
Abdomen (periumbilical, at least 2 cm from the navel) → rapid absorption
Thigh (anterior, lateral) → slower absorption
Upper arm (posterolateral) → intermediate absorption
Buttock → slower absorption
• Estimation of total daily insulin requirement in type 2 diabetes:
• The daily insulin requirement is approximately 0.7–1.5 units per kilogram body weight.
• Basal insulin requirement is roughly 50% of the total daily insulin requirement.
• Insulin pump
The insulin pump is a small, portable device that delivers insulin continuously via a catheter into the subcutaneous fat tissue.
Delivery types:
Basal rate: continuous small amounts of insulin (mostly short-acting analogue insulin) → replaces basal insulin.
Bolus delivery: additional insulin doses with meals or to correct elevated blood glucose levels.
Advantages:
More physiological insulin delivery
More flexible lifestyle and better blood glucose control
Reduction of severe hypoglycemias
Particularly suitable for type 1 diabetes or unstable metabolic control
Disadvantages:
High training effort
Technical problems possible (catheter occlusion → risk of ketoacidosis)
Costly
Extra
Names:
Kurt Hahn, Rupert Obermeier, Tom Jähriger
Occupations:
The patient works in the paint department of a hardware store.
Grammar school teacher for history
Civil servant
Details:
She arrived at the hospital by car accompanied by friends.
The next morning he missed breakfast and consumed only coffee without food before participating in a local soccer tournament. During the second game, typical symptoms of hypoglycemia occurred.
He wears a continuous glucose sensor on his arm that regularly measures blood sugar.
He had previously suffered from constipation; after starting metformin therapy his stools became mushy and occur about twice daily.
His mother reported that there is a reaction to penicillin; he himself does not know this because he has never taken penicillin so far.
He reported that three hours earlier, after lifting a flour sack of about 50 kg, he had experienced vertigo, weakness in the legs and a sweat attack. He then lay down in bed and noted an improvement after drinking apple juice. Afterwards he noticed a tachycardia.
Past medical history:
Mycosis in the right groin region/ tinea inguinalis right
There has been rhizarthrosis (thumb carpometacarpal osteoarthritis) for 10 years.
Tinea axillaris left.
Lower leg fracture after a fall event, surgically treated with plate osteosynthesis.
Two years ago she sustained a fracture of the midfoot there after a paint bucket fell on her.
There is benign prostatic hyperplasia, treated with tamsulosin.
a benign goiter, partial thyroidectomy.
Calcaneus fracture
There has been arterial hypertension for 10 years.
He underwent a coronary angiography with PTCA due to a myocardial infarction.
Medications:
She then independently purchased Canesten® at the pharmacy and is currently using it.
Social:
Family:
Mother: stroke (apoplexy) a few years ago
Her father probably died of a sinonasal carcinoma.
Questions
1. When should surgical consultation be requested for patients with diabetes mellitus?
Surgical consultation is particularly required for diabetic foot syndrome with ulcers, infections, gangrene or impending amputation.
2. What is calcium pyrophosphate diarthropathy (CPPD)?
CPPD is an arthropathy caused by deposition of calcium pyrophosphate crystals in joints, mostly in older patients. Causes include age, joint degeneration, metabolic disorders (e.g., hyperparathyroidism, haemochromatosis, hypomagnesemia) or hereditary forms. Typical symptoms are acute, gout-like arthritis with painful swelling, redness and restricted mobility – often in the knee joint. Diagnosis is made by detection of crystals in the joint fluid and by X-ray (chondrocalcinosis). Treatment is symptomatic with NSAIDs, colchicine or glucocorticoids, while causal elimination of the crystals is not possible.
3. What is a Gymnasium? Which other school types do you know?
A Gymnasium is a secondary school that leads to the general university entrance qualification (Abitur). Other types of schools include primary school, Hauptschule, Realschule, comprehensive school and vocational school.
4. What is a friendly match and a tournament?
A friendly match is a sporting contest without official ranking, usually for training or testing purposes. A tournament is a competition in which several teams or players compete against each other and a winner is determined.
5. What is the fear of confined spaces called? What is a phobia? Which phobias do you know?
The fear of confined spaces is called claustrophobia. A phobia is an inappropriate, often pathological fear of certain situations, objects or activities. Other examples are fear of heights (acrophobia), fear of spiders (arachnophobia) or fear of open spaces (agoraphobia).
6. What is Long-COVID?
Long-COVID refers to complaints that persist or newly appear more than four weeks after an acute COVID-19 infection. Typical symptoms are fatigue, concentration problems, shortness of breath, cough and muscle pain.
7. What is tetanus called in everyday language?
In everyday language, tetanus is also called lockjaw.
8. How would you explain a rapid self-test for diabetes to a patient?
A rapid diabetes self-test works similarly to a blood glucose measurement. You prick the fingertip with a small lancet, place a drop of blood on a test strip inserted into the device, and after a few seconds the device shows the current blood glucose value. This allows you to easily and quickly check whether your blood glucose is in the normal range.
9. What is glucosuria?
The appearance of glucose in the urine due to exceeding the renal reabsorption capacity (renal threshold, approx. 160–180 mg/dl blood glucose).
10. What is meant by metabolic syndrome?
Metabolic syndrome refers to the combination of several risk factors: abdominal obesity, arterial hypertension, dyslipidemia (elevated triglycerides, reduced HDL) and insulin resistance or type 2 diabetes mellitus. It is a major risk factor for cardiovascular disease.
11. What is ketoacidosis and how is it treated?
Diabetic ketoacidosis is an acute metabolic decompensation due to insulin deficiency with hyperglycemia, ketone body formation and metabolic acidosis. Typical symptoms are nausea, vomiting, abdominal pain, acetone breath, Kussmaul breathing and impaired consciousness. Treatment includes fluid substitution, intravenous insulin administration, electrolyte replacement (especially potassium) and treatment of the triggering cause.
Diagnosis of diabetic ketoacidosis (DKA):
• Hyperglycemia (usually > 250 mg/dl)
• Metabolic acidosis (pH < 7.3, bicarbonate < 18 mmol/l)
• Detection of ketone bodies in blood or urine
Notes
BMI
Calculation of the body mass index
The body mass index is a measure of the ratio of body weight to height. It is calculated by dividing weight in kilograms by the square of height in meters. With a body weight of 73 kg and a height of 1.78 m, the BMI is approximately 23, which is within the range of normal body weight.
Asthenia
Asthenia (loss of strength and energy)
Short description: Asthenia refers to pronounced general weakness and reduced physical or mental resilience.
Reduced visual acuity
Reduced visual acuity (decreased vision)
Short description: Reduced visual acuity denotes a subjectively perceived decline in visual sharpness or a restriction of the visual field.
Possible associations: Acute changes in visual acuity can have many causes, including metabolic disturbances, micro- or macrovascular ocular problems, as well as refractive or neurological events. In a patient with diabetes and sudden, short-term reduced visual acuity, both transient disturbances (e.g., in the context of hypoglycemia) and diabetes-associated ocular causes should be considered and clinically evaluated.
Paresthesias
Paresthesias are abnormal sensations such as tingling, “pins and needles” or burning on the skin that occur without external stimulus.
Hyperhidrosis
Hyperhidrosis
Short description: Excessive sweating that can be local or generalized.
Mechanism: Sweating is predominantly controlled by sympathetic nerves; the sweat glands respond via cholinergic (acetylcholine-mediated) efferents of the sympathetic system, not primarily via adrenergic receptors.
physical exertion
Physical exertion and hypoglycemia risk
Key point: Muscle work increases glucose consumption, which can lower blood glucose levels.
Additional factors: This is particularly relevant if insulin is still active (e.g., after insulin injection), because glucose uptake into muscle remains increased. An inadequate counter-regulation by hormones such as glucagon or adrenaline can also increase the risk of symptomatic hypoglycemia.
Tremor
Tremor
Definition: Tremor denotes an involuntary, rhythmic muscle contraction that presents as shaking.
Pareses
Pareses
Explanation: Pareses describe a partial or incomplete muscle weakness or partial paralysis of a muscle group.
Plegias
Plegias
A plegia is a complete loss of motor function in one or more body regions, e.g., as hemiplegia or paraplegia. Typical is the complete absence of voluntary movements in the affected musculature.
Insomnia
Insomnia
Insomnia denotes persistent difficulties initiating or maintaining sleep or nonrestorative sleep quality. It can be exacerbated situationally by stressful life events.
Constipation
Constipation
Constipation describes persistent or recurrent difficulty in bowel evacuation, often with infrequent and hard stools and a feeling of incomplete emptying.
Diabetes mellitus
Diabetes mellitus
Short description: Diabetes mellitus encompasses metabolic disorders characterized by elevated blood glucose levels. Type 1 diabetes is based on autoimmune destruction of insulin-producing beta cells resulting in absolute insulin deficiency; type 2 diabetes mainly arises from insulin resistance combined with impaired insulin secretion. Gestational diabetes is a temporary form of elevated glucose levels that occurs during pregnancy.
intertriginous
Intertriginous areas
Intertriginous regions are areas of skin where two skin surfaces lie against or rub on each other (e.g., armpits, groins, inframammary folds, skin folds between the toes). These areas tend to be prone to irritation and secondary infections, for example by yeasts, due to increased moisture and mechanical stress.
Palpitations
Palpitations
Palpitations are the subjective perception of heartbeats, often as racing, skipping or stopping. Harmless arrhythmias such as supraventricular or ventricular extrasystoles are common; psychological stress can also trigger such sensations. The aim of evaluation is to exclude dangerous heart disease.
Long-term ECGs
Long-term ECG
A long-term ECG is an outpatient, continuous recording of the electrocardiogram over usually 24–72 hours, with which short-term or intermittent arrhythmias can be detected. Typical indications are evaluation of palpitations, syncope or dizziness and detection of paroxysmal arrhythmias (e.g., atrial fibrillation).
Hypercholesterolemia
Hypercholesterolemia
Hypercholesterolemia refers to an elevated cholesterol level in the blood. LDL cholesterol is particularly relevant, as elevated levels are associated with a higher risk of atherosclerotic vascular disease.
Ankle
Anatomy of the upper ankle joint
The upper ankle joint consists of three central bones: the shinbone (tibia), the fibula and the talus. The talus forms the connection between the lower leg and the foot and articulates with the tibia and fibula, which provide weight transmission from the thigh to the foot.
Phlebitis
Phlebitis – brief overview
Definition and symptoms: Phlebitis is inflammation of a superficial vein, recognizable by pain, redness, warmth and often a palpable, cord-like induration along the vein.
Causes: Common triggers are local injuries to the vein, bacterial infections or iatrogenic interventions such as peripheral venous catheters; an insect bite can also promote a local inflammatory reaction.
Treatment and complications: Management depends on cause and severity and generally includes symptomatic measures (rest, elevation of the limb, local anti-inflammatory measures, pain therapy). If bacterial infection is proven, systemic antibiotic treatment may be necessary. Possible complications include spread to deep veins with thrombophlebitis and systemic infection.
Screw osteosynthesis
Screw osteosynthesis – overview
Definition: Screw osteosynthesis is a surgical procedure for treating bone fractures in which fracture fragments are stabilized and held in anatomical position using one or more bone screws.
Indication and procedure: It is used when stable internal fixation is necessary to allow healing and early mobilization. Screws can be placed in a fragment-compressing manner to secure bone contact. In some cases, the implants are removed after completed bone healing.
Possible consequences: Relevant complications include infection, incomplete bone healing and long-term posttraumatic osteoarthritis, especially after joint involvement.
Osteoarthritis
Osteoarthritis of the ankle joint – short description
Clinical picture: Osteoarthritis is a degenerative joint process; in the upper ankle joint it is often a consequence of previous fractures or ligament injuries; less commonly it occurs primarily.
Clinical presentation: Typical features are activity-related pain, swelling, restricted range of motion and joint stiffness.
Therapeutic principles: Conservative measures are initially sought, such as analgesic therapy, targeted physiotherapy, orthopedic aids and, if applicable, weight reduction. In advanced stages surgical options such as joint fusion or endoprosthetics are considered.
Cesarean section
Cesarean section
Definition: Operative delivery in which the child is delivered through an abdominal incision and an incision of the uterus.
Indication: Used when vaginal delivery is not possible or would be risky (e.g., in obstetric complications or fetal risk constellations).
Anesthesia and procedure: The operation is often performed under regional anesthesia (spinal or epidural anesthesia), less often under general anesthesia. The procedure includes a transabdominal approach and an incision of the uterus, followed by delivery and wound closure.
Risks: Possible complications include blood loss, infections, injury to adjacent organs as well as long-term consequences such as adhesions and effects on future pregnancies.
Macrosomia
Macrosomia
Definition: Term for a markedly increased fetal birth weight; in clinical practice macrosomia is often described as a birth weight of about over 4000 g (occasionally over 4500 g).
Causes: The most common association is maternal glucose metabolism disorder (e.g., diabetes mellitus). Other factors can be genetic disposition, prenatal overnutrition and greater maternal stature.
Clinical relevance: Macrosomia can complicate delivery and increase the risk of shoulder dystocia, birth injuries and cesarean section; neonatally there are increased risks for metabolic disturbances.
Postmenopause
Postmenopause
Definition: Life phase that begins when 12 months have passed since the last menstruation and the ovarian cycles have permanently ceased.
Clinical features: Typical complaints in this phase are vasomotor symptoms (e.g., hot flashes), changes of the urogenital mucosa with dryness and possibly dyspareunia, and an increased risk for osteoporosis and cardiovascular diseases.
Course: The intensity of symptoms varies individually; some complaints decrease over time, other long-term consequences may require specific preventive or therapeutic evaluation.
Atorvastatin
Group
Atorvastatin belongs to the drug group of statins (HMG-CoA reductase inhibitors).
Mechanism of action
It inhibits the enzyme HMG-CoA reductase in the liver, thereby reducing endogenous cholesterol production and particularly lowering LDL cholesterol.
Indications
Statins are used to treat lipid metabolism disorders and to reduce the risk of atherothrombotic events, both in primary and secondary prevention.
Important risks and notes
Reports include muscle aches up to the rare rhabdomyolysis and elevations of liver enzymes. Interactions with other drugs (e.g., via CYP3A4) can increase the risk of adverse effects and should be checked.
Diclofenac
Group
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for symptomatic treatment of pain and inflammation.
Mechanism of action
It reduces the production of proinflammatory prostaglandins by inhibiting the cyclooxygenase enzymes.
Indications
Diclofenac is used for short-term relief of inflammatory and noninflammatory pain as well as for the treatment of rheumatic complaints.
Important risks and notes
Significant risks include gastrointestinal complications (e.g., ulcers and bleeding), cardiovascular adverse events with long-term use, renal dysfunction and allergic reactions. Caution is advised in patients with increased bleeding or cardiovascular risk.
Clotrimazole
Clotrimazole — topical antifungal
Group: Azole antifungal for topical use.
Effect: Inhibits fungal cell membrane formation by blocking steps in ergosterol synthesis, producing fungistatic and at higher concentrations fungicidal effects against dermatophytes and yeasts.
Indication: Topical treatment of superficial fungal infections of the skin and mucous membranes, e.g., athlete’s foot or local Candida infections.
Important risks: Mostly local reactions such as skin redness, burning or itching; rarely contact dermatitis or hypersensitivity reaction may occur. Systemic side effects are rare with usual topical application.
urticarial
urticarial — relation to urticaria (hives)
Terminology: “Urticarial” describes something related to urticaria, i.e., transient wheals (hives).
Clinical features: Urticaria presents with itchy, soft, often fleeting wheals on the skin; it can be acute or chronic and occasionally accompanied by angioedema.
Causes and relevance: Triggers are diverse and range from medications and foods to insect stings, infections or physical stimuli. If the respiratory tract or systemic symptoms are additionally involved, action is required.
Angioedema
Angioedema — deep, localized tissue swelling
Definition: In angioedema there are painless swellings of the deeper skin layers and mucous membranes due to increased vascular permeability.
Typical locations: Mainly the lips, tongue, face and mucous membranes of the pharynx or larynx; involvement of the larynx can lead to airway obstruction.
Causes and significance: Causes include allergic (IgE-mediated) reactions, drug-induced reactions (e.g., bradykinin-mediated reactions such as from ACE inhibitors), hereditary disorders of C1 inhibitor or infections. Involvement of the upper airways is potentially life-threatening.
Wasp stings
Wasp stings — medical relevance of the sting event
Clinical picture: A wasp sting typically causes local pain, redness and swelling at the sting site. In sensitized individuals, systemic allergic reactions can occur in addition.
Allergic risks: With IgE-mediated sensitization a sting can cause generalized skin reactions, angioedema or anaphylactic reaction. Severe systemic reactions require immediate medical assessment.
Therapeutic/preventive aspects: In confirmed wasp allergy specific immunotherapy (desensitization) may be considered in suitable cases; evaluation is carried out by allergy diagnostics.
Hyposensitization
Hyposensitization (specific immunotherapy) is a treatment in which a particular allergen is administered repeatedly to accustom the immune system to it and to alleviate allergic symptoms in the long term.
Pack years
Calculation of pack years
Pack years indicate cumulative tobacco exposure. They are calculated by: (number of cigarettes smoked daily ÷ 20) × number of smoking years. This measure is used to estimate the long-term risk for tobacco-associated diseases.
Clerk (female)
Clerk – job profile
Female clerks perform administrative and organizational tasks. These include file management, processing applications and correspondence, drafting decisions and communication with citizens and internal departments. In an office such as the housing office the role often includes administrative law decisions and coordinating tasks.
Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD)
Clinical picture
In obsessive-compulsive disorder recurrent, intrusive thoughts or impulses and repetitive behaviors or mental acts occur, which the affected person carries out to reduce anxiety or discomfort.
Therapeutic approaches
The preferred psychotherapeutic treatment is cognitive behavioral therapy, in particular exposure with response prevention. Selective serotonin reuptake inhibitors can be used adjunctively. Concomitant dermatological measures are relevant for distressing skin changes such as hand eczema.
Hand eczema
Definition:
Hand eczema refers to inflammatory changes of the skin on the hands, which can present as redness, scaling, blistering, dryness and marked itching or burning.
Causes and types:
Hand eczema can have different causes: irritant contact dermatitis due to repeated contact with water or irritants, allergic contact dermatitis due to sensitizing substances, atopic hand eczema as a manifestation of atopic predisposition, or hyperkeratotic forms. Occupational exposure and skin barrier disorders play a major role.
Clinical presentation:
Depending on the cause findings range from acute blisters and weeping areas to chronic thickening and fissured skin. Hands are particularly stressed by mechanical load and wet work.
Therapy and prevention:
The main approach is avoiding or minimizing triggering substances and consistent skin protection (protective gloves, skin care products). Regular use of emollients is central; during inflammatory flares topical anti-inflammatory medications are used. If allergy is suspected, targeted diagnostics should be performed.
Complications:
Chronic changes, secondary infections and significant limitations in everyday and work activities are possible.
Dementia
Term and characteristics:
Dementia denotes a progressive syndrome with persistent impairments of multiple cognitive domains such as memory, orientation, language and executive functions, which impair everyday abilities.
Causes:
Various diseases can cause dementias; Alzheimer’s disease is a common cause. Other reasons include vascular damage, Lewy body diseases and other neurodegenerative processes.
Clinical consequences:
Typical consequences are increasing memory loss, disorientation, reduced judgement and limitations in independent living.
Therapeutic principles:
A causal cure is usually not possible; pharmacological and non‑pharmacological measures can delay or improve progression and symptoms in some cases. For certain forms of dementia, cholinesterase‑inhibiting agents and N‑Methyl‑D‑aspartate (NMDA) modulators are used for symptomatic treatment. These medicines target cognitive functions but also have possible side effects that must be weighed individually.
Prognosis:
Course and prognosis depend on the underlying cause, comorbidities and therapeutic care.
Hip joint
Anatomy of the hip joint:
The hip joint is a deeply located ball‑and‑socket joint, formed by the acetabulum of the pelvis and the head of the femur (caput femoris).
Structures involved:
The joint structure includes the bony rim of the socket, the joint capsule as well as the strong stabilizing ligaments and the surrounding muscles that enable movements such as flexion, extension, ab‑ and adduction and rotation.
Clinical relevance:
In falls at older age, fractures or dislocations of the hip joint can occur; degenerative changes and inflammatory processes are also possible causes of hip pain and movement restrictions. Anatomical knowledge is important for diagnostics and surgical or conservative assessment.
Pancreatic carcinoma
Definition:
Pancreatic carcinoma denotes a malignant tumor of the pancreas, predominantly of the exocrine pancreas, usually in the form of a ductal adenocarcinoma.
Risk factors:
Smoking, chronic inflammation of the pancreas, metabolic diseases such as diabetes mellitus, obesity and familial predispositions increase the risk.
Clinical presentation:
Symptoms vary according to the tumor’s location; tumors in the pancreatic head can present early due to bile duct obstruction causing jaundice, other locations cause nonspecific abdominal pain, weight loss or newly onset diabetes.
Diagnosis and therapy:
Diagnostic work‑up includes imaging procedures and tissue sampling. The only possibility for potentially curative treatment is surgical removal of the tumor; however, many diseases are detected only at advanced stages.
Prognosis:
Overall the disease has an unfavorable prognosis; long‑term survival chances are low compared with many other solid tumors.
Apoplexy
Apoplexy (stroke)
Brief description: An apoplexy is a sudden neurological event caused by an acute disturbance of cerebral blood flow.
Causes: The circulatory disturbance can be caused by a vascular occlusion (ischemic) or by bleeding into the brain tissue (hemorrhagic).
Clinical signs: Typical are newly occurring neurological deficits such as one‑sided weakness or paralysis, speech disturbances, visual field defects or changes in consciousness.
Urgency: An apoplexy requires immediate medical assessment and treatment, as the fastest possible measures can influence the prognosis.
transient ischemic attack
Transient ischemic attack (TIA)
Definition: A TIA is a temporary neurological disturbance caused by a short‑term reduction of cerebral blood flow.
Clinical features: It manifests as transient deficits such as weakness, speech disturbances or visual disturbances that are reversible.
Duration: The symptoms usually resolve completely; by classic definition they occur within 24 hours, but frequently already after minutes.
Significance: A TIA is a warning event for an increased stroke risk and requires diagnostic and therapeutic evaluation.
Blood pressure
Blood pressure (measurement)
Device and components: A cuff that can be inflated is used to measure blood pressure; with manual measurement a bulb and manometer as well as a stethoscope are used.
Significance: Blood pressure is one of the vital parameters and is routinely recorded at the initial examination to detect cardiovascular strain or acute deviations.
Application note: Correct placement of the cuff and standardized measurement conditions are important for reliable values.
Respiratory rate
Respiratory rate
The respiratory rate is the number of breaths per minute and is one of the vital parameters recorded at the start of the examination. In adults the normal rate is typically between about 12 and 20 breaths per minute. Values above 20 breaths per minute indicate tachypnea, values below 12 indicate bradypnea.
Oxygen saturation
Oxygen saturation (SpO2)
Oxygen saturation is measured noninvasively with a pulse oximeter, usually on the finger, fingernail bed or earlobe. The device provides a percentage value that reflects the proportion of oxygenated hemoglobin in arterial blood and should be documented as part of the vital parameters.
Temperature
Body temperature
Body temperature can be determined at various measurement sites, such as rectal, oral or axillary. The chosen measurement method should be noted during the examination, as measurement sites vary in accuracy and comparability.
peripheral perfusion
Peripheral perfusion
Peripheral perfusion is assessed by inspection of the skin (colour, temperature, oedema, trophic changes, ulcers) and by palpation of peripheral pulses. Important palpable pulses in the lower leg and foot are the posterior tibial artery, palpable behind the medial malleolus, and the dorsalis pedis artery, located on the dorsum of the foot lateral to the tendon of the extensor hallucis longus. Information on the location and characteristics of ulcers is significant for assessment.
Foot examination
Diabetic foot examination
Purpose: Early detection of diabetic foot complications, especially neuropathy, circulatory disorders, pressure points and ulcers.
Components: Systematic inspection of the skin, nail conditions, existing ulcers, local signs of infection, deformities and pressure points. Palpation of foot pulses to assess arterial circulation. Sensibility tests to detect sensorimotor neuropathy, e.g. with a 10‑g monofilament, a tuning fork for vibration sensation or temperature‑based tests.
The aim of the examination is to identify risks for wounds and amputations early and to initiate appropriate preventive or therapeutic measures.
Fundoscopy
Fundoscopy (ophthalmoscopy)
Purpose: Direct assessment of the fundus including the retina, optic disc and retinal vessels.
Findings in diabetes mellitus: Typical changes are microaneurysms, retinal hemorrhages, cotton‑wool spots and possibly neovascularizations that may indicate diabetic retinopathy.
Findings in arterial hypertension: Possible signs are generalized or focal vascular narrowing, arteriovenous crossing signs, retinal hemorrhages, hard exudates and in severe cases papilledema.
Blood count
Complete blood count
Purpose: Basic laboratory to clarify hematological changes.
Contents and utility: The complete blood count usually includes haemoglobin and haematocrit as well as parameters for erythrocytes, leukocytes and platelets. It is particularly used to exclude anaemia and for the initial assessment of infections or disorders of coagulation components.
HbA1c
HbA1c
Significance: The HbA1c value provides information about average blood glucose control over several weeks to months.
Application: HbA1c measurements are used for diagnosis and monitoring of diabetes mellitus, as they reflect the average glycaemic burden over the preceding period.
Blood gas analysis
Blood gas analysis — parameters and clinical significance
Test components: pH, pO₂, pCO₂, HCO₃⁻, base excess (BE) and O₂ saturation.
Meaning of individual values:
– pH: Indicates the current acid‑base status of the blood; helps to identify acidosis or alkalosis.
– pO₂: Measures the partial pressure of oxygen and provides information on pulmonary oxygenation performance.
– pCO₂: Reflects the ventilatory component; changes indicate hypo‑ or hyperventilation.
– HCO₃⁻: Represents the metabolic component of acid‑base regulation.
– Base excess (BE): Quantifies the non‑respiratory deviation from the normal value and supports the assessment of metabolic disturbances.
– O₂ saturation: Gives the proportion of hemoglobin saturated with oxygen and complements the information on oxygenation.
Clinical application: Blood gas analysis is used to assess oxygenation, ventilation and disturbances of the acid‑base balance; it is usually obtained from arterial blood and is requested in respiratory or metabolic problems.
PatientSalutation: Mr./Ms. Senior Consultant ……….., I would like to introduce the patient Erika Baumann to you. |
Date19/08/2025 |
| Age 61 years | Weight 73 kg | Height 178 cm |
Allergies (keywords)
Amoxicillin → urticarial reaction
Crustaceans → angioedema of the face
Wasp stings → anaphylaxis (inpatient treatment + hyposensitization)
Stimulants / drugs (keywords)
Ex-smoker (approx. 17.5 pack-years, non-smoker for 4 years)
Alcohol: approx. 1 glass of beer/week
Drug abuse: denied
Social history (keywords)
Widowed for 1 year
Occupation: clerk in the housing office
Three children (22-year-old daughter with obsessive-compulsive disorder, two sons, 19 and 15 years)
Family history (keywords)
Mother: 79 years, dementia, nursing home, currently inpatient after hip injury
Father: died at 65 years of pancreatic carcinoma
Medications (keywords)
Metformin 500 mg 1-0-1
ASA 81 mg 1-0-0
Atorvastatin 20 mg in the evening
Diclofenac 25 mg as needed
Insulin glargine (Toujeo®) 20 IE in the evening
Clotrimazole ointment topical
History (full sentences)
The patient presented about one hour ago with sudden onset dizziness, asthenia, visual impairment, palpitations, paresthesias of the extremities, restlessness, hyperhidrosis, pale lips and confusion.
She additionally reported intense hunger and a limited memory of the event.
She stated that the complaints occurred after physical exertion (bike ride) and improved significantly in the ambulance after oral glucose administration.
No evidence of emesis, traumatic brain injury, tremor, pareses, plegias, loss of consciousness, or convulsions.
Last evening the patient administered 20 IU Insulin glargin, last meal also in the evening.
Autonomic medical history is unremarkable except for stress-related insomnia, a low-carb diet with weight loss (4–5 kg in 2 months) and chronic constipation.
Previous medical conditions:
DM type 2 for 3.25 years (initially Metformin, currently Metformin + Insulin)
Hypercholesterolemia
Osteoarthritis of the right ankle joint
Mycoses (candidiasis, tinea pedis)
occasional palpitations (normal Holter ECG)
Phlebitis after insect bite 2 years ago (amoxicillin allergy).
Previous surgeries:
Screw osteosynthesis of the right ankle 25 years ago, later osteoarthritis.
Gynecology:
3 births (2× spontaneous, 1× C-section due to macrosomia), postmenopausal for 7 years with hot flashes.
Suspected diagnosis – Differential diagnosis (full sentences)
The symptoms anamnestically and clinically most likely indicate hypoglycemia, triggered by fasting, physical exertion and insulin administration. Supporting this are sympathoadrenal (hyperhidrosis, palpitations, pallor) and neuroglycopenic symptoms (dizziness, confusion, paresthesias) and the improvement after glucose administration.
Differential diagnoses
cardiac causes (e.g., arrhythmia, ACS) – currently unlikely
neurological causes such as TIA or stroke – less likely
psychiatric or toxicological causes – not supported by history.
Further management – Therapy (full sentences)
Inpatient monitoring of blood glucose and, if necessary, oral or intravenous treatment
Physical examination
ECG and, if necessary, additional cardiological diagnostics to exclude cardiac causes
Adjustment of insulin therapy, education to avoid recurrent hypoglycemia/diabetes education
Signature
First name Last name
Kind regards
To run an AI simulation, download the PDF with the prompt, then upload it to an AI application such as ChatGPT.
Page 1 · 1–20 / 78
DOCTOR: Hello,
My name is Doctor Storch.
I am working today as a junior doctor on the ward.
I would like to conduct an anamnesis interview with you.
If you do not understand something correctly or have any questions, please let me know.
First I need some personal information, then we can continue.
What is your name?
PATIENT: Erika Baumann
DOCTOR: Could you please spell your first and last name slowly?
PATIENT: Of course
My first name: E, R, I, K, A
And my last name: B, A, U, M, A, N, N
DOCTOR: First of all I would like to know whether you perceive the pain or complaints as tolerable, Ms Baumann?
PATIENT: In the ambulance I was given glucose tablets.
That is why I feel better now.
DOCTOR: How old are you, Ms Baumann?
PATIENT: I am sixty-one years old.
DOCTOR: When exactly were you born?
PATIENT: I had a birthday yesterday.
DOCTOR: Oh – belated happy birthday then!
So you were born on November seventeenth, 1965?
PATIENT: Thank you very much, Exactly, Doctor.
DOCTOR: How tall are you?
PATIENT: I am one hundred seventy-eight centimeters.
DOCTOR: How much do you weigh?
PATIENT: I weigh about seventy-three kilos.
DOCTOR: What is the name of your general practitioner?
PATIENT: My GP is Doctor Karla Scholz.
DOCTOR: What brings you to us today?
PATIENT: You know, Doctor, yesterday was my birthday.
I drank three glasses of red wine and went to bed quite late.
As a present my son gave me a bicycle tour – I cycle regularly, especially at the weekend.
Actually the alarm clock rang this morning, but I overslept. Then I had to drive straight to the meeting point. The tour started at nine o’clock.
After about an hour the complaints first appeared, which initially improved after a glass of cola.
We then continued riding. But after two hours I felt really dizzy and weak. That is why my friends called the emergency services.
There I was given glucose tablets, and afterwards I felt significantly better.
DOCTOR: Was your blood sugar measured in the ambulance?
Do you still know how high it was?
PATIENT: Yes, the paramedics measured my blood sugar right away.
I can’t remember the exact value, but it was apparently quite low.
DOCTOR: Good, then I’ll measure your blood sugar again now.
How much glucose (dextrose) did you take?
PATIENT: In the ambulance I was given three pieces.
DOCTOR: Do you suffer from any heart disease or rhythm disorders?
PATIENT: About a year ago I sometimes had palpitations.
That’s why I saw a heart specialist.
A long-term ECG was done, but nothing conspicuous came up.
DOCTOR: Have you had palpitations again recently?
PATIENT: Only when I cycle faster, otherwise not really.
DOCTOR: Have you had or do you have chest pain, a feeling of tightness, or shortness of breath?
PATIENT: No, I haven’t had anything like that so far.
DOCTOR: Have you noticed muscle weakness, paralysis in any of your limbs, or anything noticeable in your face?
PATIENT: No, I haven’t noticed that so far.
DOCTOR: What symptoms did you have?
PATIENT: About half an hour after starting the tour I felt unwell, I felt nauseous, but I kept cycling.
Then I had to take a break, and a friend brought me a glass of cola.
After that I felt better briefly.
About two hours later I felt dizzy, my vision was blurred, I had palpitations and a strange sensation in my arms and legs – like pins and needles.
I was also off balance, I couldn’t walk straight anymore.
DOCTOR: Did you perhaps injure yourself during that?
PATIENT: No, I didn’t hurt myself.
DOCTOR: Were you also hungry?
When did you last eat something?
PATIENT: Yes, I was really ravenous.
This morning I was in a hurry, so I didn’t have breakfast – I only drank a glass of black coffee.
The last time I ate properly was last night.
DOCTOR: Did you additionally notice restlessness, increased sweating, or trembling?
PATIENT: Yes, I was quite restless and sweat a lot, but I wasn’t trembling.
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DOCTOR: Were you told that you looked paler than usual?
PATIENT: Yes, a friend of mine said my lips had turned very white.
DOCTOR: Did you lose consciousness?
PATIENT: No
DOCTOR: Did you have seizures?
PATIENT: No
DOCTOR: Were there headaches or concentration problems?
PATIENT: Yes, I could no longer understand and answer questions properly.
I can’t remember much of the time after the onset of the complaints exactly, until I was given the glucose.
DOCTOR: May I ask whether you took something special yesterday?
I mean, for example, drugs or tablets.
PATIENT: Yes, of course you may ask.
But no – I didn’t take anything.
DOCTOR: Did you vomit?
PATIENT: No, I didn’t have to vomit.
DOCTOR: Do you have a blood sugar disease?
Since when exactly?
PATIENT: Yes, for about three and a quarter years.
DOCTOR: How was the diagnosis made?
PATIENT: Previously I once had a fungal infection under the right breast and another time between the left fourth and fifth toes.
After that my GP carried out some examinations, and that’s how the diagnosis was confirmed.
DOCTOR: Do you measure your blood sugar at home?
How often?
PATIENT: Not always, probably about twice a week.
DOCTOR: That’s a bit little.
So that we can better assess your values, it would be important for you to measure more regularly – preferably daily at fixed times, for example fasting in the morning and occasionally after meals.
Alternatively, we could also discuss a continuous glucose sensor so that you can keep track of the values more easily.
Which treatments have you received so far?
PATIENT: At the beginning my doctor prescribed metformin.
But after about a year she said the long-term blood sugar values were not satisfactory.
That’s why I then received insulin.
DOCTOR: When did you last inject insulin?
PATIENT: Last night at 9 PM.
DOCTOR: What is the name of the insulin and how much did you inject?
PATIENT: Insulin Toujeo, 20 units.
DOCTOR: Please note: Insulin can cause hypoglycaemia – especially if you inject too much, do not eat, or exert yourself heavily.
If you notice symptoms such as dizziness, palpitations, sweating, anxiety or tremor, measure your blood sugar immediately and take glucose tablets or something sweet, for example a glass of juice.
Please always carry glucose tablets or something sweet with you.
Also, you can attend education on diabetes in many facilities, for example in hospitals or diabetes centres.
There you will receive valuable information and tips for everyday life.
Where exactly do you inject your insulin? Have you noticed any skin changes at the injection sites, for example redness, nodules, thickening or hardening?
PATIENT: I mostly inject into my abdomen and occasionally into my thigh.
I haven’t noticed any skin changes so far – no redness or nodules.
DOCTOR: Did you take Metformin today?
PATIENT: No
DOCTOR: Why did your values fluctuate?
PATIENT: To be honest, I didn’t always follow the diet plan.
Also, during stressful periods I was irregular with the tablets.
DOCTOR: That explains the fluctuations.
It is important that you take your diet and medication more regularly.
For example, you could enter a medication schedule into your phone.
PATIENT: Thank you very much for the helpful advice, Doctor.
DOCTOR: How often do you take Metformin, and at what dosage?
PATIENT: I take 500 , twice daily.
DOCTOR: Have you recently had increased thirst, hunger or urination?
PATIENT: No, I haven’t noticed that.
DOCTOR: Have you had any problems with your eyes or kidneys so far?
PATIENT: No, not that I know of.
DOCTOR: When did you last visit an ophthalmologist?
PATIENT: So far never.
Do I have to do that?
DOCTOR: Yes, definitely. Regular eye examinations are very important because they can detect and treat changes to the retina early, before permanent damage occurs.
Do you sometimes have a tingling sensation, as if ants are crawling over the skin – especially on the feet?
PATIENT: No, I’ve never experienced that so far.
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DOCTOR: Have you noticed a wound or a deformity on your feet?
PATIENT: No, my feet are actually unremarkable, I haven’t noticed anything there.
DOCTOR: Have you observed changes in the nails or hair loss on the feet?
PATIENT: No, I haven’t noticed anything there either.
DOCTOR: Have you recently noticed that your skin or mucous membranes are paler than usual?
PATIENT: No, I haven’t noticed any changes recently.
DOCTOR: Do you have fever, night sweats or chills?
PATIENT: None.
DOCTOR: How do you eat?
PATIENT: In the last two months I followed a low-carb diet.
That means I largely avoided pasta, bread and sweets and ate more vegetables, fish and lean meat.
But you know, Doctor, sometimes I just can’t resist sweets.
DOCTOR: That’s completely understandable, Ms. Baumann.
You are doing really well.
No one can always abstain perfectly.
What matters is that you pay attention to your diet overall and enjoy sweets in small amounts.
Has your weight changed recently?
How much and over what period?
PATIENT: Yes, I lost about four to five kilos in the last two months.
DOCTOR: Great. How is your sleep?
PATIENT: My husband died of colon cancer a year ago.
Since then I often have trouble falling asleep – sometimes it takes two hours before I finally can sleep.
DOCTOR: My sincere condolences. What are you doing about it?
PATIENT: I take valerian lozenges, and I also cycle regularly, that helps me somewhat.
DOCTOR: Exercising is a very wise choice.
Physical activity not only helps with sleep, but also has a positive effect on blood sugar, circulation and general well‑being.
Have you noticed any changes in your bowel movements?
PATIENT: I’ve been dealing with constipation for quite some time.
In recent months it’s gotten better — mainly due to more exercise and my diet.
DOCTOR: How were the fungal infections treated back then?
PATIENT: With Canesten ointment.
I had to apply cream to the affected areas two to three times a day.
DOCTOR: When was that?
PATIENT: Under the breast about four years ago and between the toes about three and a half years ago.
DOCTOR: Do you suffer from any other chronic illnesses?
PATIENT: Two years ago in the summer I was on vacation in Spain. I was stung by an insect there, and a vein on my right lower leg became inflamed — it got swollen, red and painful. Then I was prescribed amoxicillin.
After taking it I developed an itchy rash all over my body.
Therefore the medication was stopped immediately, and afterward I was given azithromycin.
DOCTOR: Is there anything else you would like to mention?
PATIENT: Yes. About 25 years ago I had a climbing accident from about three meters height.
I fractured my right ankle in the process.
It was operated on at the time and fixed with screws.
A few years later I had pain there again, and I was told that the joint had become worn out in the meantime.
DOCTOR: When were the screws removed?
PATIENT: About a year after the operation.
DOCTOR: What treatments have you had so far for the joint wear?
PATIENT: As needed I took Voltaren Dolo 25, about three to four days a month.
Otherwise really no further treatments.
DOCTOR: Do you also take gastric protection medications like famotidine or pantoprazole?
PATIENT: No
DOCTOR: Because painkillers like Voltaren can irritate the stomach, it would make sense to take a gastric protector in addition if you take them frequently.
Have you been pregnant before?
PATIENT: Yes, three times. I had the first two children vaginally, and the last was delivered by cesarean section.
DOCTOR: Why was a cesarean section performed?
The child was somewhat larger and heavier than normal, so a cesarean section was chosen.
DOCTOR: Did you have any problems during your pregnancy?
PATIENT: No, actually nothing special.
Everything went smoothly and the children were each born on time.
DOCTOR: Are you in menopause? Since when?
PATIENT: Well, for 7 years.
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DOCTOR: Do you have hot flashes, night sweats or mood swings?
PATIENT: Sometimes hot flashes, but they are not too bothersome.
DOCTOR: When did you last see a gynecologist?
PATIENT: I last saw a gynecologist two years ago, and no abnormal findings were detected.
DOCTOR: Do you take any other medications?
PATIENT: Yes, I take aspirin 81 milligrams daily and atorvastatin 20 milligrams in the evening.
DOCTOR: Do you have a prescription for your medications?
PATIENT: Yes, I do.
DOCTOR: Are you fully vaccinated, meaning have you received all vaccinations since childhood?
PATIENT: I received three injections against Covid.
Other vaccinations were a very long time ago.
But you can certainly ask my GP about them.
DOCTOR: Alright.
Do you have known allergies, for example to foods, medicines, animals or other substances — aside from amoxicillin?
PATIENT: Yes, I previously had a severe reaction after a wasp sting.
I even had to go to the intensive care unit at that time.
After that I received treatment in which the body was slowly accustomed to the stings.
I am also allergic to crustaceans like shrimp or crab.
When I eat such things, my face swells up badly.
DOCTOR: Do you smoke?
PATIENT: Not currently.
After I was diagnosed with diabetes, my GP strongly advised me to quit.
And I actually managed to do so.
DOCTOR: Wonderful!
How many cigarettes did you used to smoke per day and for how long?
PATIENT: From the age of nineteen I smoked about half a pack a day.
During my pregnancies I hardly smoked though.
DOCTOR: Do you have a cough or are you sometimes hoarse?
PATIENT: No, I don’t.
DOCTOR: Do you drink alcohol?
What kind?
How much?
PATIENT: One glass of beer per week.
DOCTOR: May I ask whether you have ever used drugs?
PATIENT: No, never.
DOCTOR: What is your profession?
PATIENT: I work as a clerk in the housing office.
DOCTOR: How old are your children?
PATIENT: My daughter is 22 years old, my older son is 19 and the younger is 15.
DOCTOR: Are your children healthy?
PATIENT: My daughter had an obsessive-compulsive disorder.
She had to wash her hands with soap several times, sometimes even three times in a row.
In the meantime she has also developed an eczema on her hands because of it.
She is currently taking a medication for the obsessive-compulsive disorder, called Sertralin.
Because of the eczema she uses a special cream and sometimes an ointment from the dermatologist.
DOCTOR: Who do you live with?
PATIENT: I live together with my two sons.
DOCTOR: Are there any important illnesses in your family, for example in your parents, siblings or other close relatives?
PATIENT: My mother is 79 years old, she suffers from dementia and lives in a nursing home. For two days she has been in the hospital because she injured her right hip joint in a fall on the stairs.
My father died at the age of 65, 15 years ago, from pancreatic cancer.
DOCTOR: Do you have pets?
PATIENT: I don’t have any pets.
DOCTOR: We are finished with the medical history.
Do you have any further questions?
PATIENT: Yes, my brother is overweight.
Could he benefit from Ozempic?
DOCTOR: First, one would need to check whether he is a suitable candidate for drug treatment.
Please note: in the long term, a healthy diet and regular exercise are decisive above all.
Medications like Ozempic can provide support, but they are not a substitute for a lifestyle change.
To get closer to a diagnosis, we should perform a physical examination afterwards.