CDCES

Assessment is Domain I of the CBDCE Exam Content Outline and accounts for 37 of the 150 scored questions (about 25% of the scored exam), split across three subdomains: Physical and Psychosocial (12 items), Self- Management Behaviors and Knowledge (15 items), and Learning (10 items). Every education plan starts here. The diabetes care and education specialist gathers the health history, examines the feet and injection sites, interprets laboratory and CGM data, screens for depression, diabetes distress, disordered eating, and cognitive impairment, identifies insurance, cost, and social barriers, measures knowledge and self-care behaviors, and determines how, and whether, the person is ready to learn. Expect case scenarios that ask which finding requires follow-up, which screening tool fits, which stage of change a statement reflects, or which assessment should come FIRST before teaching begins.

A comprehensive assessment begins with a thorough medical history, because the type of diabetes, its duration, the current regimen, and existing complications determine what the person needs to learn first. The specialist confirms the type of diabetes (type 1, type 2, gestational, monogenic, cystic fibrosis–related, post-pancreatectomy, or drug-induced), since management differs for each. Duration affects complication risk and treatment approach, and previous diabetes education and current knowledge guide content selection so that time is not spent re-teaching what the person already does well.

Table1.1—Componentsofthediabeteshealthhistory

Component	Whattoaskorreview	Whyitmatters
Diabetestypeand	Ageandcircumstancesatdiagnosis(DKAatonset ,	Confirmsthecorrecttreatmentmodel;longer
duration	weight loss autoantibodies C -peptide) how , , ,	durationraisesmicrovascularriskandthe
	diagnosed yearssincediagnosis ,	likelihoodofhypoglycemiaunawareness
Prioreducationand	PreviousDSMES sourceofcurrentinformation ,	Avoidsrepetition;uncoversmisinformation
currentknowledge	(providers family internet) whatthepersonalready , , ,	thatmustbecorrected
	does
Currentmedications	Alldiabetesagentswithdosesandtiming medications ,	Identifiesinteractions drugsthatraise ,
	for comorbidities over-the-counter products , ,	glucoseormaskhypoglycemia duplications , ,
	supplements herbalremedies;howtheperson ,	costbarriers andadherencegaps ,
	actuallytakesthem
Allergiesandadverse	Drugallergies intolerances(GIeffectsofmetforminor ,	Documentedtoguidetherapychangesand
reactions	GLP-1 RA) prior hypoglycemia on sulfonylureas ,	preventrepeatharm
Comorbidconditions	Hypertension dyslipidemia cardiovasculardisease , , ,	Shapeseducationprioritiesandmedication
	heartfailure chronickidneydisease obesity , , , obstructivesleepapnea fattyliverdisease , , depressionandanxiety	selection (for example SGLT2 inhibitor 1for , heartfailureorCKD)

Table1.1—Componentsofthediabeteshealthhistory(Continued)

Component	Whattoaskorreview	Whyitmatters
Acutecomplications	Frequency severity andtimingofhypoglycemia , ,	PriorseverehypoglycemiaorDKAsignalsrisk
	(includingepisodesneedingassistance) awarenessof ,	ofrecurrenceandtheneedforpreventionand
	symptoms DKAorhyperglycemichyperosmolarstate ,	glucagonteaching
	episodesandtriggers
Chroniccomplications	Retinopathy nephropathy peripheralandautonomic , ,	Directs risk -reduction teaching and activity
	neuropathy footulcersoramputation cardiovascular , ,	precautions
	disease gastroparesis sexualdysfunction , ,
Surgicalhistory	Bariatricsurgery pancreatectomy amputation , , ,	Bariatricsurgerychangesnutrientabsorption ,
	transplant	medicationneeds andhypoglycemiarisk ,
		(post-bariatric hypoglycemia);
		pancreatectomycausesinsulindeficiency;
		amputationchangesactivityoptions
Familyhistory	Diabetes cardiovasculardisease earlydeath , , ,	Prognosticinformationandmotivational
	autoimmunedisease kidneydisease ,	context;familyhistoryofheartdiseaseor
		earlydeathheightensriskawareness
Lifestyleandsocial	Eatingpattern activity sleep tobaccoandvaping , , , ,	Identifies risks (alcohol -related hypoglycemia ,
history	alcohol cannabisandothersubstances occupation , ,	drivingsafety)andpracticalconstraintsonthe
	andshiftwork livingsituation driving , ,	plan
Reproductivehistory	Pregnancyplans contraception historyofgestational , ,	Preconceptionplanningtargetsand
	diabetesormacrosomia	medicationreview;priorGDMraiseslifelong
		type2risk
Preventivecare	Lastdilatedeyeexam dentalvisit footexam kidney , , ,	Identifiesoverduescreeningtocoordinate
	screening;immunizations(influenza pneumococcal , ,	withthecareteam
	hepatitis B COVID-19 zoster RSV as eligible) , , ,

Medication Review

The specialist reviews every medication the person takes, including those that are not for diabetes, because several classes raise glucose, cause hypoglycemia, or hide its warning signs. Asking the person to bring all bottles and devices (a "brown-bag" review) reveals what is actually being taken, expired supplies, and confusion between similar-looking insulins.

Table1.2—Non-Diabetesmedicationsthataffectglucose

Effect	Examples
Raiseglucose	Glucocorticoids (oral injected high -dose inhaled) atypical antipsychotics (olanzapine clozapine) , , , , ,
	thiazidediuretics calcineurininhibitors(tacrolimus cyclosporine) someHIVproteaseinhibitors , , , ,
	niacin statins(smalleffect;benefitoutweighsrisk) sympathomimetics , ,
Increasehypoglycemiarisk	Alcohol fluoroquinolones combinationswithinsulinorsulfonylureas weightlossorreducedintake , , ,
	whileoninsulinorinsulinsecretagogues
Maskhypoglycemiasymptoms Affectlaboratoryorsensor values	Beta-blockers especially nonselective agents blunt tremor and palpitations; sweating is pre1served , , andbecomesanimportantwarningsign Long-term metformin lowers vitamin B12; erythropoiesis-stimulating agents and transfusions lower A1C; high -dose vitamin C and acetaminophen can interfere with some glucose sensors

When a person on a stable regimen suddenly has high glucose, look for a new medication (a steroid injection for joint pain, prednisone for a respiratory illness) or an acute illness before assuming nonadherence. When a person has new or more frequent hypoglycemia, look for weight loss, declining kidney function (reduced insulin and sulfonylurea clearance), increased activity, or alcohol use.

Physical Assessment

Physical examination components relevant to diabetes education include vital signs, anthropometric measurements, and focused assessments of the skin, injection sites, feet, and mouth. Blood pressure is measured at every routine visit; the target for most people with diabetes is <130/80 mm Hg, and readings guide hypertension management and medication titration. Orthostatic blood pressure is checked when the person reports dizziness on standing, falls, or has long- standing diabetes: a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3 minutes of standing, without an appropriate rise in heart rate, suggests cardiovascular autonomic neuropathy (also consider volume depletion and antihypertensive or SGLT2 inhibitor effects). A resting heart rate above 100 beats per minute may be another sign of autonomic neuropathy.

Height, weight, and body mass index establish a baseline and track progress. Waist circumference reflects central adiposity, which is associated with insulin resistance and cardiovascular risk (higher risk at >40 in for men and >35 in for women; lower thresholds apply to many Asian populations, and BMI ≥23 kg/m² is used to screen Asian Americans for diabetes). A weight history, including highest adult weight, recent changes, and previous weight-loss attempts, informs nutrition counseling. Unintentional weight loss in a person with diabetes may signal worsening insulin deficiency, uncontrolled hyperglycemia, or insulin omission.

Table1.3—Focusedphysicalassessmentfindings

Area	Finding	Signifi canceandaction
Skin	Acanthosisnigricans:velvety darkenedskininthe ,	Markerofinsulinresistance;supportsscreeningfor
	neck axillae orgroinfolds , ,	type2diabetesinyouthandadults
Skin	Poorwoundhealing recurrentskinoryeast ,	Suggestshyperglycemia vascularcompromise or , ,
	infections drycrackedskin ,	infection;drynessfromautonomicneuropathy
		(reducedsweating)
Skin	Necrobiosis lipoidica (shiny yellow-brown plaques	Diabetes-associated skin conditions; refer for
	onshins) diabeticdermopathy(brown"shinspots") ,	evaluationifulcerated
Injectionandinfusion	Lipohypertrophy:soft rubbery raisedswelling , ,	Insulinabsorbserratically causingunexplained ,
sites	fromrepeatedinjectionsinonearea	highsandlows;teachsiterotation avoidthearea ,
		untilitresolves andexpecttoneedalowerdose ,
		oncehealthytissueisused
Injectionandinfusion	Lipoatrophy:dimpledlossoffat;redness ,	Lipoatrophyisuncommonwithmoderninsulins;
sites	induration bruising infection orscarringatinfusion , , ,	infectionorscarringrequiressitechangeand
	orsensorsites	reviewoftechniqueandhygiene
Mouth	Red swollen bleedinggums;looseteeth , ,	Periodontaldiseaseismorecommonandmo1re severeindiabetesandworsensglycemiccontrol; recommenddentalcareatleastevery6months

Table1.3—Focusedphysicalassessmentfindings(Continued)

Area	Finding	Signifi canceandaction
Eyesandvision	Blurredvision difficultyreadingameterorpen ,	Mayreflectglucoseswingsorretinopathy;adapt
	dosewindow	teachingmaterialsandconfirmthedateofthelast
		dilatedexam
Hearingandfunction	Difficultyhearinginstructions tremor arthritis , , ,	Affectstheabilitytousedevices;selectadaptive
	limiteddexterity	toolsandadjustteachingmethods

Foot Examination

Foot ulcers and amputations are among the most preventable complications of diabetes. The ADA Standards of Care call for a comprehensive foot examination at least annually for every person with diabetes (type 2 at diagnosis, type 1 starting 5 years after diagnosis), and visual inspection of the feet at every visit for anyone with loss of protective sensation (LOPS), foot deformity, peripheral artery disease (PAD), or a history of ulcer or amputation. The person removes shoes and socks so the feet can be inspected, and the footwear is checked too.

Table1.4—Componentsofthecomprehensivefootexamination

Component	Howitisdone	Abnormalfni dings
History	Askaboutpriorulcersoramputation numbness burning , ,	Priorulceroramputationisthestrongest
	ortingling legpainwithwalking(claudication) smoking , , ,	predictorofanewulcer
	visionproblems
Inspection	Skin nails betweenthetoes pressureareas;shapeof , , ,	Calluses blisters fissures ulcers tinea , , , , ,
	thefoot;footwearandsocks	ingrownorthickenednails hammertoes , ,
		bunions Charcotdeformity(warm red , , ,
		swollenfootwithcollapsedarch)
Neurologic: 10 -g	StandardtestforLOPSattheplantarhalluxand	InabilitytofeelthefilamentindicatesLOPS
monofilament	metatarsalheads(seediagram)
Neurologic:one	Plus at least one of vibration (128-Hz tuning fork) ,	Reducedvibrationisoftenanearlysignof
additionaltest	pinprick temperatureperception oranklereflexes , ,	large-fiber neuropathy
Vascular	Palpatedorsalispedisandposteriortibialpulses;check	Diminishedorabsentpulsesorclaudication
	skintemperature hairloss capillaryrefill , ,	warrant an ankle-brachial index (ABI) and
		referralforPADevaluation

Abnormal findings require referral (podiatry, vascular surgery, or a foot-care specialist) and intensive, repeated self-care education: daily inspection using a mirror or a family member's help, washing and thorough drying between the toes, moisturizing but not between the toes, never walking barefoot, testing bath water with the elbow or a thermometer, well- fitting shoes with socks, and prompt reporting of any break in the skin. People with LOPS, deformity, or PAD benefit from therapeutic footwear and professional nail and callus care.

A person with LOPS cannot rely on pain to warn of injury. A painless ulcer, a new blister after new shoes, or a warm, swollen, red foot without pain (possible acute Charcot neuroarthropathy) requires same-day evaluation, not watchful waiting. Charcot foot can be mistaken for cellulitis or a sprain.

Confirm the type and duration of diabetes, prior education,

Comprehensive foot exam at least annually: inspection, 10-g

and the actual (not prescribed) medication routine before

monofilament plus one other test, and pedal pulses.

teaching.

Inspect the feet at every visit for anyone with LOPS,

Review all medications: glucocorticoids and atypical

deformity, PAD, or prior ulcer or amputation.

antipsychotics raise glucose; beta-blockers mask

Diminished pulses or claudication → ankle-brachial index

hypoglycemia warning signs except sweating.

and vascular referral.

Blood pressure every visit (target <130/80); orthostatic drop

Periodontal disease is more common in diabetes and worsens glycemic control: recommend regular dental care.

Acanthosis nigricans signals insulin resistance; lipohypertrophy causes erratic insulin absorption and unexplained glucose swings.