Table of Contents HistoryExaminationInvestigationsTreatment planTest your knowledge Diabetic patients should have a thorough review at least once annually. History Background Diabetes type Do they monitor capillary glucose? Current treatments Other medical problems (include recurrent infections/abscesses) Medications (include steroid use) Control Capillary glucose measurements HbA1c readings Any episodes of DKA/hyperosmolar hyperglycaemic state/hypoglycaemia Coping and compliance with regimen (and any side effects) Any changes in regular lifestyle Macrovascular complications Stroke/TIA MI Claudication Microvascular complications Eyes Kidneys (note deterioration can reduce excretion of insulin/hypoglycaemic agents and lead to hypoglycaemia) Neuropathy/feet Other cardiovascular risk factors Smoking Diet Weight Cholesterol Blood pressure Other issues Planning pregnancy Sexual dysfunction Examination Weight, height, BMI Eyes Xanthelasma/cataract/ophthalmoplegia Visual acuity Ophthalmoscopy (diabetic retinopathy) Cardiovascular Pulse Blood pressure Heart sounds Carotid bruits Insulin injection sites (lipodystrophy) Feet Inspect: shoes, skin (ulcers, infection, pallor, fissures), nails (dystrophy), webspaces (cracking, maceration), deformities (Charcot joints) Arteriopathy: temperature, pulses, capillary refill Neuropathy: 10g monofilament sensation, vibration sense with 128Hz tuning fork, proprioception, ankle jerks Learn more…The full diabetic foot exam is covered here! Investigations HbA1c Lipid profile Renal and liver function Urinalysis (protein, blood, ketones) Urine albumin-creatinine ratio Treatment plan Review/adjust medication Educate patient about diabetes, monitoring, treatment and complications Address other cardiovascular risk factors – consider: Statin → If 10-year risk of cardiovascular disease (QRISK2 score) of ≥10%. OR if type 1 and >40 years/diabetic >10 years/nephropathy/cardiovascular risk factors Antihypertensives → aim <135/85mmHg (type 1) or <140/80 (type 2) Aspirin → if cardiovascular disease (heart disease, stroke/TIA, peripheral vascular disease) ACE-inhibitor → if diabetic nephropathy present Weight loss/exercise/diet Smoking cessation Refer if needed Ophthalmologist – patients should have annual retinopathy screens Dietitian Podiatrist Educational team Address any patient worries/concerns Test your knowledge What is the target for HbA1C for a patient with diabetes? Oops! This section is restricted to members. What is the target capillary glucose for patients with type 1 and type 2 diabetes respectively? Oops! This section is restricted to members. How would you adjust a basal bolus insulin regimen if the capillary glucose levels are too high before breakfast? Oops! This section is restricted to members.
