Diabetic care review

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

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?

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What is the target capillary glucose for patients with type 1 and type 2 diabetes respectively?

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How would you adjust a basal bolus insulin regimen if the capillary glucose levels are too high before breakfast?

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