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?

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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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