Table of Contents
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 – full diabetic foot exam covered on p61
- 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 (aim HbA1c 48-53mmol/mol)
- 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