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Diabetic care review

Diabetic patients should have a thorough review at least once annually.

History

  • Background
    • Diabetes type I/II
    • Do they monitor capillary glucose?
    • Current diabetes treatments
    • Other medications (include steroid use)
    • Comorbidities
  • Control
    • Capillary glucose measurements
    • HbA1c readings
    • Any episodes of DKA/hyperosmolar hyperglycaemic state/hypoglycaemia
    • Adherence with current regimen, side effects, any concerns
    • Any changes in lifestyle, e.g. exercise, travel
  • Macrovascular complications
    • Stroke/TIA
    • MI/heart failure
    • Claudication
  • Microvascular complications
    • Vision
    • Kidneys (note deterioration may require re-dosing of hypoglycaemics/insulin)
    • Peripheral neuropathy
  • Adderess cardiovascular risk factors
    • Smoking
    • Diet
    • Weight
    • Cholesterol
    • Blood pressure

    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
    • Discuss about diabetes understanding, monitoring, treatment and complications
    • Address other cardiovascular risk factors – consider:
      • Statin  β†’ If 10-year risk of cardiovascular disease (QRISK2 score) of β‰₯10%. OR if type 1 and >40 years/diabetic >10 years/nephropathy/cardiovascular risk factors
      • Antihypertensives β†’ aim <135/85mmHg (type 1) or <140/80 (type 2)
      • Aspirin β†’ if cardiovascular disease (heart disease, stroke/TIA, peripheral vascular disease)
      • ACE-inhibitor β†’ if diabetic nephropathy present
      • SGLT2 inhibitor β†’ if heart failure or cardiovascular diseases
      • Weight loss/exercise/diet       
      • Smoking cessation
    • Refer if needed
      • Ophthalmologist β€“ patients should have annual retinopathy screens
      • Dietitian
      • Podiatrist
      • Community diabetes 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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