FOLLOW UP: DIABETES MELLITUS

CONCERNS Uncontrolled blood sugar level

Diabetic foot
Insulin therapy

“How can I help you today?” / “Apart from the follow up, do you have other concerns?”

Diagnosis

CONTROL Symptoms

Sx of Hyperglycaemia Sx of Hypoglycaemia (​sudden onset​)

Polyuria (↑ urination) Hungry

Polydipsia (↑ thirst) Shakiness/ tremor
Polyphagia (↑ appetite/often hungry) Sweating
Weight gain/loss Headache
Blurred vision Anxious/ palpitation
Tiredness Confusion

“Have you had frequent urination/wake up “Have you had any episode where you feel
in the middle of the night to urinate?” dizzy/sweaty/shaky/weak/heart beating
​ ”
strongly?
“Do you often feel thirsty?”
If so:
“Any changes in your appetite/weight?​” - When did it happen?
- How often did this happen?
- How do you treat this episode?

Blood Glucose Level

“Do you monitor your own sugar level at home?”

→ ”Usually what are the readings like?”
→ “When do you usually take the readings?”
“Do you know how much is your sugar level when you check in the clinic?”
“When was your most recent HbA1C (3 monthly control)? How much was it?”

Random Blood Glucose Diabetes → ≥11.1

Target for known Diabetic​ → <8.0

Fasting Blood Glucose Diabetes → ≥7.0

Target for known Diabetic​ → < 7.0

Oral Glucose Tolerance Test (OGTT) 2H Postprandial

Impaired glucose tolerance → 7.8-11.0

Diabetes → ≥11.1
Target for known Diabetic​ → < 8.5

HbA1C Pre-diabetes 5.6-6.2%

Diabetes ≥6.3%
Target for known Diabetic
● Newly Dx/Young/ Less risk of
Hypoglycaemia → ≤6.5%
● Comorbidities/Old age/ Prone to
hypoglycaemia → 7.1-8.0%
COMPLIANCE MEDICATION
“ What type of medication are you taking?”
“ How do you normally take your medication everyday?”

Class Medication Dosage

Biguanides Tablet Metformin 250mg-1000mg daily bd

Tablet Glibenclamide 2.5mg-10mg daily bd

Sulphonyluria
Tablet Gliclazide 40mg-160mg daily bd

Short acting - Actrapid

Insulin
Long acting - Insulatard

“Have you ever missed the medications?”

“Do you have any problem with the medications?”

LIFESTYLE CHANGES
Diet - ​“Do you have any diet plan? Have you been following your diet plan?”
Exercise - “​ Have you been doing your exercise regularly​?”

COMPLICATION MICROVASCULAR

Retinopathy- ​“How is your vision?” “Were you told to have any eye problem d/t diabetes?”
- Annually after diagnosis of DM
- Visual acuity using Snellen chart
- Fundus examination with dilated pupil - yearly

Nephropathy ​- ​“Any problem with your urination? Frothy urine? Recurrent UTI”
- Presence of proteinuria (microalbuminuria or overt proteinuria) → urine dipstick
- Positive: 24H urine collection
- Microalbuminuria → early morning urine specimen
- Positive: 2 further test within 6M
- Negative: screening annually
- Target BP is <140/80mmHg
- Proteinuria > 1g/day, target BP is <125/75mmHg *individualised

Neuropathy ​- ​“How are your limbs sensation? Any tingling or numbness?” “Any pain or injury
at your feet”
- Tx: Gabapentin, Lamotrigine, Carbamazepine
- These are anticonvulsant but it is effective in treating neuropathic pain in
diabetics

MACROVASCULAR

Coronary Heart Disease ​- ​“Any episodes of chest pain, numbness radiation to jaw or left
arm?” “Have you experience​ reduced effort tolerance symptoms?”
- Resting ECG
- CV risk assessment tool (Framingham Risk Score)
- Lipid levels, smoking Hx, family Hx of premature CHD, blood pressure

Cerebrovascular Disease - ​“Have you had a stroke? Limb weakness, slurred speech?”
- Risk of stroke
Diabetic Foot/ Peripheral Vascular Disease - ​“​Have you had any calf pain? (intermittent
claudication) “Any open wound on your feet?”
- Feet examination: ulcer, deformity, amputation; examine dorsalis pedis pulse for PVD
- Advice to patient - feet care using a mirror, flat soft and well fitted shoes
 MEDICATION

Drugs Function Common side effects

Biguanides (Metformin) ↑ insulin sensitivity, GIT disturbances (diarrheoa,

↓ hepatic glucose production anorexia, N+V)

Sulfonylureas (Gliclazide) ↑ insulin secretion Hypoglycaemia, weight gain

Alpha-glucosidase inhibitors ↓ rate of absorption of Flatulence, skin rashes,

(Acarbose) polysaccharides in prox. diarrheoa
small intestines

Thiazolidinediones ↑ insulin sensitivity in Oedema

muscles

Gliptins/DPP4 inhibitors Inhibit glucagon → Nasopharyngitis, headache,

(Sitagliptin) Increases insulin secretion hypersensitivity, allergic
reactions

COMORBID “Do you have ________ :”

- Hypertension
- Target <140/80
- Dyslipidaemia
- Target - TC <4; TG <1.7mmol/L, HDL >1.1 mmol/L, LDL <2.6 mmol/L
- Cardiac disease
- Obesity, smoking
- Reduce weight by 10% in 6 months