Diabetes
Julia von Oettingen, MD
History
Insulin Regimen:
□ Twice a day 70/30 Insulin (Mixtard)
□ AM breakfast dose_________IU
□ PM dinner
dose________IU
□ Total Daily Dose per kg = ______(total Units per day) ÷ ______ (weight in
kg) = ______U/kg/day
Review of blood sugars:
•blood sugar check in clinic today : ________________mg/dL
•If patient keeps log at home, average blood sugar was
AM
□ not checked Lunch □ not checked PM
□ not checked
□ <100
□ <100
□ <100
□ 100-150
□ 100-150
□ 100-150
□ 151-200
□ 151-200
□ 151-200
□ 200-300
□ 201-300
□ 201-300
□ >300
□ >300
□ >300
•Any recorded overnight (2AM) blood sugars:________________mg/dL
•Highest sugar recorded:___mg/dL Lowest sugar recorded:_____ mg/dL
• Number of times EXTRA dose was given: ______________
History
Review of high / low symptoms:
Hyperglycemia
Frequent urination (polyuria) □ YES □NO
Hypoglycemia
shaking (tremor) □ YES □ NO
Increased thirst and fluid intake (polydipsia) sweating
□ YES □NO
□ YES □ NO
Increased hunger/food intake (polyphagia)
□ YES □ NO
Vomiting
□ YES □ NO
headaches
□ YES □ NO
Abdominal pain □ YES □ NO
Other:
Other:
Frequency:
□ daily □ weekly □ monthly
unconsciousness □ YES □ NO
Frequency:
□ daily □ weeky
monthly
□
History
Review of Diet:
Number of meals per day: □ 1 □ 2 □ 3 □ >3 □ food insecurity (irregular)
Types of foods eaten: □ rice □ fish □ meat □ vegetables □ fruit □ other___
Intake of high sugar drinks / foods: □ never
□ daily □ weekly □ monthly
Patient’s problems:
Ask about problems with costs, access to medication or diabetes supplies, access
to clinic, inability to contact medical provider by phone, lack of caregiver to
administer insulin.
Describe:_____________________________________________________
Other History:
• Retinopathy:
□ vision changes
□ trouble seeing
• Hypothyroidism:
□ low energy □ wt gain □ constipation □ dry
skin
• Psychosocial:
□ coping strategies □ feelings of depression
• 10y after diagnosis:
□ pain or hyperaesthesia in hand/feet
□ regular
foot check (every night) □ bloating / abdominal pain / vomiting
(gastroparesis)
Physical Exam
check box or circle if 2 choices given
HR_____
BP___/___
RR_____
Gen:
HEENT:
Heart:
Lungs:
Abd:
GU:
Neuro:
Skin:
Extr:
□
□
□
□
□
□
□
□
□
□
□
Temp______
Wt________kg
well appearing □ weak or dehydrated
□ altered mental status
moist MM
□ acetone odor □ thyroid exam_____________
S1 and S2
□ RRR
□ no murmur
□ other___________
clear
□ tachypnea
□ Kussmaul resp □ other___________
soft □ ND □ NT □ BS positive
□ other___________________
normal external MALE / FEMALE genitalia
□ pubertal / not pubertal
awake and alert□ altered mental status
□ GCS_____
□ DTRs____
cap refill ____sec
□ dry
□ pallor □ rash
sensation to light touch tested: intact / not intact, describe________________
vibration sense tested: intact / not intact, describe_______________________
foot inspected for ulcers: present / absent, describe______________________
Other:
□ Injection sites: infection – present / absent; lipohypertrophy - present / absent,
location__________________________________
□ Joint exam:
limited mobility – present / absent
□ hypothyroidism: goiter – present / absent; brittle hair – present / absent; dry skin –
present / absent
Education:
□ insulin regimen reviewed □ blood sugar testing reviewed
□ proper insulin administration reviewed (drawing up insulin, subQ route, changing sites)
□ symptoms of hypo- and hyperglycemia reviewed
□ plan for hypoglycemia reviewed:
1. give sugar ASAP (sugar water, juice, syrup, hard candy)
2. check BS after 20min
3. eat light meal after 30min
4. CALL YOUR DOCTOR
□ plan for hyperglycemia reviewed:
1. check your sugar
2. if >300, drink a lot of water (1L/h for big children, 0.5L/h for small children) to avoid
DKA, and check BS before every meal
3. if >400 or read “hi” on glucometer, continue to drink a lot of water and give 10% of
total daily insulin =_________ and advise to CALL DOCTOR
4. if you are feeling unwell CALL YOUR DOCTOR or COME TO THE EMERGENCY ROOM
□ short- and long term complications of type 1 diabetes reviewed
1.both hypo- and hyperglycemia can lead to coma and death
2. poor BS control leads to problems with the eyes (risk of blindness), kidney (risk of
kidney failure and death), nerves (painfull hands and feet, foot ulcers) and heart (early
death)
□ diet and avoidance of high sugar foods/drinks
□ patient questions answered
Assessment:
□ good control
□ acceptable control
□ fair control
□ poor control
□ DKA
Plan:
•Insulin dose:
•Yearly checks:
(BS levels 100-170, patient compliant)
(BS levels 150-250, patient compliant)
(BS levels 250-300, partial compliance)
(BS levels >300, poor compliance consider admission)
(BS levels >>300, non-compliant  needs admission)
□ no change
□ following changes:______________________
□ new TDD = ____U/day ÷ ___ wt in kg = ____U/kg/day
□ new EXTRA dose = _____Units
□ eyes
□ clinical suspicion of thyroid disease low / unsure /high □ check TSH
□ urine for microalbuminuria or protein (as a marker of kidney disease)
•Medication refill:
□ cooler/refrigerator or other method of storing (specify: _________)
□ Insulin vial
□ Insulin syringes
□ Lancets
□ Needles
□ glucometer
□ glucometer strips
□ book for logging BS
•Referrals: □ ophthalmology □ dietician □ social work □ other: _______________
Insulin start doses
• Estimate Total daily dose (TDD) of insulin:
– <3y:
0.3U/kg/day
– 3-12 y: 0.5-0.8 U/kg/day (always err on the lower side first, go
up later as needed)
– 12-16y: 0.8-1 U/kg/d
– >16y:
0.8 U/kg/d
• Using 70/30 insulin (70% NPH and 30% Regular) give:
– AM dose: 2/3 TDD before breakfast
– PM dose: 1/3 TDD before supper
Insulin start doses
Example:
• 10 year old boy with first manifestation of
type 1 diabetes who weighs 30kg
• TDD= 0.5 U/kg/day=0.5x30= 15U per day
• AM dose= 2/3 x 15U= 10U
• PM dose= 1/3 x 15U= 5U
Goal blood sugars
• Generally: the younger the child, the higher
• If child has food security and can measure
RBS:
– 150-200 in young children
– 100-200 in older children
• If child has no food security, no RBS:
– 150-250 in all children
General Principles before making
adjustments:
• Check for external factors of different demand:
– Has the insulin consistently been properly stored?
– Has a new vial recently been opened?
– Is the patient repeatedly using the same injection sites?
Look for signs of lipohypertrophy!
– Is the patient using the right type of insulin and the right
dosages?
– Has there been a change in the caregiver who provides the
insulin (and may not know the right doses)?
In all these cases DO NOT change dose but readjust
external factor and follow up with patient whether
glycemia improves
General Principles before making
adjustments:
• Check for causes of different demand:
– Is the patient entering his/her “honeymoon”phase
– Has the patient been ill?
– Has the patient made a change to their diet?
(quantity, types of foods, frequency of meals)
– Have they made changes in their level of exercise?
• More exercise  less insulin required  lower sugars
• Less exercise  more insulin required  higher sugars
Adjusting the dose:
• Find a pattern of high/low sugar levels
– Sugars high or low in the MORNING  adjust PM dose
– Sugars are high or low in the EVENING  adjust the AM dose
• Adjust one dose (AM or PM) at one time, unless ALL sugars
are >300 or persistent symptoms of hyperglycemia
• Do not adjust the insulin dose by more than 10%
• Wait 2-3 days before making a new change to a change that
was just made
– UNLESS the patient is having hypoglycemia after a dose increase
 change back to lower dose
• Upon changing a dose:
– Have patient measure sugars for a minimum of 2 days (in AM
and PM)
– call or return to clinic to see if a readjustment is needed
Adjusting the dose
• Example:
• 10year old 30kg boy in the above example
who takes 10U in AM and 5U in PM.
• All his sugars are HIGH (>250) in the morning…
you would increase the PM dose by 10% of 5U
= 0.5U and thus increase his PM dose to 5.5U
No blood sugars?
In patients who are not checking blood sugars:
• Base your adjustment on clinical symptoms and a
blood sugar check, urine glucose and urine ketones in
the clinic  increase AM and/or PM dose by 10% if all
of these are indicative of hyperglycemia
• If the patient has persistent polyuria, polydipsia,
polyphagia, you should increase the AM and/or PM
dose by 10%
• Have the patient check in with you frequently (if
necessary every 2 days) after any change to see if they
are improving
• Provide teaching about hypo/hyperglycemia symptoms
Example 1
• 4yo girl, weighs 15kg, AM=4U, PM=3U.
DATE
AM
MON
Lunch
PM
2AM
200
330
-
TUE
220
350
-
WED
180
 Patient is running high in PM
adjust AM dose by 10% (=0.4U), round to
0.5U and give 4.5U in AM, 3U in PM
 re-calculate TDD/kg/day: 7.5U/15kg=0.5U
Example 2
• 13yo boy, wt 40kg, AM dose=14U, PM dose=10U
DATE
AM
MON
Lunch
PM
2AM
--
350
--
TUE
380
400
--
WED
--
Overall running high, but few values!
 adjust AM dose by 10% (=1.4U) can round to 2U
and give 16U in AM
 TDD = 26U/40kg = 0.65U/kg/day
Follow up in 2days , give your phone number for
earlier problems
Example 3
• 6yo girl, wt 20kg, AM dose=8U, PM dose=4U
DATE
AM
MON
Lunch
PM
2AM
--
--
--
TUE
--
--
--
WED
--
Ask about symptoms!!
Check RBS, urine glucose and urine ketones!!
Educate about need to check sugars 2d before
coming to clinic
Adjust only if patient persistently hyperglycemic
and above tests are suggestive of hyperglycemia
TDD = 12U/20kg = 0.6U/kg/day