Approach to DM patient
Dr.Mohammed Almansour
MRCGP(INT),ABFM,SB-FM
Assistant professor ,Majmaah University
 What are the questions you should ask diabetic patient?
 Current acute symptoms
 Diabetes symptoms
 Compliance to Rx,lifestyle change,diet
 Complication of DM
 Comorbid disease
 Risk factors
 ICEE????
Medical history
 Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic
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laboratory finding)
Eating patterns, physical activity habits, nutritional status, and weight history;
growth and development in children and adolescents
Diabetes education history
Review of previous treatment regimens and response to therapy (A1C records)
Current treatment of diabetes, including medications, medication adherence
and barriers , meal plan, physical activity patterns, and readiness for behavior
change
Results of glucose monitoring and patient’s use of data
DKA frequency, severity, and cause
Hypoglycemic episodes
Hypoglycemia awareness
Any severe hypoglycemia: frequency and cause
 History of diabetes-related complications
 Microvascular: retinopathy, nephropathy, neuropathy
(sensory, including history of foot lesions; autonomic,
including sexual dysfunction and gastroparesis)
 Macrovascular: CHD, cerebrovascular disease, and PAD
 Other: psychosocial problems, dental disease
Physical examination
 Height, weight, BMI
 Blood pressure determination, including orthostatic
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measurements when indicated
Fundoscopic examination
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection
sites)
Comprehensive foot examination
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Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament
sensation
complications
 Macrovascular vs microvascular
 macrovascular:
 CHD
 Peripheral vascular diseases
 cerebrovascular disease
Risk Factors:
obesity, hypertension, dyslipidemia, smoking
 Microvascular:
 Retinopathy
 Nephropathy
 Neuropathy
Nephropathy
 How to monitor it?
 A/C Ratio
 How frequent?
 Prevention?
Neuropathy
 Foot examination:
 Guidelines from ADA recommend performing a
comprehensive foot examination annually on patients with
diabetes to identify risk factors predictive of ulcers and
amputation
 should include inspection, assessment of foot pulses, and
testing for loss of protective sensation
Advice for prophylactic foot care
 Avoid going barefoot, even in the home.
 Test water temperature before stepping into a bath.
 Trim toenails to shape of the toe; remove sharp edges with a
nail file. Do not cut cuticles.
 Wash and check feet daily.
 Shoes should be snug but not tight and customized if feet are
misshapen or have ulcers.
 Socks should fit and be changed daily
Monitoring blood glucose
 American Diabetes Association recommends the following
 Aim to achieve normal or near normal glycemia with an A1C
goal of <7 %. More stringent goals (ie, a normal A1C, <6.5
%) can be considered in individual patients. Less stringent
treatment goals (eg, <8 %) may be appropriate for patients
with a history of severe hypoglycemia, patients with limited
life expectancies, older adults, and individuals with comorbid
conditions.
 Obtain an A1C at least twice yearly in patients who are
meeting treatment goals and who have stable glycemic
control, and quarterly in patients whose therapy has changed
or who are not meeting glycemic goals
management
 Non pharmacological:
 Dietary modification
 Exercise
 Weight reduction
 Pharmacological:
 Metformin : ADA and EASD conclude that metformin therapy
should be initiated concurrent with lifestyle intervention at the
time of diagnosis
 Many types of oral hypoglycemic agents
 Insulin therapy with its various types and route of
administration
Tailored management
 Well control
appreciate ,continue,consider
step down
 Uncontrolled
search why?,reach a deal with
patient,consider alternative/addition/shifting
 Complicated
glycemic control /referral
 Resistance
confirm,referral
Guidelines
 American Diabetes Association (ADA)
 European Association for the Study of Diabetes (EASD)
 NICE
References
 Uptodate
 ADA 2013
Thank you