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Toronto Notes 2019
Common Presenting Problems
Family Medicine FM23
Assessment and Monitoring
Table 13. Assessment and Monitoring
History
Physical Exam
Investigations
Management
Initial Assessment
Symptoms of hyperglycemia, ketoacidosis, hypoglycemia Past medical history Functional inquiry
Family history Risk factors Medications Sexual function Lifestyle
General: Ht, Wt, BMI, BP, WC
Head and neck: fundoscopy, thyroid exam
Cardiovascular exam: signs of PVD, pulses, bruits
Abdominal exam (e.g. for organomegaly) Hand/foot/skin exam
Neurological exam
FBG, HbA1c, fasting lipids, Cr, microalbumin:creatinine ratio Baseline ECG; repeat testing q2yr for those at high risk
Nutritional and physical education Consider referral to DM
education program if available Monitoring BG: explain methods and frequency
Medication counselling: oral hypoglycemics and/or insulin, method of administration, dosage adjustments Pneumococcal vaccination Ophthalmology consult
type 1 DM within 5 yr type 2 DM at diagnosis
q2-4mo
DM-directed history
Screen for awareness and frequency of hypoglycemia and DKA
Glucose monitoring
Use of insulin and oral agents Smoking cessation
Wt, BP, BMI, WC
HbA1c q3mo FBG as needed
Assess progress towards long- term complications
Adjust treatment plan if necessary
Annually
DM-directed history
Screen for awareness and frequency of hypoglycemia and DKA
Glucose monitoring
Use of insulin and oral agents Sexual function
Lifestyle counselling
Screen for depression
Foot exam for sensation (using a 10 g monofilament), ulcers or infection
Remainder of exam as per PHE
Fasting lipid profile
Annual random ACR and eGFR
Calibrate home glucose monitor Arrange retinopathy screening Influenza vaccination annually
Calculate Total Insulin Required
type 1 DM: 0.5-0.7 units/kg/d type 2 DM: 0.3 units/kg/d
Dietary Advice for Treatment of Type 2 DM in Adults
Cochrane Database Syst Rev 2007;3:CD004097 Purpose: To assess the effects of type and frequency of different dietary advice strategies for adults with type 2 diabetes.
Methods: Systematic review of RCTs with follow- up of 6 mo or longer, where dietary advice was the main intervention.
Results: 36 RCTs with 1,467 participants were included, all measuring weight and glycemic control measures, and some reporting mortality, blood pressure, serum cholesterol and triglycerides, maximal exercise capacity and compliance. No data was available for efficacy of dietary advice in terms of dietary changes. Adoption of regular exercise was found to promote HbA1c glycemic control in type 2 diabetic patients.
Conclusion: No high-quality data is available for the efficacy of dietary treatment of type 2 diabetes, though exercise has been shown to improve HbA1C at 6 and 12 mo follow-up in patients.
Nonpharmacologic Management
• diet
■ can reduce HbA1c by 1-2%
■ moderate weight loss (5%) improves glycemic control and CVD risk factors
■ all diabetics should see a registered dietician for nutrition counselling
■ decrease combined saturated fats and trans-fatty acids to <10% of calories
■ avoid simple sugars, choose low glycemic-index foods, ensure regularity in timing and spacing of
meals
• physicalactivityandexercise
■ at least 150 min of aerobic exercise plus 2 sessions of resistance training per wk is recommended
■ encourage 30-45 min of moderate exercise 4-7 d/wk
■ promote cardiovascular fitness: increases insulin sensitivity, lowers BP, and improves lipid profile
■ if using insulin, may require alterations of diet, insulin regimen, injection sites, and self-monitoring
Self-Monitoring of Blood Glucose
• type1DM:3ormoreself-tests/disassociatedwitha1%reductioninHbA1c
• type2DM:recommendationsvarybasedontreatmentregimen(e.g.insulindependentrequiresmore
frequent monitoring – refer to 2013 Canadian Practice Guidelines)
• ifFBG>14mmol/L,performketonetestingtoruleoutDKA
• ifbedtimelevelis<7mmol/L,havebedtimesnacktoreduceriskofnocturnalhypoglycemia