The Diabetic Patient: A Clinical Approach

Diabetes Mellitus is a metabolic disorder affecting millions of people across the globe. We as doctors and medical students should know these patients from A-Z. The following is a quick review of points to remember when approached by someone with diabetes in your clinic.

History: Take a normal history as with any other patient, but keep these points in mind...

Hypoglycemia- tremors, fatigue, palpitations, sesting, coma
Neuropathy- calf muscle pain, burning muscles, "losing shoes"
Nephropathy- decreased urine output, frothy urine, periorbital swelling, recurrent UTI
Cardiovascular- pain, dyspnea, loss of breath
Retinopathy- blurry vision, halos, spots
Autonomic- orthostatic hypotension, GIT disturbances, recurrent infections
Dermopathy- poor wound healing


Investigations: (for the known diabetic)

Fasting blood sugar- <110>125 is established diabetes
Lipid profile- ALT and SGPT every 6 months
Urine DR in special regards for microalbuminuria (<200>200 is irreversible).
Creatinine clearance
Serum creatinine and Urea
ECG
Fundoscopy


Examinations: Perform foot, abdominal, CVS, respiratory, 3rd 4th 6th 7th cranial nerves, and check of dehydration.

Particularly in Foot examination:
Inspection- look for discoloration, ulcers, callus', skin changes, loss of shin hair, cuts, and bruises. Pay special attention to the intertarsal spaces.
Palpation- pedal edema, vibration (this is usually the first sense to be compromised in 'diabetic foot'- diabetic neuropathy), proprioception, temperature, touch, reflexes, pulses.


Diet: The following diet pertains particularly to those patients from the Indian subcontinent. Please refer to a diabetic book for patients of other ancestry.

Contraindications- bakery sweets, white bread, white a'ata (use chokaar instead), rust, cold drinks (sodas), sharbaats, gosht, biryani, mattar plow, biscuits, jam, jelly, honey, red meat.

Foods that help-
chaana with chai, boiled eggs, akhroat, dhalia, omega 6 fatty acids (fish and walnut).

Keep in mind-
eating 1/2 cup rice is okay but only once a day, oil should be decreased in all foods, dhai with no sugar or malai, only 1 fruit is allowed per day.


Management:
Management of diabetes varies from patient to patient. Please refer to medicine books for details.


Diabetic Emergencies:

Diarrhea and vomiting can cause uremia leading to hiccups.
Acute renal failure
Diabetic ketoacidosis- Patient is usually young with Type I DM.
Hyperosmotic nonketotic diabetic coma causes high bloog glucose levels and dehydration

Plasma osmolarity can be calculated by the following equation: (normal is 275-290 mmol)
Plasma osmolarity = (sodium x 2) + (BUN / 2.8) + (blood glucose / 18)

Managed initially by I/V insulin and isotonic saline. Followed by dextrose with insulin to allow for intracellular free water absorption.
Check blood pressure for orthostatic hypotension.

Further investigations: CBC, blood culture, urine culture, head to toe examination for signs of infection.


Note: The following was just a quick review of what to expect when dealing with a patient with known diabetes mellitus. Please refer to a textbook for further details.

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