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DIABETES: ROUTINE CAREAssess the patient with diabetesAssess When to assess NoteSymptoms Every visit Manage symptom as on symptom page. Ask about chest pain 15 and leg pain 36.BP Every visit Diagnose hypertension if > 140/80 on 2 days. Treat to target: 120/70–140/80 74.BMI At diagnosis, yearly or 3 monthly if trying to lose weight BMI is weight (kg)/[height (m) x height (m)]. Aim for BMI < 25.Waist circumference At diagnosis, yearly or 3 monthly if trying to lose weight Aim for < 80cm in woman and < 94cm in man.Pregnancy status Every visit Discuss family planning needs 91. Refer for specialist care if pregnant.Eyes for retinopathy At diagnosis, yearly and if visual problems develop Refer if new diabetes diagnosis, visual problems, cataracts or retinopathy.Feet At diagnosis, 3 months, then yearly, more often if high risk Check for pain, pulses, sensation, deformity, skin problems. For foot screen and foot care education 37.Random glucose Every visit Finger prick sample is adequate. See below: aim for < 8.Protein on urine dipstick At diagnosis and yearly • If no protein on dipstick, send urine to lab for microalbuminuria.• If albuminuria or proteinuria: start enalapril 10mg daily regardless of BP. Doctor to increase to 20mg after 1 month.Ketones on urine dipstick If glucose ≥ 15 If glucose ≥ 15 and ≥ 1+ ketones, see below.HbA 1c6 monthly if HbA 1c< 7% but 3 months after treatmentchangeAim for HbA 1c< 7%. HbA 1creflects glucose control over past 3 months. See below.eGFR At diagnosis and yearly Give patient’s age and sex on form. If eGFR < 60, refer to doctor.Fasting total cholesterol, triglycerides At diagnosis if not already done. Refer to specialist if total cholesterol ≥ 7.5 or triglycerides ≥ 15.Check random finger prick glucose at every visit and HbA 1c6 monthly if HbA1c ≤ 7% but 3 months after change in glucose-lowering treatment.Glucose < 4With/without hunger, palpitations,sweating, tremors, fatigue,headache, mood changes, fits,confusion, drowsiness, coma.• Give sugar water orally orif coma give 50ml dextrose50% IV. Repeat if glucose < 4.• Identify cause and educateabout meals and doses 72.• Refer same day if incompleterecovery or on glibenclamideor long-acting insulin.Continue 5% dextrose water1l 6 hourly IV.• Review in 6months.• Check HbA 1cyearly.Glucose 4–14.9Review HbA 1cresult from within past 3 months.HbA 1c≤ 7% or not done in past 3 months HbA 1c> 7%Glucose < 8 Glucose 8–14.9No HbA 1c< 3 monthsCheck HbA 1c.Review in1 month.HbA 1c≤ 7%Reviewin 3months.• Not adherent: educateand review in 1 month.• Adherent: step uptreatment and review in1 month 72.Glucose ≥ 15Is there any of nausea, vomiting, abdominal pain, hyperventilation,difficult breathing, dehydration, fever, drowsiness, confusion, coma?No - check urine for ketonesNo/≤ 1ketones> 1+ ketones:• Give sodiumchloride 0.9%1l 4 hourly IVand 10IU shortactinginsulinIM 1 (not IV).• Refer same day.Yes• Rehydrate urgently:sodium chloride 0.9%IV (1.5l in first hour, 1lover next 2 hours andcontinue 1l every 2hours).• Give 10IU short-actinginsulin IM 1 (not IV).• Refer urgently tohospital: avoid delay.1Do not give IV insulin without checking electrolytes, as it may cause low potassium and heart dysrhythmia.71