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Diabetes - Follow Up of Patients with Established Diabetes

Diabetes - Follow up of Patients with Established Diabetes

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Introduction

Once diabetes has been diagnosed and an initial treatment plan drawn up there is a need to enter into regular, planned follow up. 

The aims of diabetes follow up are:

To deal with any current problems relating to control or other issues

To optimise control of blood glucose, blood pressure and lipids

Surveillance for complications of diabetes

Management of known complications

Ongoing updating on current diabetes education

Motivation and empowerment around self management

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Annual Review

 

The need for regular surveillance for complications and for review of glycaemic control has lead to the concept of the annual review in diabetes care: this is a convenient way of ensuring that the various elements which need reviewing are completed and are not missed out. 

 

The purpose of the review is to guide management and highlight necessary change: the collection of the data is to allow this to be done effectively.

  The key elements of any review are to:
  Measure and Examine
 

Discuss and Educate
 

Set Targets and Manage Actively
 

Agree a Review

   
  Checklist
  Measure & Examine:
 
 

Measure

 

 

Examine
 

Weight / BMI

   

 

 

Feet

Learn More
 

Waist circumference

Learn More

 

 

Eyes (usually done as part of Retinal Screening Service)

Learn More

 

Blood pressure

Learn More

 

 

Injection sites (if on insulin)

   

 

Haemoglobin A1C

Learn More

 

 

 

   
 

Serum Creatinine / eGFR

Learn More

 

 

 

   
 

Lipid profile

Learn More

 

 

 

   
 

Microalbuminuria

Learn More

 

 

 

   
   
   
   
  Discuss and Educate:
 

Issues raised by patient

 

Review progress towards previously agreed goals

 

Current control and concordance with current medication

 

Diet and exercise

 

Explain test results and examination findings

 

Smoking / alcohol (if relevant)

 

Pre-conception / Contraception (if relevant)

  Educational update
     
  Set Targets and Manage Actively:
 

Assess findings of annual review against evidence base and personal agenda

 

Prioritise and plan: agree and record goals for ongoing care.

 

Agree medication (if relevant)

     
  Agree a Review:
 

Achieving targets may need repeated titration steps.

 

The goals set will determine the nature and timing of the next planned contact.

 

Arrange next contact / appointment
   

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What Care to Expect

(see - the Diabetes UK Guide in the Useful Resources and Links section ).
 
  What to expect when your diabetes is reasonably controlled:  
     
 

Once your diabetes is reasonably controlled, you should:

 
     
 

Have access to your diabetes care team at least once a year — in this session, take the opportunity to discuss how your diabetes affects you as well as your diabetes control.

 
     
 

Be able to contact any member of your diabetes care team for specialist advice, in person or by phone.

 
     
 

Have further education sessions when you are ready for them.

 
     
 

Have a formal medical annual review once a year with a doctor experienced in diabetes.

 
     
 
  What to expect on a regular basis:  
     
 

On a regular basis, your diabetes care team should:

 
 

 

 
 

Provide continuity of care, ideally from the same doctors and nurses — if this is not possible, the doctors or nurses who you are seeing should be fully aware of your medical history and background.

 
 

 

 
 

Work with you to continually review your care programme, including your diabetes management goals.

 
 

 

 
 

Let you share in decisions about your treatment or care.

 
 

 

 
 

Let you manage your own diabetes in hospital after discussion with your doctor, if you are well enough to do so and that is what you wish.

 
 

 

 
 

Organise pre and post pregnancy advice, together with an obstetric hospital team, if you are planning to become or already are pregnant.

 
 

 

 
 

Encourage a carer to visit with you, to keep them up to date on diabetes so that they can make informed judgements about diabetes care.

 
 

 

 
 

Encourage the support of friends, partners and/or relatives.

 
 

 

 
 

Provide you with educational sessions and appointments if you wish.

 
 

 

 
 

Give you advice on the effects of diabetes and its treatments when you are ill or taking other medication.

 
     

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What to Expect at Your Annual Review

 
  Annual Review Checklist  
     
 

It is important to remember that your annual review is to enable you to lead a normal and healthy life. It must be about what you want and need as well as what healthcare professionals recommend.

 
     
 

The following should be checked at least once a year:

 
   
 

Laboratory Tests and Investigations:

 
       
 

Blood glucose control: an HbA1c blood test will measure your long-term blood glucose control. The range to aim for should be 6.5 per cent or below.

 
     
 

Kidney function: urine and blood tests to check for protein will show that your kidneys are working correctly. There should not be any protein in your urine.

 
     
 

Blood fats (lipids, cholesterol and triglyceride levels): a blood test that measures your blood fat levels. A total cholesterol of below 4.0mmol/l or less and a fasting triglyceride of 1.7mmol/l or below are accepted as national target ranges.*

 
     
 

* Please note all normal and good ranges will vary from person to person — it is meant to be a guide so you know what to aim towards. If you have any questions, ask your diabetes care team.

 
     
 

Physical Examinations:

 
     
 

Weight is often calculated as a Body Mass Index (BMI) which expresses adult weight in relation to height. From this you will be advised if you need to lose weight to better control your diabetes. Your GP will record your BMI in your notes.

 
     
 

Legs and feet should be examined to check your skin, circulation and nerve supply. If necessary, you should be referred to a state registered chiropodist/podiatrist.

 
     
 

Blood pressure should be taken. You should aim for your blood pressure to be at or less than 130/80. If it is at higher levels discuss this with your doctor to discuss why your blood pressure may be high. Keeping your blood pressure down has been proven to be beneficial for people with diabetes (UKPDS research trails).

 
     
 

Eyes should be examined regularly through a ‘fundoscopy’ review where your pupils are dilated to enable your optometrist/ophthalmologist to detect any early changes at the back of the eye (retinopathy). Photographs may be taken to record the appearance at the back of your eyes.

 
     
 

If you’re on insulin, your injection sites should be examined.  
     
 

Lifestyle Issues:

 
 

The review should also provide enough time to discuss:

 
 

Your general wellbeing; how you are coping with your diabetes at home, work, school or college.

 
     
 

Your current treatment.

 
     
 

Your diabetes control, including your home monitoring results and hypos.

 
     
 

Any problems you may be having.

 
     
 

It should include discussion about smoking, alcohol consumption, stress, sexual problems, physical activity and healthy eating issues. You should feel free to raise any or all of these issues with your diabetes care team.

 
     

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Useful External Links & Resources
 

PDF File

Diabetes UK |  What Care To Expect Leaflet

 

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