Poorly controlled diabetes

Question 1

a 43 year old male has had type 2 diabetes mellitus since he was 28. he has not worried about it. he reports burning in his feet at night that keeps him awake. his BMI is 38, bp164/92mmhg and urine ACR 14 mol/L (<2.5) How would you manage him?`

Answer 1

Impression
In the setting of poorly controlled diabetes it is likely that this patient has developed microvascular complications of diabetes including peripheral neuropathy with the burning feet and diabetic nephropathy with the elevated uACR. Concerned about micro and microvascular complications in this patient.

Other causes of peripheral neuropathy;

• Alcohol neuropathy
• B12/folate deficiency

Goals of management include;

• Thorough Hx/Ex/Ix to determine extent of diabetes complications
• Escalation of pharmacological treatment for better diabetes control, optimisation of non-pharm mx options, specific treatment for peripheral neuropathy pain.
• referral to specialty including ophthalmology and endocrine as necessary, patient education and counselling, then appropriate follow-up/review interval

Question 2

Diabetes - History

Answer 2

History

• sx: polydipsia, polyphagia, polyuria. as about peripheral neuropathy, SOCRATES, how high-up, any walking problems, ulcers?
• complications: visual changes, headaches, urinary changes
• CVD risk: HTN, obesity, sedentary, smoking, alcohol, fam hx, past history
• PMHx, SNAP
• 5A’s for readiness for change

Question 3

Diabetes - Examination

Answer 3

Examination

• General appearance + vitals
• Anthropometric - confirm BMI and baseline
• Cardiovascular exam
• LL neuro and peripheral neuropathy exam
• skin: acanthuses nigricans
• eyes: fundoscopy for DR

Question 4

Diabetes - Investigations

Answer 4

Investigations

• Bedside: uACR, urinalysis
• Bloods: FBC, UEC, LFT, lipid panel, HbA1C, fasting BSL
• Imaging: nil relevant for monitoring
• Other

Question 5

Diabetes - Management

Answer 5

Management
Supportive
- Counsel on need for diabetes control
- peripheral neuropathy may improve but could be permanent
- Need for non-pharm and pharm interventions to control

Non-pharm

• lifestyle mods
• allied health input (educator, nurse, etc)

Pharm
- escalate diabetes management

Peripheral neuropathy
Pharmacological;
- Amitryptilline
- Pregablin/Gabapentin
- Duloxetine

Ongoing
- regular review, bloods, GP F/U