Type 2 Diabetes

Question 1

“John is a 54-year-old man with type 2 diabetes. He presents for yearly review.

Impression/Complications/DDx/Goals

2020: 62F, well, lost 4kg in 1 year, walks 5 days a week, quit smoking last year. diagnosis of T2DM managed on metformin 500mg BD, HT ramipril 5mg. BP 135/85 today. What are the complications of DM? What examinations and investigations would you do to monitor for these complications? How often would you want to see this patient? Who else does this person need to see in management?”

Answer 1

Impression/Complications:
Review of Type 2 Diabetes. Important complications to consider;

Macrovascular
- CVA
- IHD
- PVD (contributes to poor wound healing)
Microvascular
- Diabetic nephropathy (cause of nephrotic syndrome)
- Diabetic retinopathy (CMO, blindness)
- Neuropathy (inadequacy of vasovasorum +/- osmotic damage); peripheral neuropathy, mononeuropathy

Also want to consider risk of HHS/DKA or euglycaemic DKA in T2DM patients

Goals:

• screen for diabetic complications
• review current management plan and progress
• review individualised glycaemic targets

Question 2

T2DM - History

Answer 2

History:

• Sx of hyperglycaemia (polydipsia, polyuria, polyphagia)
• Sx of HHS/DKA: headache, confusion, lethargy
• Other: wounds, neuropathy, visual changes
• record of glycaemic control
• PMHx, FamHx, medications
• SNAP - review of lifestyle mods

Question 3

T2DM - Examination

Answer 3

Exam:

• baseline obs: height, weight, waist circumference
• Cardio exam: BP, HR, heart sounds,
• LL neuro exam: peripheral neuropathy
• Other: acanthosis nigricans,
• Foot check
• Fundoscopy (DR)

Question 4

T2DM - Investigations

Answer 4

Investigations:
Centred around monitoring glycaemic control and diabetes complications
Bedside: vitals, absolute CVD risk calculation, uACR
Bloods: HbA1c, FBC, lipid panel, UEC, LFT (NAFLD)
Imaging: not indicated routinely

Question 5

T2DM - Management

Answer 5

Non-pharm:
Lifestyle modifications
- Diet: low carb/keto
- Exercise: regular, 30 min/ day

Pharm
Titrate according to current glycaemic control, refer to glycaemic targets on eTG (varies depending on level of control/presence of other risk factors)
- Metformin
- DPP4
- GLP-1 analogue
- SGLT2
- Sulphonylurea
- Insulin

Review/Referral

• R/V every 3 months for repeat of bloods
• referrals to; endocrinologist, diabetes educator, podiatrist, optometrist, other allied health

Safety-netting
- to present to ED if symptoms of HHS/DKA - confusion, loss of consciousness, nausea/vomiting, etc