2024 Diabetes History Lecture PDF

2024 25 History Taking in Patients with Type 2 Diabetes DEM2: EndoBreast Dr Shane Dunlea Clinical Lecturer Department of General Practice Dr Abeer Khalaf Family Medicine Lecturer RCSI Bahrain LEARNING OUTCOMES Students will be able to : Identify and assess key components of a diabetes hi...

2024 25 History Taking in Patients with Type 2 Diabetes DEM2: EndoBreast Dr Shane Dunlea Clinical Lecturer Department of General Practice Dr Abeer Khalaf Family Medicine Lecturer RCSI Bahrain LEARNING OUTCOMES Students will be able to : Identify and assess key components of a diabetes history, including the duration of the disease, family history, symptoms, and complications. Take a thorough medical history, including comorbidities, medications, and lifestyle factors that may impact diabetes management  HISTORY TAKING FUNDAMENTALS REVISITED… The heart of patient care Helps lead to diagnosis in approx. XX% of cases The power of language (see additional reading slides) As always – Be respectful – Be present (active listening) – Be professional – Be kind – Do not judge COMMUNICATION SKILLS Calgary Cambridge Consultation Model: Summary HISTORY TAKING SEQUENCE 1. Introduction and Consent 2. Presenting Complaint 3. History of Presenting Complaint 4. Past History - Medical History, Surgical History 5. Medications 6. Allergies 7. Social History 8. Family History Systems Review Summary Differential Diagnosis Management Plan  TYPE 2 DIABETES IN PRIMARY CARE Increasing prevalence of DM, 90% of these T2DM – In Ireland: ▪ affects 10% of adults > 50 ▪ 16% of adults > 80 ▪ a further 6% of adults pre-diabetic Majority (approx. 90%) of T2DM managed in primary care 20% of people with Diabetes are undiagnosed... 1. PRESENTING COMPLAINT Presenting complaints in the patients with T2DM might include: I. New Diagnosis - Symptomatic or Asymptomatic II. Symptoms/Complications of Diabetes Including (but not limited to) symptoms relating to: – Hyperglycaemia – Hypoglycaemia – Macrovascular complications – Microvascular complications – Therapeutic related complications – Others…e.g. infections etc etc  HISTORY TAKING IN DIABETES i. New Diagnosis Symptomatic patient (Hyperglycaemic symptoms) Consider how you might ask about the classical symptoms of: – Polyuria – Polydipsia – Weight loss – Polyphagia – Blurred vision – Fatigue/weakness Asymptomatic patients – Incidental finding: – Patients may present with complications of T2DM rather than classic hyperglycaemic symptoms HISTORY TAKING IN DIABETES ii. Pre-existing Diabetes 1. Establish the type of diabetes the patient has 2. Establish their level of control 3. Symptoms/ complications of diabetes HISTORY TAKING IN DIABETES ii. Pre-existing Diabetes 1. Establish the type of diabetes the patient has – If the patient is unsure or their answer seems less likely, you can ask if they were started on medication at time of diagnosis – If the answer is no > T2DM more likely (diet controlled) – If answer is yes –> what medication were they started on? – If answer is oral hypoglycaemics (tablets) –> T2DM – If answer is insulin (s/c injection) –> most likely T1DM 2. Establish their level of control 3. Symptoms/ complications of diabetes  HISTORY TAKING IN DIABETES ii. Pre-existing Diabetes 1. Establish the type of diabetes the patient has 2. Establish their level of control Consider how you might ask about this: – e.g. "What /When was your last HbA1C? " comparison to previous readings? stable/ better/worse? – Do you check your blood sugars (BMs)? Not all T2DM patients do. If yes: "Is your Dr. happy with the readings?" – Do you attend a GP / an endocrinologist (‘diabetes doctor’) for care? – Previous hospitalizations? Have you ever been admitted to hospital because of your diabetes? – If yes why? (?DKA/HHS/Infection/ ulcer/Other) 3. Symptoms/ complications of diabetes HISTORY TAKING IN DIABETES ii. Pre-existing Diabetes 1. Establish the type of diabetes the patient has 2. Establish their level of control 3. Symptoms/ complications of diabetes – Hyperglycaemia – Hypoglycaemia – Macrovascular complications – Microvascular complications – Therapeutic related complications – Others…e.g. infections etc etc II. PRE-EXISTING DIABETES KEY QUESTIONS 3. SYMPTOMS/ COMPLICATIONS OF DIABETES HYPERGLYCAEMIA Consider how you might ask about the classical symptoms of hyperglycaemia? – Polyuria – Polydipsia – Weight loss – Polyphagia – Blurred vision – Fatigue/ weakness II. PRE-EXISTING DIABETES KEY QUESTIONS: 3. SYMPTOMS/ COMPLICATIONS OF DIABETES HYPOGLYCAEMIA Generally more relevant in T1DM patients, but can also occur in T2DM on certain medications. "Have you ever had a hypoglycaemic episode/low blood sugars?“ ▪ If YES: "Do you know when your blood sugars are low?“ (i.e. do they get symptoms/ hypoglycemic awareness?) What symptoms do you get? How do you treat yourself? Have you ever needed assistance treating an episode? Not having hypoglycemic awareness is dangerous as patients will not treat the hypoglycemia! → altered mental state/ coma/ driving implications etc. II. PRE-EXISTING DIABETES KEY QUESTIONS DIABETIC SYMPTOMS/COMPLICATIONS: SCREENING FOR COMPLICATIONS If screening for complications it can be helpful to categorise in terms of: – Microvascular complications Smaller bloods vessels: Kidneys/ eyes/ neuropathy – Macrovascular complications Larger blood vessels: CV/ PVD – Other (see slide in Additional Resources at end of ppt) II. PRE-EXISTING DIABETES KEY QUESTIONS MICROVASCULAR DIABETIC COMPLICATIONS 1 When taking a history in patient with DM consider how you might ask if patient has any symptoms suggestive of microvascular complications e.g. "I would like to ask you some questions about symptoms some people with diabetes have. Have you..." Ophthalmological/Diabetic Retinopathy e.g. "Any changes in your vision /sight/ floaters/ previous laser treatments?" Kidney/Diabetic nephropathy Often asymptomatic, e.g. hypertension/ proteinuria – e.g. "Has doctor ever mentioned any kidney problems? " II. PRE-EXISTING DIABETES KEY QUESTIONS MICROVASCULAR DIABETIC COMPLICATIONS CONTINUED... e.g. "I would like to ask you some questions about symptoms some people with diabetes have. Have you..." Neuropathy – e.g. "Any pins and needles/numbness/pain in your legs or arms" – Autonomic neuropathy: Consider how you would ask about... CV: orthostatic hypotension symptoms/ e.g. lightheaded on standing GI: e.g. gastroparesis: e.g. any nausea/early satiety, GI upset Sudomotor: e.g. dry skin/ increased sweating II. PRE-EXISTING DIABETES KEY QUESTIONS MACROVASCULAR DIABETIC COMPLICATIONS When taking a history in a patient with DM consider how you might ask if patient has any macrovascular complications/symptoms e.g. "I would like to ask you some questions about symptoms some people with diabetes have. Have you..." – Coronary arteries: e.g. "Have you experienced any chest pain/ shortness of breath/ SOBOE/ swelling of your lower legs?" – Carotid arteries: e.g. "Have you experienced any dizziness/passed out or felt like you might pass out/ previous TIA or stroke/ memory issues?" – Peripheral arterial disease (PAD): e.g. "Have you experienced any symptoms in your legs such as...?" – Specify re symptoms of intermittent claudication symptoms/ rest pain, ulcers etc. “any issues with erectile dysfunction?" etc. II. PRE-EXISTING DIABETES OTHER DIABETIC SYMPTOMS/COMPLICATIONS Time allowing Other T2DM Symptoms Consider how you might ask about these symptoms? "I would like to ask you some questions about symptoms some people with diabetes have. Have you previously experienced..." – Infections Poor wound healing, cellulitis etc. GU infections: – Urinary tract infections – Candidiasis (Thrush )(Oral/PV/ penile) ENT – rare cx: necrotizing otitis externa) etc. 4. PAST MEDICAL HISTORY – Open Questions “How is your health otherwise?” "Do you have any medical diagnoses/ previous surgeries?“ – Closed Questions Consider what comorbidities you might find in patients with T2DM e.g. "Have you ever been diagnosed with high blood pressure/ high cholesterol" etc. Common Comorbidities associated with T2DM include: – Hypertension: "do you know what your last BP was/when was it last checked?“ Have you had a 24-hour blood pressure monitor? When? – Dyslipidemia: "do you know what your last cholesterol level was/when was it last checked? Has it been steady/improving/getting worse?" – CKD : "Do you know what your last kidney function test showed? – MSK: "Do you suffer from back pain/gout?" etc. 4. PAST MEDICAL HISTORY... Closed questions continued Other common comorbidities Include....: – Obesity: – "Has your doctor been monitoring your weight/ BMI? Has it been steady/increasing/ decreasing? – OSA (Obstructive sleep apnoea) 1 (18-86%): "Do you snore? Has your partner noticed gaps in your breathing during the night? Are you very fatigued during the day?" – Depression 2 (RR :2-3): "How is your mood/energy/ do you enjoy your usual hobbies?" 5. MEDICATIONS (SEE PHARMACOLOGY LECTURES FOR FURTHER INFORMATION) What medications do you take for your diabetes? T2DM medications – How many times a day (OD/BD/TDS) – What dose – Any recent changes? Compliance/ Adherence – Do you often miss any doses of your medications – If so, why? ( SE/s Tolerability?/ Forgetfulness ?) Metformin (Glucophage) Class Biguanide Most commonly used medication for T2DM (well-studied/ cheap/effective Dosage and dosing: start low and titrate upwards: 500mg OD→ 1g BD) Side Effects Include (open vs closed questions): – GI: stomach upset/reflux/ early or prolonged satiety/ nausea or vomiting Diarrhoea/ Constipation, crampy abdo pain/bloating/gas  5. MEDICATIONS: OTHERS… (SEE PHARMACOLOGY LECTURES FOR FURTHER INFORMATION) There are many newer classes of medications (Gliclazides/GLP-1 agonist/DPP-4 inhibitors/ SGLT-2 inhibitors etc. ), details of which are beyond scope of this lecture, see pharmacology lecture for specifics Patient may know specific medications. If not, clues may lie in route and dosing regimens: – Do you take a tablet/ injection? How often? e.g. Daily sc: Liraglutide (Victoza) (GLP-1) e.g. Weekly sc: Semaglutide (Ozempic) (GLP-1) – Are there any side effects your doctor is mentioned/ is monitoring you for? if asked re pancreatitis/C2H05 excess/Gall bladder stones (? GLP1) If Dr mentioned risk of UTIs / PV or penile yeast infections(?SGLT2) If Dr mentioned risk of low bloods sugars/hypos (? Gliclazide(Diamicron) 5. MEDICATIONS: OTHERS… (SEE PHARMACOLOGY LECTURES FOR FURTHER INFORMATION) INSULIN More commonly used in T1DM but can be used in difficult to control T2DM Dose/ type – Basal (long acting) : e.g. Insulin glargine (Lantus) – Bolus (short acting): e.g. Insulin aspart (Novorapid) Side effects Hypos/ sweating/ headache Injection site reactions etc. Blood glucose readings (BMs) Finger prick (How often?/ Average readings?) VS. Continuous glucose monitor (CGM) 5.MEDICATIONS (SEE PHARMACOLOGY LECTURES FOR FURTHER INFORMATION) Non-DM medications – Open: Do you take any other medicines? – Closed: Consider what medications a patient with diabetes might also be prescribed (re common comorbidities) E.g Do you take any medicines for your blood pressure/ cholesterol ?etc Medications related to DM complications/comorbidities might include: Antihypertensives Lipid lowering agents Anti-coagulants/anti-platelets Meds related to renal or eye disease PDE inhibitors etc Others: medications that can affect blood glucose levels: – Steroids*/ statins/ pseudoephedrine/anti-psychotics 6. ALLERGIES ‘Do you have any allergies to medications, latex or other materials?’ – If yes important to know nature of reaction what happened when you took this medicine in the past? – E.g. stomach upset vs rash vs anaphylaxis etc.  7. SOCIAL HISTORY Home ‘who do you live with?’ e.g. partner/parents ‘do you have any dependents /children?’ ‘do you have good support from family and friends/neighbours?’ "Do you drive ? – If yes what do you drive? (Re Type 1 vs 2 licence?) – Consider why important to ask in diabetic patients Occupation ‘Are you studying or working currently? Does your diabetes diagnosis impact on your work? If so how? 7. SOCIAL HISTORY… Smoking History "‘do you smoke? have you ever smoked?’ – If yes ‘how many per day? for how long?’ (? Pack Year History) Alcohol History "do you drink alcohol? " – "how much, how often?’"would you drink everyday/week/month? " Diet "How is your diet?" – "tell me about your typical /breakfast/ lunch/ dinner/snacks etc“ – "Have you ever seen a dietician since being diagnosed with diabetes?“ Physical Activity levels – What type of physical activities do you do/ enjoy doing? – Duration/ frequency/ Intensity levels/recent changes in activity levels 8. FAMILY HISTORY Parents/Siblings – “are there any conditions that run in family?” – “are you aware of any conditions that can occur frequently in your family?” e.g. Diabetes (if yes type 1 or type 2?), heart disease, stroke , high blood pressure, AI diseases IDEAS CONCERNS & EXPECTATIONS PATIENT CENTERED CARE Consider how you might ask the patient about any specific ideas /concerns / expectation. – Does the patient have any specific thoughts/ideas regarding their symptoms/diagnosis? – Does the patient have specific concerns regarding their symptoms and diagnosis? – What are the patient's expectations from the consultation today? "How does your diabetes diagnosis most impact on you?“ – work life/ family life/ social life etc. " Do you have any questions for me?" "Is there anything that you are particularly worried about today?"  HISTORY TAKING IN DIABETES LEARNING OUTCOMES REVISITED Students will revise the Calgary Questions? Cambridge consultation model for communicating within the consultation Students will identify and assess key components of a diabetes history, including the duration of the disease, family history, symptoms, and complications. Students will demonstrate how to take a history from a patient with Type 2 diabetes ADDITIONAL RESOURCES Chronic Disease Management Programme (CDM) o CDM Screening Programmes The Power of Language Sick Day Rules in patients with T2DM Social History Resources  TYPE 2 DIABETES IN PRIMARY CARE CHRONIC DISEASE MANAGEMENT PROGRAMME Chronic Disease Management Programme (CDM) 2020 HSE Initiative – aims to prevent and manage patient chronic diseases using a structured population-approach. – helps you identify and manage patients at risk of chronic disease or who have been diagnosed with specified chronic diseases. – screens for common diabetic complications, by inviting the patient to attend for biannual appointments with the GP team in which physical and biochemical examinations and investigations are performed to help prevent/screen/treat diabetic complications – For T2DM patients this involves: History taking/lifestyle advice Physical examination: Weight/Height/BP/Foot exam Investigations – Bloods: FBC, UE, LFT, Hba1c, Fasting Glucose, lipids – Urinalysis: ACR & ECG CDM SCREENING PROGRAMES FOR DIABETES CONSIDER HOW YOU WOULD ASK IF THE PATIENT HAS ATTENDED RELEVANT SCREENING PROGRAMMES EYES: Do you attend the HSE's retinal screening programme? "When were your eyes last checked?“ “ Do you have any new visual problems?” "have you been diagnosed with any eye problems ?“ "have you had laser treatment/injections in your eyes?" FEET: e.g. Do you have any problems with your feet now or in the past?“ Infections/ulcers etc. “ Have your feet been examined by a doctor/ nurse/yourself recently ?" "Have you ever attended a podiatrist?",If yes: When? /why?/how often? KIDNEYS: e.g. “Have you attended your GP as part of the Chronic Disease Management programme?" (“blood/urine test with the GP/nurse”) "When did you go last? how often do you go?“ "any problems with your kidneys?“ "Has your doctor ever mentioned Chronic Kidney Disease / protein in your urine/ discussed dialysis?"  TYPE 2 DIABETES IN PRIMARY CARE (BAHRAIN) In Bahrain, Central Diabetes Clinics (CDC) are established in Primary care local health centers since 2006. It composed of the diabetologist clinic and the diabetic nurse clinic. Its objective is to provide comprehensive management of diabetes, to manage and prevent complications, to detect micro- and macro- vascular complications early by screening, and to refer to secondary care as needed. Patients are referred to the CDC by physicians following the below criteria: 1. HBA1C above individualized target for ≥ 6 months. 2. Severe or recurrent hypoglycemia of less than 70 mg/dL. OR Hypoglycemia requiring several admissions. 3. Patient eligible for multiple daily injections (MDI). 4. Patient is on dialysis. OR pre- and post- transplant patients. 5. GFR below 60 mLs/min/1.7m². 6. History of previous ulcers, amputation, painful neuropathy and Charcot for regular foot risk classification and monitoring. THE POWER OF LANGUAGE Good communication skills improve patient outcomes/ compliance/ overall satisfaction. Basic principles of practicing good communication: – Active Listening – Empathy – Non-judgement – Paying attention to the para-verbal and non-verbal components – https://www.diabetes.org.uk/professionals/resources/shared- practice/psychological-care/emotional-health-professionals- guide/chapter-1-communication THE POWER OF LANGUAGE Poorly controlled vs. Compliant/non-compliant vs THE POWER OF LANGUAGE – These principles can be applied to all conditions, particularly relevant in conditions with a strong stigma attached. SICK DAY RULES IN PATIENTS WITH T2DM SICK DAY RULES IN PATIENTS WITH DM2 SOCIAL HISTORY RESOURCES Cycle of Change HEALTHY EATING ADVICE FOR PEOPLE WITH TYPE 2 DIABETES