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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
Diabetes UK have produced a list of 15 Care essentials for those with diabetes

Learn More - Diabetes UK 15 Healthcare Essentials

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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
 

Refer to specialist care if appropriate.

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Useful External Links & Resources
 

PDF File

Diabetes UK 15 Healthcare Essentials
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