Early Symptoms

 Sluggish, extreme tiredness

 Fruity smell to breath/compare to nail polish remover
 Extreme thirst, despite large fluid intake
 Constant urination
 Extreme weight-loss
 Oral Thrush may be present, or/ yeast infections that fail to go away, this is because the normal
fungal/flora present in oral cavity/cervix in women, the balance is upset and bacterial began to feast on
the high sugar from urine output/ dry mouth from extreme thirst.
 Muscle wasting
 Agitation / Irritation / Aggression / Confusion

Other symptoms
 Extreme hunger
 Sudden vision changes/Difficulty in vision
 Tingling or numbness in hands or feet
 Fatigue
 Very dry skin
 Sores that are slow to heal
 Recent skin infection.
 Nausea, vomiting, or stomach pain
 Autonomic postural hypotension
 Gastroparesis

Late Symptoms
 Emesis (vomiting), although this is not always a sign of late-stage ketoacidosis, and can occur both in
early-stage ketoacidosis and in non-ketoacidic hyperglycaemia.
 Confusion
 Abdominal pain
 Loss of appetite
 Flu-like symptoms
 Lethargy and apathy
 Extreme weakness
 Kussmaul breathing ("air hunger"). Patients breathe more deeply and/or rapidly.
 Unconsciousness (diabetic coma) after prolonged DKA.

HOPI
 Has the patient had any symptoms of cardiovascular, cerebrovascular, renal, ophthalmological or
neurological complications of diabetes?
 Has the patient had any problems with sexual function? Ask specifically about erectile dysfunction,
vulvovaginitis/balanitis.
o Are you satisfied with your sexual function?
o How long have you been dissatisfied with your sexual function? __________
o Little or no interest in sex
 o Decreased genital sensation (feeling)
o Decreased vaginal lubrication (dryness)
o Problem reaching orgasm
o Pain during sex
 Has the patient been otherwise well, or had any other illness of note over the preceding year for which
they have consulted their GP or other healthcare services?
 How has their mood been? Has there been any problem with, or treatment for, depression?
o Feeling of despair
o Inappropriate sense of guilt
o Sleep disturbance
o Loss of interest in daily activities
o Suicidal thoughts
 Has the patient received adequate education in respect of their diabetes, both in their and in your view?
 Treatment:
o How is the patient coping with and complying with their medication regimen for diabetes?
o Have there been any problems with injection of insulin?
o Have there been any problems with timing of insulin or oral medication?
o Do they miss injections or medication regularly?
o Patients may present with a history of poor compliance with insulin therapy or missed insulin
injections due to vomiting or psychological reasons.
 Monitoring:
o Are there any problems with the equipment that they have to monitor their capillary glucose?
o When did they last calibrate their glucose monitoring equipment?
o Do they have their records of their blood glucose monitoring?
o HbA1c; or check when last done.
o Home capillary glucose monitoring results.
o Frequency and severity of hypoglycaemic episodes
 Level of physical activity
 Pregnancy and pre-pregnancy:
o Are they pregnant or planning on having any children?
o Pregnancies complicated by hyperglycemia

Age of onset
 Young children (age less than or equal to 2 years) tend to present more likely with DKA
 Peripubertal and adolescent girls are affected more than other age groups.

Family history
 Families harboring HLA-associated high-risk genotypes
 Patients who have a family history of type 1 diabetes have less chance of developing DKA, possibly due
to increased awareness of the disorder.

Past Medical History

 DKA is associated with a past medical history of type 1 diabetes.
o When? How long?
 Any hospital admissions in the preceding year for diabetic decompensations such as hypoglycaemia,
diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state?
 Any treatment or hospital admissions for complications in the preceding year?
o Angina/myocardial infarction, cerebrovascular event/transient ischaemic attack (TIA), diabetic
nephropathy, diabetic retinopathy, diabetic neuropathy or diabetes foot problems?
 History of infections (for example, urinary tract infections, pneumonia in an individual suffering from
type 1 diabetes.

Gynae History
 Delivered a baby weighing >4 kg or were diagnosed with gestational diabetes mellitus (GDM)
 Polycystic ovarian syndrome (PCOS)
Drug history
 Current diabetic medication and doses - insulin (short- and long-acting), biguanides, sulfonylureas and
thiazolidinediones.
o How is the patient coping with and complying with their medication regimen for diabetes?
o Have there been any problems with injection of insulin?
o Have there been any problems with timing of insulin or oral medication?
o Do they miss injections or medication regularly?
o Patients may present with a history of poor compliance with insulin therapy or missed insulin
injections due to vomiting or psychological reasons.
 Current medication for other conditions, especially those designed to ameliorate cardiovascular risk such
as diuretics, antihypertensives, ACE inhibitors, aspirin, beta-blockers, etc.
 Special populations (those who are receiving antiretroviral therapy or atypical antipsychotic drugs)

Social history
 History of use of illicit drugs, alcohol, smoking and cocaine.
 Poor socioeconomic status contributes to poor medication adherence in diabetics.

Diet history
 Total caloric intake
 Intake of sugar-containing foods
 Intake of saturated fat and cholesterol
 Timing of meals in type I diabetes

Appearance of the Patient

May look thin, cachexic, ill-appearing, diaphoretic or disoriented due to severe hyperglycemia and ketosis.

Vital Signs
 Weight: ___ kg, height: ___ cm; BMI: ___
 Abdominal circumference:
 Temperature: Normal or elevated or hypothermia
 BP – lying and standing: Hypotension
 PR: Tachycardia, weak pulse due to dehydration
 RR: Tachypnea & Kussmaul breathing may be present in severe DKA

Skin
 Injection sites
 Lipoatrophy and lipodystrophy / lipohypertrophy
 Cutaneous infection (non-healing ulcer)
 Poor skin turgor due to dehydration
 Xerosis
 Hair loss
 Acanthosis nigricans in type 2 diabetics
 Diabetic dermopathy (small <1 cm, well-demarcated, atrophic depressions, macules, or papules on the
pretibia) in type 2 diabetics; pigmented pretibial patches
 Skin thickening has been frequently seen on feet and hands. Skin appears waxy and edematous.
 Eruptive xanthomas in type 2 diabetics
 Necrobiosis lipoidica (irregular, painless ovoid plaques with a yellow atrophic center & a red to purple
periphery)
 Vitiligo
 Diabetic bullae
 Other skin disorders
o Onychomycosis
o Tinea pedis
o Candidiasis
o Non-candidal intertrigo
o Eczema
o Psoriasis
o Furuncles, carbuncles
o Corns and calluses, dermatophytosis, ulceration

HEENT
 Opacity of lens. (Cataract)
 Xanthelasmata
 Ophthalmoplegia
 Retinopathy (examine dilated pupils)
 Visual acuity, with distance vision glasses, if worn
 Cranial nerve mononeuropathies of third, fourth, sixth, and seventh cranial nerves affecting ocular
movements
 Necrotizing (malignant) otitis externa (black eschar)
 Periorbital edema is a finding in patients with diabetic nephropathy.

Neck
Carotid bruits may be auscultated unilaterally using the bell of stethoscope; suggestive of atherosclerosis.
Lungs
Rales/crackles due to pulmonary edema (in case of complication of DKA) or pneumonia (in cases where
infection is a precipitating cause)
Pneumonia:
 Decreased breath sounds
 Bronchial breath sounds
 Rhonchi
 Crackles, Rales
 Increased vocal fremitus

Heart
 S1 normal
 S2 normal

Abdomen
 Nausea
 Vomiting
 Abdominal pain & tenderness

Genitourinary
 Polyuria
 Vulvovaginitis/balanitis

Extremities
 Decreased sensation
 Muscle cramping
 Cold extremities
 Pretibial myxedema
 Ankle edema
 Interdigital lesions
 Inspect footwear

Neuromuscular
 Hemianopia
 Hemiparesis
 Seizures
 Bilateral sensory loss in the upper and lower extremities may develop as neuropathy progresses.
 Diabetic amyotrophy
 Ankle & knee reflexes
 Vibration
Diagnostic criteria:
All three must be met:
a) Capillary blood glucose >11 mmol/L
b) Capillary ketones >3 mmol/L or urine ketones > 2+
c) Venous pH <7.3 and/or bicarbonate <15 mmol/L

DKA is categorised by the severity of acidosis:

 mild (venous pH <7.3, bicarbonate <15 mmol/L)
 moderate (venous pH <7.2, bicarbonate <10 mmol/L)
 severe (venous pH <7.1, bicarbonate <5 mmol/L)
High-dependency unit (HDU) admission and insertion of central line may be required in the following
circumstances:
a) Elderly
b) Pregnant ladies
c) Heart or kidney failure
d) Other serious comorbidities
e) Severe DKA by following criteria:
i. Venous bicarbonate <5 mmol/L
ii. Blood ketones >6 mmol/L
iii. Venous pH <7.1
iv. Hypokalaemia on admission (<3.5 mmol/L)
v. Glasgow Coma Scale (GCS) <12
vi. Oxygen saturation <92% on air (arterial blood gases required)

Complications
 Acute Complications
a) Hypoglycaemia
b) Hyperglycaemic states (e.g. diabetic ketoacidosis, hyperglycaemic hyperosmolar state)
c) Microbial infections
 Chronic Complications
a) Macrovascular (e.g. cardiovascular, cerebrovascular, peripheral vascular diseases)
b) Microvascular (e.g. retinopathy, nephropathy, and neuropathy)

Laboratory and diagnostic tests should include, when appropriate:

 Fasting plasma glucose (FPG)
 Glycosylated hemoglobin
 Fructoseamine
o The higher the fructosamine value, the poorer the degree of glycemia control. A trend from high
to normal fructosamine levels may indicate that changes to a person's treatment regimen are
effective.
o The advantage of fructosamine over HbA1c is that it's not affected by changes in red blood cells
and hemoglobin caused by anemia, blood loss, or nutrient deficiencies
 Arterial blood gas
 Urinary or blood ketones – uncontrolled hyperglycaemia & impending ketoacidosis
 renal profile – serum electrolytes, potassium levels
 o When DKA occurs, the renal function deteriorates significantly because the electrolytes are
generally elevated due to hemoconcentration. Hyperkalemia is the main manifestation,
 BUN
o Diabetic ketoacidosis is usually accompanied by dehydration resulting in prerenal azotemia, in
which the levels of blood urea nitrogen are elevated out of proportion to those of the serum
creatinine
 lipid profile – dyslipidemia is a RF for microalbuminuria in DN
 LFT
o elevated liver transaminases in a patient with poorly controlled type 1 diabetes.
 A standard urine dipstick test for proteinuria & glucosuria in DKA
o To screen for diabetic nephropathy
o If the test is negative, it is recommended to screen for microalbuminuria using the first morning
urine sample or a random urine sample without excessive water intake.
o If negative microalbuminuria: Urine-Albumin Creatinine Ratio (ACR)
 >2.5 mg/mmol in men and >3.5 mg/mmol in women
 Serum creatinine
o The serum creatinine should be used to estimate GFR and stage the level of CKD
 CBC with differential
 ECG
o Hypokalaemia: prolongation of PR interval, T-wave flattening and inversion, ST depression,
prominent U waves and apparent long QT interval
o Hyperkalaemia: tall, peaked and symmetrical T waves, and shortening of the QT interval
 Autoantibodies testing (glutamic acid decarboxylase antibody, anti-islet antibody, insulin autoantibodies
and protein thyrosine phosphatase antibody)
 Ophthalmoscopy
o To screen for diabetic retinopathy

Management
 Diet
 Food exchanges
 Exercise
 Medication
 Complications (acute and chronic)
 Self-care/SMBG/foot care
 Stop smoking
 Problem solving skills e.g. management of hypoglycaemia, sick days
 Psychosocial adaptation to diabetes e.g. to manage the stress associated with the initial diagnosis of
diabetes or its complications and initiation of insulin
 ED:
• Psychosexual counseling for patient and partner is recommended for the functional, organic and
mixed (functional and organic) types of ED, and should be performed by a trained
psychologist/psychiatrist.
• Avoid medications that may cause or worsen ED such as thiazides, beta-blockers, calcium
channel blockers, methyldopa, H-2 antagonists, spironolactone, ketoconazole, digoxin,
amiodarone, tricyclic anti-depressants, SSRIs, phenothiazines, narcotics, and NSAIDs.
• Phosphodiesterase-5 (PDE-5) inhibitors e.g. sildenafil, tadalafil and vardenafil can be used to
treat ED and should be offered as first-line therapy to men with diabetes wishing treatment
 PDE-5 inhibitors are contraindicated in unstable angina, poor exercise tolerance or nitrate
medication.
• Other therapies include intracavernosal injections, intraurethral alprostadil, vacuum devices with
constricting band and surgery.

Target control
 Glycaemic control
o Fasting or pre-prandial 4.4–7.0 mmol/L
o Post-prandial 4.4–8.5 mmol/L
o A1c++ < 6.5%
 Lipids
o Triglycerides < 1.7 mmol/L
o HDL-cholesterol: >1.0 mmol/L (male); >1.2 mmol/L (female)
o LDL-cholesterol < 2.6 mmol/L
 Blood pressure < 135/75 mm Hg
 Exercise 150 minutes/week
 Body weight: If overweight or obese, aim for 5-10% weight loss in 6 months