Screening for Diabetes
This is done routinely at the well woman and new patient checks when we endeavour to check urine samples of all those attending for sugar. We check urine samples in anyone who appears to be at risk of diabetes such as those attending with infections, those overweight, the older patient and anyone attending with any suggestive symptoms. Anyone with sugar in the urine (glycosuria) gets a fasting blood sugar level measured.
Diagnosis of Diabetes
The following criteria are used:-
Glucose Tolerance Test
A fasting blood sugar sample is taken and then standard sugar load is drunk comprising 388ml of flat Lucozade. A further blood sample is taken two hours after the drink. Criteria for diabetes are as above.
Patients with impaired glucose tolerance are at risk if developing diabetes later and require annual follow up with a random blood sugar.
Almost all patients who come to the surgery's diabetic clinic are non-insulin dependent diabetics (NIDDM). The care they receive can be considered under the following headings:
First Attendance
This is essentially the same as a standard review but with the emphasis on education. Every patient receives a comprehensive booklet about the disease and sees the dietitian. At this stage we set targets for weight, level of blood glucose, smoking habits, cholesterol levels, BP and HbA1c (a measure of blood sugar control). This is done mainly by the nurse followed by a consultation between patient and doctor. The doctor does a full medical at this stage with examination for signs of nerve damage, circulation problems, heart disease or foot conditions. Eye examination is carried out by the retinal screening unit at the diabetes centre at the General Hospital. The centre operate a call/recall system liaising with the practice and the practice follows up any patients who fail to attend there. Any patients with foot ulcers are also seen at the diabetes centre at the hospital.
Blood is taken for blood glucose, HbA1c, fasting blood fat levels - cholesterol and triglycerides, and HbA1c and creatinine to check kidney function. At this stage we also demonstrate self monitoring to the patient, either by blood glucose analysis or, if appropriate, urine analysis by Diastix.
Six monthly check
This full screen is repeated every six months.
Follow up
This will obviously depend upon the tests taken so the patient is seen again two weeks later to discuss them. He/she will then be asked to attend at appropriate intervals depending on the severity of the condition. Follow up checks are with the doctor or, when the patient's diabetes is well controlled, by the nurse. Typical patients who attend the nurse are those with a stable condition, without complications, who would need simple monitoring (mainly their HbA1c) in between annual checks. Patients who need to see the doctor are those with evidence of other illness, complications of diabetes, or poor control as indicated by:-
Administration
All diabetic patients (whether they attend the surgery clinic or not) are included in the diabetic register. This is to ensure no one is lost to follow up, either at the surgery or hospital. After attending the surgery clinic a patient is given a review period by the doctor or nurse and an appointment sent out to them. A reminder of this appointment is sent two weeks prior to the date. Any patient who fails to attend either for blood tests, or the clinic itself, also receives a reminder letter from the secretary. A note of any correspondence is made on the patient's medical record.
Diabetes Clinic
The diabetes clinic is held fortnightly, run by the practice nurse (Sister Jeanette Best) and Dr Mike Scott. The dietitian is at the clinic to give diet advice. Shared care and surgery based care patients are seen at regular intervals determined by the level of control of the diabetes. Extra attention continues to be given to those with higher than recommended HbA1c values and BP readings. A group of elderly housebound diabetics have been identified and monitoring is carried out at home on a regular basis.