Who you are:
You are an F2 in GP Surgery.Who the patient is:
Mr. David Smith, age 50, was referred by Optometrist for early diabetic retinopathy.Special note:
A referral letter may be handed inside.Additional Information:
He is diagnosed with non-insulin dependent diabetes mellitus, which is controlled with diet.What you should do:
Please talk to the patient and discuss plan of management with the patient.
Doctor: Hello, can I get your full name and date of birth please ?
Patient: My name is David Smith, I am 50.
D: How can I help you today?
P: Doctor I went to the opticians to check my eyes and he gave me this note:
Letter:
We examined the eyes of 50-year-old gentleman.
Patient has been diagnosed with Diabetes.
Patient visual acuity is normal and on examination there is diabetes in the retina.
Carry this letter when you see your GP.
Follow up is required.
D: Why did you go to the opticians?
P1
P: I just went to check my eyes to see if I need glasses, I am a painter and I’m having
trouble seeing fine lines while working.
ODIPARA + EYE STRUCTURE
D: This eye problem, when did it start? (Duration)
P: A few days ago.
D: How did it start? (Onset)
P: Slowly.
D: Any change since it started? (Progression/course)
P: It’s getting worse.
D: Is there anything that makes it better or worse?
P: I don’t know.
D: Is it affecting both eyes?
D: What about the other eye?
D: Are you able to see?
D: Any Pain/ Itching?
P: No.
D: Any bleeding/discharge/ watery eyes?
P: No.
D: Do you sometimes feel that there are shapes floating in your field of vision (floaters) or like you have blurred or patchy vision?
P: No.
D: Has your optician told you what is going on? (Idea)
P: No doctor, he just gave me this letter and asked me to see you.
D: Do you have any particular expectations from us today?
P: I want to understand what’s wrong with me.
P2: Explore DM
D: How long have you been diagnosed with diabetes?
P: 2 years.
D: How has your Diabetes been managed?
P: My condition is controlled by diet.
D: Do you take any medications?
P: No.
D: Is your diabetes well controlled?
P: I think so.
D: Do you check your blood sugars regularly?
P: No to be honest.
D: When did you last check your blood sugar?
P: 2 years ago.
D: Do you visit your GP regularly? (Follow up)
P: No. I don’t have any symptoms to go to the GP.
D: Do you go for your annual check-up?
P: No. I missed my last one.
D: Have you been diagnosed with any other medical condition in the past? HTN, heart and kidney diseases?
P: No.
D: Are you taking any medications?
P: No.
DESA very important
D: Tell me about your diet?
P: I eat everything.
D: Do you do physical exercise?
P: I don’t give much time.
D: Do you smoke?
P: Yes/no
D: Do you drink alcohol?
P: Yes/no
D: Do you have any kind of stress?
P: Yes. I am self-employed.
Examination:
Ideally, I would like to examine you now, check your observations, your blood sugar levels and the back of your eyes, if that’s OK with you.
Provisional diagnosis:
You told me that you have been missing some of your follow ups at the GP clinic for your DM and from the assessments we have done we found that your blood sugar was a bit on the higher side. It seems that you have a condition called diabetic retinopathy.
It is one of the complications of having diabetes for a long time, especially if blood sugar is on the higher side. Does that make sense to you?
Diabetes can cause damage to small or large blood vessels. Damage to large blood vessels will cause heart disease, kidney disease and stroke.
Damage to small blood vessels at the back of the eye causes retinopathy.
Management:
Refer to eye specialist.
Senior
Investigations:
Routine bloods – HbA1C (average blood sugar level over the past few weeks) –
cholesterol – random blood sugar.
Lifestyle:
You can reduce your risk of developing diabetic retinopathy, or help stop it getting worse, by keeping your blood sugar levels, blood pressure and cholesterol levels under control.
This can often be done by making healthy lifestyle choices, although some people will also need to take medication.
Eating a healthy, balanced diet – in particular, try to cut down on salt, fat and sugar
losing weight (if overweight ) –aim for a BMI of 18.5-24.9;
Exercising regularly – aim to do at least 150 minutes of moderate-intensity activity, such as walking or cycling, a week; doing 10,000 steps a day can be a good way to reach this target
Stopping smoking
Not exceeding the recommended alcohol limits – men and women are advised not to regularly drink more than 14 alcohol units a week.
To keep your blood sugar levels, blood pressure and cholesterol levels under control , it is important to monitor them regularly and know what level they are.
You might be prescribed medications to control your blood sugar, blood pressure and cholesterol level.
Symptomatic:
In the early stages of diabetic retinopathy, controlling your diabetes can help prevent vision problems developing.
Diabetic retinopathy usually only requires specific treatment when it reaches an advanced stage and there’s a risk to your vision.
The main treatments are: laser treatment – eye injections – eye surgery. (Same as before ARMD)
Safety netting:
Any problems in your eyes or your vision and DRIVING.
Follow up: Regular screening is still important to attend your annual diabetic eye screening appointment, as this can detect signs of a problem before you notice anything is wrong.
5 POINTS RECAP:
- EXPLORE EYE AND DM
- FUNDUSCOPY
- BLOOD SUGAR AND HBA1C
- LIFESTYLE
- DRIVING