1. Diabetes
Julia von Oettingen, MD

2. History Insulin Regimen: □ Twice a day 70/30 Insulin (Mixtard)
□ AM breakfast dose_________IU □ PM dinner dose________IU
□ Total Daily Dose per kg = ______(total Units per day) ÷ ______ (weight in kg) = ______U/kg/day
Review of blood sugars:
blood sugar check in clinic today : ________________mg/dL
If patient keeps log at home, average blood sugar was
AM □ not checked Lunch □ not checked PM □ not checked
□ <100 □ <100 □ <100
□ □ □
□ □ □
□ □ □
□ >300 □ >300 □ >300
Any recorded overnight (2AM) blood sugars:________________mg/dL
Highest sugar recorded:___mg/dL Lowest sugar recorded:_____ mg/dL
Number of times EXTRA dose was given: ______________

3. History Review of high / low symptoms: Hyperglycemia Hypoglycemia
Frequent urination (polyuria) □ YES □NO
shaking (tremor) □ YES □ NO
Increased thirst and fluid intake (polydipsia)
□ YES □NO
sweating □ YES □ NO
Increased hunger/food intake (polyphagia)
□ YES □ NO
headaches □ YES □ NO
Vomiting □ YES □ NO
unconsciousness □ YES □ NO
Abdominal pain □ YES □ NO
Other:
Frequency:
□ daily □ weekly □ monthly
□ daily □ weeky □ monthly

4. History
Review of Diet: Number of meals per day: □ 1 □ 2 □ 3 □ >3 □ food insecurity (irregular)
Types of foods eaten: □ rice □ fish □ meat □ vegetables □ fruit □ other____
Intake of high sugar drinks / foods: □ never □ daily □ weekly □ monthly
Patient’s problems:
Ask about problems with costs, access to medication or diabetes supplies, access to clinic, inability to contact medical provider by phone, lack of caregiver to administer insulin.
Describe:_____________________________________________________
Other History:
Retinopathy: □ vision changes □ trouble seeing
Hypothyroidism: □ low energy □ wt gain □ constipation □ dry skin
Psychosocial: □ coping strategies □ feelings of depression
10y after diagnosis: □ pain or hyperaesthesia in hand/feet □ regular foot check (every night) □ bloating / abdominal pain / vomiting (gastroparesis)

5. Physical Exam check box or circle if 2 choices given
HR_____ BP___/___ RR_____ Temp______ Wt________kg
Gen: □ well appearing □ weak or dehydrated □ altered mental status
HEENT: □ moist MM □ acetone odor □ thyroid exam_____________
Heart: □ S1 and S2 □ RRR □ no murmur □ other___________
Lungs: □ clear □ tachypnea □ Kussmaul resp □ other___________
Abd: □ soft □ ND □ NT □ BS positive □ other___________________
GU: □ normal external MALE / FEMALE genitalia □ pubertal / not pubertal
Neuro: □ awake and alert □ altered mental status □ GCS_____ □ DTRs____
Skin: □ cap refill ____sec □ dry □ pallor □ rash
Extr: □ sensation to light touch tested: intact / not intact, describe________________
□ vibration sense tested: intact / not intact, describe_______________________
□ foot inspected for ulcers: present / absent, describe______________________
Other:
□ Injection sites: infection – present / absent; lipohypertrophy - present / absent, location__________________________________
□ Joint exam: limited mobility – present / absent
□ hypothyroidism: goiter – present / absent; brittle hair – present / absent; dry skin – present / absent

6. Education:
□ insulin regimen reviewed □ blood sugar testing reviewed
□ proper insulin administration reviewed (drawing up insulin, subQ route, changing sites)
□ symptoms of hypo- and hyperglycemia reviewed
□ plan for hypoglycemia reviewed:
1. give sugar ASAP (sugar water, juice, syrup, hard candy)
2. check BS after 20min
3. eat light meal after 30min
4. CALL YOUR DOCTOR
□ plan for hyperglycemia reviewed:
1. check your sugar
2. if >300, drink a lot of water (1L/h for big children, 0.5L/h for small children) to avoid DKA, and check BS before every meal
3. if >400 or read “hi” on glucometer, continue to drink a lot of water and give 10% of total daily insulin =_________ and advise to CALL DOCTOR
4. if you are feeling unwell CALL YOUR DOCTOR or COME TO THE EMERGENCY ROOM
□ short- and long term complications of type 1 diabetes reviewed
1.both hypo- and hyperglycemia can lead to coma and death
2. poor BS control leads to problems with the eyes (risk of blindness), kidney (risk of kidney failure and death), nerves (painfull hands and feet, foot ulcers) and heart (early death)
□ diet and avoidance of high sugar foods/drinks
□ patient questions answered

7. Assessment:
□ good control (BS levels , patient compliant)
□ acceptable control (BS levels , patient compliant)
□ fair control (BS levels , partial compliance)
□ poor control (BS levels >300, poor compliance consider admission)
□ DKA (BS levels >>300, non-compliant  needs admission)
Plan:
Insulin dose: □ no change □ following changes:______________________
□ new TDD = ____U/day ÷ ___ wt in kg = ____U/kg/day
□ new EXTRA dose = _____Units
Yearly checks: □ eyes
□ clinical suspicion of thyroid disease low / unsure /high □ check TSH
□ urine for microalbuminuria or protein (as a marker of kidney disease)
Medication refill:
□ cooler/refrigerator or other method of storing (specify: _________)
□ Insulin vial
□ Insulin syringes
□ Lancets □ Needles
□ glucometer □ glucometer strips
□ book for logging BS
Referrals: □ ophthalmology □ dietician □ social work □ other: _______________

8. Insulin start doses Estimate Total daily dose (TDD) of insulin:
<3y: 0.3U/kg/day
3-12 y: U/kg/day (always err on the lower side first, go up later as needed)
12-16y: U/kg/d
>16y: 0.8 U/kg/d
Using 70/30 insulin (70% NPH and 30% Regular) give:
AM dose: 2/3 TDD before breakfast
PM dose: 1/3 TDD before supper

9. Insulin start doses Example:
10 year old boy with first manifestation of type 1 diabetes who weighs 30kg
TDD= 0.5 U/kg/day=0.5x30= 15U per day
AM dose= 2/3 x 15U= 10U
PM dose= 1/3 x 15U= 5U

10. Goal blood sugars Generally: the younger the child, the higher
If child has food security and can measure RBS:
in young children
in older children
If child has no food security, no RBS:
in all children

11. General Principles before making adjustments:
Check for external factors of different demand:
Has the insulin consistently been properly stored?
Has a new vial recently been opened?
Is the patient repeatedly using the same injection sites? Look for signs of lipohypertrophy!
Is the patient using the right type of insulin and the right dosages?
Has there been a change in the caregiver who provides the insulin (and may not know the right doses)?
In all these cases DO NOT change dose but readjust external factor and follow up with patient whether glycemia improves

12. General Principles before making adjustments:
Check for causes of different demand:
Is the patient entering his/her “honeymoon”phase
Has the patient been ill?
Has the patient made a change to their diet? (quantity, types of foods, frequency of meals)
Have they made changes in their level of exercise?
More exercise  less insulin required  lower sugars
Less exercise  more insulin required  higher sugars

13. Adjusting the dose: Find a pattern of high/low sugar levels
Sugars high or low in the MORNING  adjust PM dose
Sugars are high or low in the EVENING  adjust the AM dose
Adjust one dose (AM or PM) at one time, unless ALL sugars are >300 or persistent symptoms of hyperglycemia
Do not adjust the insulin dose by more than 10%
Wait 2-3 days before making a new change to a change that was just made
UNLESS the patient is having hypoglycemia after a dose increase  change back to lower dose
Upon changing a dose:
Have patient measure sugars for a minimum of 2 days (in AM and PM)
call or return to clinic to see if a readjustment is needed

14. Adjusting the dose Example:
10year old 30kg boy in the above example who takes 10U in AM and 5U in PM.
All his sugars are HIGH (>250) in the morning…
you would increase the PM dose by 10% of 5U
= 0.5U and thus increase his PM dose to 5.5U

15. No blood sugars? In patients who are not checking blood sugars:
Base your adjustment on clinical symptoms and a blood sugar check, urine glucose and urine ketones in the clinic  increase AM and/or PM dose by 10% if all of these are indicative of hyperglycemia
If the patient has persistent polyuria, polydipsia, polyphagia, you should increase the AM and/or PM dose by 10%
Have the patient check in with you frequently (if necessary every 2 days) after any change to see if they are improving
Provide teaching about hypo/hyperglycemia symptoms

16. Example 1 4yo girl, weighs 15kg, AM=4U, PM=3U.
 Patient is running high in PM
adjust AM dose by 10% (=0.4U), round to 0.5U and give 4.5U in AM, 3U in PM
 re-calculate TDD/kg/day: 7.5U/15kg=0.5U
DATE AM
Lunch PM
2AM
MON
200
330 -
TUE
220
350
WED
180

17. Example 2 13yo boy, wt 40kg, AM dose=14U, PM dose=10U
Overall running high, but few values!
adjust AM dose by 10% (=1.4U) can round to 2U and give 16U in AM
TDD = 26U/40kg = 0.65U/kg/day
Follow up in 2days , give your phone number for earlier problems
DATE AM
Lunch PM
2AM
MON --
350
TUE
380
400
WED

18. Example 3 6yo girl, wt 20kg, AM dose=8U, PM dose=4U
Ask about symptoms!!
Check RBS, urine glucose and urine ketones!!
Educate about need to check sugars 2d before coming to clinic
Adjust only if patient persistently hyperglycemic and above tests are suggestive of hyperglycemia
TDD = 12U/20kg = 0.6U/kg/day
DATE AM
Lunch PM
2AM
MON --
TUE
WED