Editor: Linda Wu
Contributors: Eddy Tabet, Kharis Burns, Matthew Luttrell
Reviewed: Barbara Depczynski, Bruce Way
In a hurry? Make sure you know
- Type of diabetes
- Regimen: oral hypoglycaemics, insulin and doses
- BSL trend and HbA1c
- Current sodium, trend
- Fluid status
- Serum osmolality, urine sodium and osmolality
- Clinical examination findings
- TSH, T3, T4
What history should JMOs know/collect?
- The reason for admission
- Patient’s age
- Patient’s likely discharge date
- Type of Diabetes (type 1 or type 2)
- Duration of Diabetes and macro/microvascular complications
- Current diabetes regimen include type of insulins and doses
- Usual/at home medication regimen – orals, insulin (and doses are important)
- HbA1c in the last 3 months?
- Specialist or GP care
- Pattern of BSaLs in hospital including any hypos
- Current feeding regimen – NBM, EN, Parenteral feeds, and whether any changes planned
- Steroids and what is likely regimen going forward
- Any planned procedures e.g. surgery, angiogram
- Renal or liver function impairment
- Cognition – is the patient currently coping with DM at home and would they cope with insulin or do they have a carer. Brief social History – i.e. lives alone or has supports
- Following up correspondence from relevant GP or specialist
- Symptoms – to suggest a cause (e.g. vomiting/diarrhoea) or symptoms to suggest there is neurological compromise
- Acute versus chronic – i.e. the trajectory of sodium; when was the cortisol last normal? (which may need getting bloods from LMO)
- Past medical history
- Previous history of adrenal or pituitary disorder
- History of recent infection, weight loss, postural dizziness, vomiting?
- Setting: is this patient acutely unwell?
- Any associated autoimmune conditions?
- Past medical history
- Recent TFTs
- Medications – in particular thyroxine or carbimazole, amiodarone or IV contrast
What examinations and investigations should JMOs perform/collect results of?
- QID if eating or q4-q6h if NBM readings. Fasting glucose levels and some pre plus 2 hour post-meal paired tests
- HbA1c (if not done in past 2-3 months and if no blood loss to confound result) or obtain from LMO
- BP and fasting lipids useful
- LFT and UEC useful in choosing medication regime
- Patient weight, height
- Referral to diabetes educator and dietitian if appropriate
- Fluid status – including postural BP
- Serum Na and osmolality
- Urine Na and osmolality (paired with serum)
- Weight trend
- Morning cortisol and ACTH (paired) – but if haemodynamically unstable – draw blood for cortisol and ACTH at any time, and start empirical GC without waiting for result, with discussion with senior colleagues – so this is related to setting.
- Blood pressure (including postural)
- Medications – any GC exposure: oral, inhalers, eye drops, IA
- Serum electrolytes
- Clinical assessment of thyroid activity – is the thyroid palpable? Tender? Is there clinical evidence of hyper/hypothyroidism? Obstructive symptoms
- TSH, T4 and T3 level
- As appropriate TPO, TRab
What additional information would impress you?
- Information sourced from the GP/ endocrinologist/ pharmacist
- If the JMO had a formed a clinical impression and considered how they might manage the patient
- Use ISBAR as initial structure; this is the situation (admission and current issue), and suggested management plan to discuss further guidance on that endocrine aspect of the case
What are common mistakes/omissions made by JMOs?
- Not taking history themselves and relying on power chart notes
- For BGL control – lack of HbA1c, no blood glucose readings, no history from GP, wrong insulin eg humalog vs humalog mix
- For hyponatraemia – need to order paired urine and serum tests, not examining fluid status, ordering both FT4 and TSH – to exclude secondary hypothyroidism, ordering cortisol/ACTH
- For thyroid disorders – not examining the patient clinically, not knowing the recent TFT results
Depczynski, Barbara. (2016). Diagnosing diabetic ketoacidosis (DKA). [podcast]. Available at: https://onthewards.org/diagnosing-diabetic-ketoacidosis-dka/ [Accessed 9 October 2018]
Depczynski, Barbara. (2016). Perioperative management of diabetic patients. [podcast]. Available at: https://onthewards.org/perioperative-management-diabetic-patients/ [Accessed 9 October 2018]
Ross, Glynis. (2018). Part 1: Blood Glucose Monitoring – Hyperglycaemia. [podcast]. Available at: https://onthewards.org/part-1-blood-glucose-monitoring-hyperglycaemia/ [Accessed 9 October 2018]
Ross, Glynis. (2018). Part 2: Blood Glucose Monitoring – Hypoglycaemia. [podcast]. Available at: https://onthewards.org/part-2-blood-glucose-monitoring-hypoglycaemia/ [Accessed 9 October 2018]