home Audience 12 Children's diabetes mellitus - clinical observation. Diabetes mellitus and endocrinological clinic Dynamic monitoring of children with diabetes mellitus

Children's diabetes mellitus - clinical observation. Diabetes mellitus and endocrinological clinic Dynamic monitoring of children with diabetes mellitus

Clinical examination of patients with diabetes is a system of preventive and therapeutic measures aimed at early detection of the disease, prevention of its progression, systematic treatment of all patients, maintaining their good physical and spiritual condition, maintaining their ability to work and preventing complications and concomitant diseases.

Well-organized clinical monitoring of patients should ensure that they eliminate the clinical symptoms of diabetes - thirst, polyuria, general weakness and others, restoration and preservation of working capacity, prevention of complications: ketoacidosis, hypoglycemia, diabetic microangiopathies and neuropathy and others by achieving stable compensation of diabetes mellitus and normalization of body weight.

Currently, due to the rapid increase in the number of patients with diabetes as a result of improved detection and treatment, there is an increase in the number of patients undergoing follow-up with an endocrinologist in city clinics and central district hospitals.

On average, from 400 to 700 patients with diabetes are registered with an endocrinologist, which leads to significant overload of the doctor and reduces the quality of clinical follow-up. A large number of visits by patients to an endocrinologist is often not justified. Patients turn to him for help, bypassing the local therapist [Larichev L. S. et al., 1985], in connection with diseases that are not within the competence of the endocrinologist.

At the same time, local therapists and other specialists believe that if a patient is diagnosed with diabetes, he should be treated only by an endocrinologist. This situation is incorrect; it leads to a deterioration in dispensary monitoring of patients with diabetes, to non-compliance with the local-territorial principle of patient care, and to a decrease in the level of knowledge of doctors of various specialties about diabetes.

“Diabetes mellitus”, A.G. Mazowiecki

Medical examination of the population for diabetes mellitus includes the following activities. Active detection of patients with diabetes mellitus and persons with impaired glucose tolerance The need for active detection is determined by the ability to prevent or delay the development of diabetes mellitus. It should be carried out by doctors of various specialties using preventive departments in clinics. Ideally, it is necessary to cover the entire population of the area served by the clinic with prevention...

Training patients with diabetes in self-control techniques, medical education of their family members and medical workers. This is the basis for maintaining stable compensation of diabetes mellitus, preventing complications and maintaining working capacity, an integral part of medical examination and is aimed at preventing both diabetes and its complications. Properly administered education improves health and keeps the sick alive, providing consistent social and economic benefits to society….

There are 5 interconnected groups for training: patients with diabetes, members of their families, medical personnel, people with risk factors for diabetes and health care managers planning the development of care for patients with diabetes and the prevention of diabetes. Training should be targeted at specific groups of patients according to age, type of diabetes, complications. Immediately after diagnosis, treatment must be carried out and...

Registration of patients with diabetes mellitus Registration of patients with diabetes mellitus is carried out by an endocrinologist. This is important for diagnosing emergency conditions accompanied by loss of consciousness. It is advisable for a patient with diabetes to have a diary in which he enters data on the dose of insulin, oral hypoglycemic agents, diet, results of glycemic tests, glycosuria and acetonuria, and changes in health. The outpatient card of diabetic patients must be labeled. It is advisable to separate patient records...

Dynamic observation of patients with diabetes. The frequency of observation of patients depends on the course and severity of diabetes. An ophthalmologist, a neurologist, and a therapist remain permanent consultants. Other specialists are involved as needed. During pregnancy, the patient is observed together with an obstetrician-gynecologist. Persons with impaired glucose tolerance are examined by a therapist 1-2 times a year, by an endocrinologist upon referral, and by other specialists if necessary. Try…

The patient himself should be able to determine the sugar content in the urine at home using Glucotest indicator strips, and in case of their absence using the Althausen, Trommer or Nylander reactions, determine the acetone content in the urine using kits for the rapid determination of acetone, the glucose content in the blood using indicator strips such as dextranal or glucosamtest. The patient should be taught to be careful...

Patients with severe diabetes are examined by an endocrinologist once a month, and more often if necessary. Glycemia is determined on an empty stomach and 2 hours after meals, and, if necessary, at other times; it is better to study the daily glycemic profile. Daily and portioned glucosuria is checked once a week; on other days of the week, the patient, using a glucotest, conducts a glucosuria study...

Self-monitoring system for patients with diabetes mellitus as part of dispensary observation. Like every chronic non-communicable disease, diabetes mellitus requires systematic monitoring. This control is carried out during dispensary observation. However, diabetes mellitus has features associated with maintaining stable compensation. Clinical observation cannot fully ensure its achievement if there is not sufficient cooperation between the doctor and the patient. In each case...

The medical and social significance of diabetes mellitus requires preventive measures to reduce morbidity, maintain working capacity and increase the life expectancy of patients. Modern information about the etiology and pathogenesis of diabetes mellitus, epidemiological studies that provide data on the prevalence of not only diabetes mellitus, but also its vascular complications, risk factors and the natural evolution of the disease become the scientific basis of preventive measures. The prevention strategy is based...

In the prevention of IDDM, primary prevention can be used in first-degree relatives genetically predisposed to diabetes mellitus (including healthy identical twins) and very early implementation of strict control over the compensation of newly diagnosed diabetes mellitus. Primary prevention for relatives of patients with IDDM is based on HLA typing, which makes it possible to determine which of them is predisposed to the disease. Relatives with...

The second way used in the prevention of IDDM is early intervention in immunopathogenesis in newly diagnosed patients. Today, various methods are available for early intervention in the processes of immunopathogenesis of IDDM. Glucocorticoids, plasmapheresis, antilymphocyte serum, cyclosporine A, interferon and antimetabolites (cyclophosphamide, azathioprine, etc.) are used. In the experiment, such interventions brought some success. However, their use in clinical practice...

Involves a dispensary method of observation.

Thanks to this method, various deviations in the course of the disease are identified, the deterioration/improvement of the patient’s health condition is monitored, they are provided with the necessary assistance, and correct treatment is provided.

While under the supervision of medical professionals, diabetics take their prescribed medications in a timely manner. This helps return patients to normal life and maintain their ability to work for as long as possible.

Thus, medical examination for diabetes plays a very important role. It is simply unreasonable to refuse this procedure.

Follow-up plan for patients with diabetes

Dispensary procedures ensure the elimination of all:

general weakness of the body;

In addition, this will prevent severe -,.

All of the above is achievable, since medical examination normalizes the patient’s body weight, as a result of which persistent weight loss occurs.

There is an opinion that a single specialist, an endocrinologist, is sufficient for observation. However, practice has shown that this is not the case. The most effective clinical examination is observation by many specialists. This will identify all complications in the early stages.

Type 1 diabetics

An initial visit to an endocrinologist for such patients is accompanied by examinations by a therapist, ophthalmologist, and neurologist. Women should also visit a gynecologist.

Even before scheduling a medical examination, you must undergo the following tests:

fluorography;
blood;
detailed blood test to detect glucose levels, .

In addition, body weight, height are measured, and an electrocardiogram is performed.

Proper treatment can freeze diabetes in its latent stage. If this happens, the patient is removed from dispensary observation.

As for medical examination, it must be carried out once every three months. But doctors advise visiting the doctor even more often.

Type 2 diabetics

This form of the disease is not transmitted by, but is acquired as a result of an unhealthy lifestyle. Patients suffer from and lead an inactive lifestyle.

The risk group also includes people who have been diagnosed with:

all kinds of purulent diseases (barley, carbuncles, abscesses, furunculosis);
dermatitis;
polyneuritis;
eczema;
obliterating endarteritis.

There are other unfavorable circumstances that can lead a woman to the pregnancy pathology department. Obstetricians pay special attention to the first hospitalization; it should be carried out as early as possible. Thorough clinical examinations will help resolve the issue of the possibility of preserving the fetus and correct the course of the disease.

Childbirth is planned at 38 weeks of pregnancy. If there is a threat to the life of the mother or child, a caesarean section is prescribed at 36-37 weeks.

In order for pregnancy to proceed favorably, some time before its onset, a woman needs.

If this is done, the potential mother will retain her ability to work and will not have complaints of ketoacidosis. However, even with this, a favorable pregnancy outcome cannot be guaranteed.

Children

An endocrinologist (or therapist) examines you once a month. Dentist, ENT, ophthalmologist – once every 6 months.

Girls should also visit a gynecologist. When there is no endocrinologist in the clinic at the child’s place of residence, you need to go with him to the district or regional center once every three months.

During the examination, specialists assess the general state of health, physical, sexual, neuropsychic development, and motor activity. Attention is drawn to the presence of complications. Diary keeping is assessed.

Particular attention is paid to timely sanitation of the oral cavity. Depending on the development of the disease, recommendations are given aimed at maintaining a healthy lifestyle, organization, and compliance with physical activity.

Old people

People over 40 years of age are at risk for type 2 diabetes according to their age. Their disease is often asymptomatic.

During medical examination, he has the right to:

developing a special diet designed specifically for him;
calculation of the required dose of other drugs;
development of individual;
regular testing.

Which doctors should I visit?

In addition to a therapist and endocrinologist, you need to see a neurologist and an ophthalmologist. Women also visit a gynecologist.

For children, an ENT specialist or dentist is required. It seems like the list of doctors is long, but you definitely need to take the time to visit them.

During medical examination, specialized specialists will immediately identify all complications and prescribe appropriate treatment.

What examinations do you need to undergo every year?

Even if you feel well, it is not recommended to neglect medical examination. Analyzes and instrumental studies, which must be carried out every year, are mandatory for a diabetic.

Mandatory studies include:

clinical, biochemical blood test;
general urine test (every 3 months);
examination of 24-hour urine for microalbuminuria;
X-ray;
taking a cardiogram.

When is medical examination necessary for diabetes mellitus?

This is an annual event that cannot be neglected.

Prevention of diabetic complications

Timely clinical examination allows you to assess the level of red blood cells, leukocytes, platelets, and hemoglobin.

Often, based on a clinical blood test, anemia and other pathologies are detected.

Particular attention is paid to the possible development of fatty hepatosis and chronic renal failure. A biochemical blood test will show the presence of these complications.

Glucose, acetone, bacteria, red blood cells, white blood cells in the urine will tell you about the state of the excretory system and carbohydrate metabolism. X-ray is necessary to detect pulmonary tuberculosis, since patients with diabetes are at risk.

Determined using a 24-hour urine test. An ECG is necessary to identify abnormalities in the functioning of the heart muscle. This is how its irregular rhythm, overload of the atrium, ventricles, and the presence of myocardial ischemia are determined.

Video on the topic

About the reasons for medical examination for diabetes mellitus in the video:

Medical examination is the most important measure with which you can avoid severe complications of the disease, improve the quality of life, and prolong it.

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Forms and methods of clinical observation

Diabetes- chronic lifelong disease. To maintain their ability to work and prevent the development of disabling complications, these patients require active and systematic medical examination. We should strive to maximize the life expectancy of each patient diabetes mellitus (SD) , and to providing a chronically ill person with the opportunity to actively live and work.

Patients with diabetes of all degrees of severity and persons with risk factors are subject to medical examination. This can prevent, at least in some cases, the development of manifest forms of the disease or the transition to more severe forms.

The work of the endocrinology office of city and district clinics is provided by an endocrinologist and a nurse; in many regional centers and urban areas, general practitioners are specially allocated and trained to solve these problems. The functions of a doctor in an endocrinology office include: receiving primary and dispensary patients, carrying out all measures for medical examination of patients; carrying out their hospitalization in the presence of emergency indications and on a planned basis.

In order to identify and treat complications of diabetes mellitus and possible concomitant diseases, the doctor of the endocrinology office works in close collaboration with specialists of related professions (ophthalmologist, neurologist, gynecologist, dentist, surgeon) working in the same or in other institutions (specialized dispensaries and hospitals).

An outpatient card (form No. 30) is issued for a patient with newly diagnosed diabetes mellitus, which is stored in the office.

The main tasks of medical examination of patients with diabetes mellitus:

1. Assistance in creating a daily routine for the patient, including all therapeutic measures and maximally corresponding to the usual way of life of the family.
2. Assistance in vocational guidance, recommendations for employment of patients and, if indicated, carrying out a labor examination, that is, completing the necessary documentation and referring the patient to MSEC.
3. Prevention of acute emergency conditions.
4. Prevention and treatment of vascular complications of diabetes mellitus - late diabetic syndrome.

The solution to these problems largely determines:

1) systematic provision in the clinic of patients with diabetes mellitus with all necessary therapeutic agents (tablets of hypoglycemic agents, a sufficient set of various types of insulin);
2) adequate monitoring of the course of the disease (monitoring the state of compensation of metabolic processes) and timely identification of possible complications of diabetes mellitus (special examination methods and consultations with specialists);
3) development of individual recommendations for patients to perform dosed physical activity;
4) timely inpatient treatment in emergency situations, in case of decompensation of the disease, detection of complications of diabetes mellitus;
5) training patients in methods of monitoring the course of the disease and self-correction of treatment.

The frequency of outpatient examinations of patients depends on the type of diabetes mellitus, the severity and characteristics of the course of the disease.

The frequency of planned hospitalization of patients is also determined by these parameters.

The main indications for emergency hospitalization of patients with diabetes mellitus (this often applies to patients with newly diagnosed diabetes mellitus):

1. Diabetic coma, precomatose state (intensive care and resuscitation department, in the absence of the latter - an endocrinological or therapeutic hospital of a multidisciplinary hospital with round-the-clock laboratory monitoring of basic biochemical parameters).
2. Severe decompensation of diabetes mellitus with or without symptoms of ketosis or ketoacidosis (endocrinology hospital).
3. Decompensation of diabetes mellitus, the need to prescribe and/or correct insulin therapy (endocrinology hospital).
4. Diabetes mellitus in any state of compensation for symptoms of allergies to various hypoglycemic drugs, a history of polyvalent drug allergies (endocrinology hospital).
5. Varying degrees of decompensation of diabetes mellitus in the presence of another disease (acute pneumonia, exacerbation of chronic cholecystitis, pancreatitis, etc.), possibly triggering the manifestation of diabetes mellitus, when its clinical picture prevails, and this disease becomes the main one (therapeutic or other in profile hospital).
6. Varying degrees of decompensation of diabetes mellitus in the presence of pronounced manifestations of angiopathy: hemorrhage in the retina or vitreous body, trophic ulcer or gangrene of the foot, other manifestations (hospitalization in the appropriate hospital).

Hospitalization of patients with newly diagnosed diabetes mellitus, mainly type 2, is not necessary if the patient’s general condition is satisfactory, the absence of ketosis, relatively low levels of glycemia (11-12 mmol/l on an empty stomach and during the day) and glycosuria, the absence of significant concomitant diseases and manifestations of various diabetic angiopathies, the possibility of achieving compensation for diabetes without insulin therapy by prescribing a physiological diet or diet therapy in combination with tableted glucose-lowering drugs (TSP).

The selection of glucose-lowering therapy on an outpatient basis has advantages over inpatient treatment, since it allows you to prescribe glucose-lowering drugs taking into account the regimen that is usual for the patient, which will accompany him on a daily basis. Outpatient treatment of such patients is possible subject to sufficient laboratory control, using self-monitoring and examination of patients by other specialists to assess the condition of vessels of various locations.

For hospitalization of patients with manifest diabetes mellitus, for which they have already received treatment, in addition to the medical examination provided for by the medical examination plan, the following situations serve as the basis:

1. Development of diabetic or hypoglycemic coma, precomatose state (in the intensive care unit or endocrinology hospital).
2. Decompensation of diabetes mellitus, the phenomenon of ketoacidosis, when there is a need to adjust insulin therapy, the type and dose of tableted glucose-lowering drugs with the development, possibly, of secondary resistance to TSP.

In patients with diabetes mellitus, especially type 2 of moderate severity, with ketosis without signs of ketoacidosis (satisfactory general condition, relatively low levels of glycemia and daily glucosuria, the reaction of daily urine to acetone is from traces to weakly positive), measures to eliminate it can be started on an outpatient basis.

They boil down to eliminating the cause that caused ketosis (restoring the disturbed diet and taking sugar-lowering medications, canceling biguanides and starting treatment for an intercurrent disease), recommendations to temporarily limit the amount of fat in the diet, increase the consumption of fruits and natural juices, add alkalizing agents (alkaline drinks, cleansing soda enemas). For patients receiving insulin treatment, an additional injection of short-acting insulin in a dose of 6 to 12 units can be added at the required time (day, evening) for 2-3 days. Often these measures can eliminate ketosis within 1-2 days on an outpatient basis.

3. Progression of diabetic angiopathies of various localizations and polyneuropathies (hospital of the appropriate profile - ophthalmological, nephrological, surgical, with consultation of an endocrinologist; endocrinological, regardless of the state of metabolic processes). Patients with severe diabetic angiopathy, and especially stage retinopathy, nephropathy with symptoms of chronic renal failure stage, should be treated in hospitals 3-4 times a year and more often, according to indications. If there is decompensation of diabetes mellitus, it is advisable to adjust the dose of glucose-lowering drugs in an endocrinology hospital, while the remaining courses can be carried out in specialized departments.

4. Diabetes mellitus in any state of compensation and the need for surgical intervention (even with a small volume of surgery; surgical hospital).
5. Diabetes mellitus in any state of compensation and the development or exacerbation of an intercurrent disease (pneumonia, acute pancreatitis, cholecystitis, urolithiasis and others; a hospital of the appropriate profile).
6. Diabetes mellitus and pregnancy (endocrinology and obstetric departments; terms and indications are formulated in the relevant guidelines).

In the hospital, diet therapy tactics and insulin doses are worked out, the need is justified and a set of physical exercises is selected, recommendations are given for treatment and monitoring the course of the disease, but a patient with diabetes spends most of his life at home and is under the supervision of a clinic doctor. Diabetes mellitus requires a lot of effort and restrictions from patients and family members, and forces them to give up their usual lifestyle or modify it. In this regard, family members have many new concerns.

Helping families learn to “live with diabetes”- a very important section of the work of a clinic doctor. An indispensable condition for successful therapy is contact and the possibility of telephone communication with the patient’s family. Knowledge of the nutritional characteristics, lifestyle and psychological climate in the family will help the doctor bring his recommendations as close as possible to the living conditions of the family, that is, make them more convenient to implement. At the same time, telephone communication will allow the patient and family members in urgent situations to coordinate their actions with the doctor and thereby prevent the development of decompensation of the disease or mitigate its manifestations.

Education for patients with diabetes mellitus

Diabetes is a chronic, lifelong disease, in which situations may arise almost daily that require adjustments in treatment. However, it is impossible to provide daily professional medical care to patients with diabetes, so there is a need to educate patients in methods of controlling the disease, as well as to involve them in active and competent participation in the therapeutic process.

Currently, patient education has become part of the treatment of diabetes of any type; Therapeutic education of patients is formalized as an independent direction in medicine. There are schools for teaching patients for a variety of diseases, but diabetes is the undisputed leader and model for the development and evaluation of teaching methods. The first results demonstrating the effectiveness of education in diabetes mellitus appeared in the early 1970s.

For 1980-1990 Many training programs have been created for different categories of patients with diabetes and their effectiveness has been assessed. It has been proven that the introduction of education for patients with diabetes and self-control methods into medical practice leads to a reduction in the incidence of decompensation of the disease, ketoacidotic and hypoglycemic coma by approximately 80%, and lower limb amputation by approximately 75%.

The purpose of the learning process is not simply to compensate for the lack of knowledge in patients with diabetes, but to create motivation for such a change in their behavior and attitude towards the disease, which will allow the patient to independently adjust treatment in various life situations, maintaining glucose levels at levels corresponding to the compensation of metabolic processes. During training, it is necessary to strive to form such psychological attitudes that place a significant share of responsibility for their health on the patient himself. The patient himself is primarily interested in the successful course of the disease.

It seems most important to form such motivation in patients at the onset of the disease, when diabetes mellitus type 1 (SD-1) there are still no vascular complications, and with diabetes mellitus type 2 (SD-2) they are not yet expressed. When conducting repeated training cycles in subsequent years, the developed attitudes in patients with diabetes are consolidated.

The methodological basis for training patients with diabetes are specially developed programs, which are called structured. These are programs divided into educational units, and within them - into “educational steps”, where the volume and sequence of presentation are clearly regulated, and an educational goal is set for each “step”. They contain the necessary set of visual materials and pedagogical techniques aimed at assimilation, repetition, and consolidation of knowledge and skills.

Training programs are strictly differentiated depending on the categories of patients:

1) for patients with type 1 diabetes;
2) for patients with T2DM receiving dietary or oral glucose-lowering therapy;
3) for patients with diabetes mellitus-2 receiving insulin therapy;
4) for children with diabetes and their parents;
5) for patients with diabetes with arterial hypertension;
6) for pregnant women with diabetes.

Each of the noted programs has its own characteristics and fundamental differences, therefore it is irrational and even unacceptable to conduct joint (for example, patients with T1D and type 2 diabetes mellitus) patient education.

Main forms of training:

group (groups of no more than 7-10 people);
individual.

The latter is more often used when teaching children, as well as for newly diagnosed diabetes mellitus in adults, for diabetes in pregnant women, and for people who have lost their sight. Education of patients with diabetes can be carried out both in inpatient (5-7 days) and outpatient (day hospital) conditions. When training patients with type 1 diabetes, preference should be given to the inpatient model, and when training patients with type 2 diabetes, preference should be given to the outpatient model. To implement the knowledge acquired during training, patients must be provided with means of self-control. Only under this condition does it become possible to involve the patient in active participation in the treatment of his disease and achieve optimal results.

Self-control and its role in the treatment of patients with diabetes mellitus

Self-control in the broad sense of the word- this is the recording and analysis by patients with diabetes mellitus who have undergone training, subjective sensations, glycemia, glucosuria and other indicators, as well as diet and physical activity for the purpose of decision-making.
Using modern methods of express analysis of blood glucose, urine, and urine acetone, patients can independently assess the most important metabolic indicators with an accuracy close to laboratory ones. Since these indicators are determined in everyday conditions familiar to the patient, they are of greater value for adjusting therapy than glycemic and glucosuric profiles studied in the hospital.

The goal of self-control is to achieve stable compensation of metabolic processes, prevent late vascular complications and create a sufficiently high level of quality of life for patients with diabetes.

Sustained compensation of diabetes mellitus is achieved by implementing the following methods to achieve this goal:

1) the presence of scientifically based criteria for metabolic control - target values of glycemia, lipoprotein levels, etc. (National standards for the treatment of diabetes mellitus);
2) a high professional level of doctors providing care to patients with diabetes (endocrinologists, diabetologists, vascular surgeons, podiatrists, ophthalmologists) and sufficient staffing in all regions, i.e. availability of highly qualified care for patients;
3) providing patients with high-quality genetically engineered types of insulin, modern oral hypoglycemic agents (depending on the allocation of funds under the federal program “Diabetes Mellitus”);
4) creation of a system for training patients with diabetes mellitus to self-monitor their disease (system of schools for patients with diabetes mellitus);
5) provision of self-monitoring tools to determine various clinical and biochemical parameters at home.

Currently, based on international research, national standards for providing care to patients with diabetes and criteria for compensation of metabolic processes have been developed. All specialists are trained and provide treatment according to these criteria. Patients become familiar with the target values of glycemia, glucosuria, and blood pressure by undergoing training in schools several times during the period of illness: “Diabetes is a way of life.”

One of the most important results of training in schools for diabetics is the creation of motivation for patients to participate in the treatment of their disease through self-monitoring of the most important parameters, primarily carbohydrate metabolism.

Self-monitoring of blood glucose

Blood glucose should be determined for routine assessment of the quality of compensation on an empty stomach, in the postprandial period (after meals) and before the night break. Thus, the glycemic profile should consist of 6 determinations of glycemia during the day: in the morning after sleep (but before breakfast), before lunch, before dinner and before bed. Postprandial glycemia is determined 2 hours after breakfast, lunch and dinner. Glycemic values should correspond to the compensation criteria recommended by national standards.

An unscheduled determination of glucose by a patient should be carried out in cases of clinical signs of hypoglycemia, fever, exacerbation of a chronic or acute disease, as well as in case of errors in diet or alcohol intake.

The physician should remember and explain to patients that an increase in blood glucose levels does not meet the patient’s subjective criteria of well-being.

Patients with DM-1 and DM-2 receiving intensified insulin therapy should measure blood glucose repeatedly daily, both before and after meals, in order to assess the sufficiency of the administered dose of insulin, and, if necessary, its correction.

For patients with type 2 diabetes mellitus(even those not receiving insulin), the following self-monitoring program is recommended:

well-compensated patients carry out self-monitoring of glycemia 2-3 times a week (on an empty stomach, before main meals and at night) - on different days or the same points during one day, 1 time per week;
poorly compensated patients control glycemia on an empty stomach, after meals, before main meals and at night every day.

Technical means for measuring blood glucose levels: Currently, glucometers are used - portable devices with consumable test strips. Modern glucometers measure glucose in whole blood and plasma. It should be remembered that values in plasma are slightly higher than those in whole blood; there are correspondence tables. Glucometers, based on their mechanism of action, are divided into photocalorimetric ones, the readings of which depend on the thickness of a drop of blood on the test strip, and electrochemical ones, which do not have this drawback. Most modern generation glucometers are electrochemical.

Some patients use visual test strips for an approximate assessment of glycemia, which, when a drop of blood is applied to them, changes color after exposure time. By comparing the color of the test strip with the standard scale, you can estimate the glycemic value interval in which the resulting analysis currently falls. This method is less accurate, but is still used because... cheaper (diabetes patients are not provided with self-monitoring tools free of charge) and allows you to obtain approximate information about the level of glycemia.

Blood glucose, determined by a glucometer, indicates glycemia at a given moment, on a given day. To retrospectively assess the quality of compensation, the determination of glycated hemoglobin is used.

Self-monitoring of glucose in urine

A study of glucose in urine suggests that when the target values for compensation of carbohydrate metabolism are reached (which are currently obviously below the renal threshold), aglucosuria occurs.

If the patient has aglucosuria, then in the absence of a glucometer or visual test strips to determine glycemia, urine glucose should be determined 2 times a week. If the urine glucose level is increased to 1%, measurements should be daily, if more - several times a day. In this case, a trained patient analyzes the causes of glucosuria and tries to eliminate it; most often, this is achieved by adjusting diet and/or insulin therapy. The combination of glucosuria more than 1% and poor health is grounds for immediate consultation with a doctor.

Self-control of ketonuria

Ketone bodies in urine should be determined in case of clinical symptoms of decompensation of carbohydrate metabolism (polydipsia, polyuria, dry mucous membranes, etc.) and the appearance of nausea and vomiting - clinical signs of ketosis. If the result is positive, medical assistance is required. Ketone bodies in urine should be determined in cases of long-term hyperglycemia (12-14 mmol/l or glycosuria 3%), in newly diagnosed diabetes mellitus (first visit to a doctor), in cases of clinical signs of exacerbation of a chronic or acute disease, fever, and also errors in diet (eating fatty foods), drinking alcohol.

Things to remember:

1) ketonuria in a patient with diabetes mellitus in some cases can be observed with a slight increase in blood sugar;
2) the presence of ketonuria can occur in liver diseases, prolonged fasting and in patients who do not suffer from diabetes.

The most frequently determined self-control parameters in outpatient settings are indicators of carbohydrate metabolism: fasting and postprandial glycemia, glucose in the urine and ketonuria.

Indicators of compensation of metabolic processes are currently also the level of blood pressure and body mass index. Patients should be guided to monitor blood pressure at home daily, 1-2 times a day (taking into account individual daily peaks in blood pressure) and compare blood pressure with target values, and control (measurement) of body weight.

All information obtained during self-monitoring, information about the quantity and quality of food eaten on the day of measuring the glycemic profile, blood pressure level and antihypertensive therapy at this time, physical activity should be recorded by the patient in a self-monitoring diary. The self-monitoring diary serves as the basis for the patient’s self-correction of their treatment and its subsequent discussion with the doctor.

Professional guidance for patients with diabetes mellitus

The long-term chronic course of diabetes mellitus leaves a significant imprint on the patient’s social problems, primarily on employment. The district endocrinologist plays a big role in determining the professional orientation of the patient, especially the young one, who is choosing a specialty. In this case, the form of the disease, the presence and severity of diabetic angiopathy, other complications and concomitant diseases are of significant importance. There are general provisions for all forms of diabetes.

Hard work associated with emotional and physical stress is contraindicated for almost all patients. For patients with diabetes mellitus, work in hot shops, in conditions of extreme cold, as well as sharply changing temperatures, work associated with chemical or mechanical irritating effects on the skin and mucous membranes is contraindicated. For patients with diabetes mellitus, professions associated with an increased risk to life or the need to constantly maintain one’s own safety are unsuitable (pilot, border guard, roofer, fireman, electrician, climber, high-altitude fitter).

Patients receiving insulin cannot be drivers of public or heavy freight transport, or perform work near moving, cutting machinery, or at heights. The license to drive private cars for patients with persistently compensated stable diabetes without a tendency to hypoglycemia can be granted on an individual basis, provided that the patient sufficiently understands the importance of treating their disease (WHO, 1981). In addition to these restrictions, professions associated with irregular working hours and business trips are contraindicated for persons in need of insulin therapy.

Young patients should not choose professions that interfere with strict adherence to a diet (cook, pastry chef). The optimal profession is one that allows for a regular alternation of work and rest and is not associated with differences in the expenditure of physical and mental strength. The possibility of changing a profession should be especially carefully and individually assessed in persons who became ill in adulthood and with an already established professional position. In these cases, first of all, it is necessary to take into account the patient’s health status and the conditions that allow him to maintain satisfactory diabetes compensation for many years.

When deciding on the issue of work ability, the form of diabetes, the presence of diabetic angio- and polyneuropathies, and concomitant diseases are taken into account. Mild diabetes mellitus usually does not cause permanent disability. The patient can be engaged in mental as well as physical labor that does not involve much stress. Some restrictions in work activity in the form of establishing a standardized working day, excluding night shifts, and temporary transfer to another job can be carried out by an advisory and expert commission.

In patients with moderate diabetes mellitus, especially with angiopathy, the ability to work is often reduced. Therefore, they should be recommended to work with moderate physical and emotional stress, without night shifts, business trips, or additional stress. Restrictions apply to all types of work that require constant attention, especially in patients receiving insulin (possibility of developing hypoglycemia). It is necessary to ensure the possibility of insulin injections and compliance with the dietary regime in a production environment.

When transferred to a lower-skilled job or with a significant reduction in the volume of production activity, patients are determined to have Group III disability. The ability to work in persons involved in mental and light physical work is preserved; the necessary restrictions can be implemented by decision of the advisory and expert commission of the medical institution.

Table 14. Clinical expert classification of working capacity in DM-1

In case of decompensation of diabetes, the patient is given a certificate of incapacity for work. Such conditions, which occur frequently and are difficult to treat, can cause permanent loss of ability to work in patients and the need to establish group II disability. Significant disability, characteristic of patients with severe diabetes mellitus, is caused not only by disruption of all types of metabolism, but also by the addition and rapid progression of angio- and polyneuropathy, as well as concomitant diseases.

Table 15. Clinical expert classification of working capacity in T2DM

The rapid progression of nephropathy, retinopathy, atherosclerosis can lead to loss of vision, the development of severe renal failure, heart attack, stroke, gangrene, that is, to permanent disability and transfer to disability group II or I by the decision of a medical and social expert commission.

An assessment of the degree of disability in patients with visual impairment due to diabetic retinopathy or diabetic cataracts is carried out after consultation with an expert ophthalmologist in a special medical and social expert commission on diseases of the organ of vision. Currently, in connection with the adoption at the government level of the federal program “Diabetes Mellitus” (1996-2005), a special diabetes service has been created. The main responsibility of a diabetes doctor at a district clinic is the treatment of patients with diabetes and clinical observation of them.

All patients with diabetes are registered at their place of residence and at the diabetes center. This is necessary in order to monitor treatment.

If the patient is registered, he may be prescribed subsidized medications and scheduled for an annual examination. Typically, hospitalization in a hospital is not necessary for such medical examination. But sometimes the clinic at the place of residence does not have the necessary diagnostic facilities, so the patient is sent to the central hospital.

Patients with diabetes are monitored by endocrinologists. If there is no such specialist in the area, then the medical examination is carried out by a therapist or general practitioner.

Unfortunately, the therapist does not always have time to organize proper medical examination of patients with diabetes. In such a situation, it is advisable for the patient to make an appointment himself and undergo all the necessary tests.

What examinations are needed annually?

Absolutely all patients are prescribed tests and instrumental studies. This examination is considered preventive. It helps identify complications of diabetes in the early stages.

clinical blood test;
blood chemistry;
general urine test (4 times a year);
examination of 24-hour urine for microalbuminuria;
fluorography (FLG);
electrocardiography (ECG).

In a clinical blood test, the doctor evaluates the level of hemoglobin, red blood cells, leukocytes, platelets, etc. The patient may have anemia and other pathological conditions.

In a biochemical blood test for patients with diabetes, the following parameters are especially important:

calcium;
potassium;
sodium;
direct and total bilirubin;
transaminases (ALT and AST);
creatinine;
urea;
total cholesterol;
triglycerides;
cholesterol fractions (HDL, LDL, VLDL), etc.

Based on these indicators, an endocrinologist can suspect and confirm: fatty hepatosis, chronic renal failure (diabetic nephropathy), lipid disorders (high risk of atherosclerosis), etc.

In a general urine test, the presence of glucose, acetone, bacteria, leukocytes, and red blood cells is analyzed. Based on this analysis, one can judge the state of carbohydrate metabolism and the state of the urinary system.

A 24-hour test for protein in the urine (microalbuminuria) can detect diabetic nephropathy at an early stage.

FLG is used to detect pulmonary tuberculosis. This infectious disease often occurs when the immune system is weakened. All patients with diabetes are at risk for tuberculosis.

An ECG is prescribed to detect gross disturbances in the functioning of the heart. The cardiogram may show cardiac arrhythmias, atrial or ventricular overload, and signs of myocardial ischemia.

If the patient’s test results reveal abnormalities, he is recommended to consult with specialists: a cardiologist, nephrologist, gastroenterologist, phthisiatrician, etc.

Visiting doctors

Even if there are no abnormalities in tests, ECG or FLG, the patient still needs to visit specialists.

Every year, all patients need consultation:

neurologist;
ophthalmologist;
gynecologist (women).

A neurologist evaluates the condition of the nervous tissue. The doctor checks sensitivity, muscle strength, reflexes. In addition, the neurologist evaluates memory, intelligence, and emotional reactions. This specialist most often diagnoses peripheral sensorimotor neuropathy and encephalopathy in patients with diabetes.

An ophthalmologist diagnoses eye diseases.

At the reception the following must be assessed:

visual acuity;
condition of the fundus vessels;
transparency of the media of the eye (vitreous body, lens);
intraocular pressure.

An examination may reveal complications of diabetes:

diabetic retinopathy;
diabetic glaucoma;
diabetic cataract.

Based on the results, treatment may be prescribed: active observation, drops, other medications, surgery.

An annual examination by a gynecologist for women with diabetes is needed to identify infectious and oncological processes and other gynecological diseases.

In addition, the doctor provides advice on contraception and pregnancy planning.

Where to watch

Clinical examination is carried out at the district clinic at the place of residence. To register and start being observed, you need to come to an appointment with a doctor with documents (passport, insurance policy, SNILS card, extracts).

If it is inconvenient for you to be observed at the place of registration, then choose a more suitable medical institution. It is possible that registration will require permission from the head of the clinic and a certificate from the medical institution at the place of registration.

Specialized care is also provided to patients in Diabetes Centers. These departments can be organized in the central district hospital, city or regional hospital.

Diabetes centers usually have a fairly good diagnostic base, and consultations with doctors of various specialties are organized (podiatrist, vascular surgeon, andrologist, etc.).

Diabetes centers also conduct regular classes for patients. These educational programs are called “Diabetes School.” It is advisable to attend such classes every year. The educational program is regularly updated and expanded.