TYPE 2 DIABETES RISK EVALUATION

HISTORY

updating the patient’s history

PREVIOUS CARDIOVASCULAR RISK

List any previous cardiovascular risks

PREVIOUS METABOLIC AND CARDIOVASCULAR SEROLOGY

LFTs

Fasting Lipids

TC

HDL

LDL

TG

HBa1c

FBSL

SNAPE

  • Smoking – nil
  • Alcohol – minimial at x per day
  • Nutrition – adequate and varied good nutritional intake that appears toy be inaccordance with the NHMRC guidelines
  • Mental Health – NAD
  • Exercise – 30 min per day on average

SUN EXPOSURE

History of sun exposure

early signs of skin cancer

FAMILY HISTORY

Any familiy histpry of chronic disease

MEDICATIONS

List medications

EXAMINATION

undertaking physical examinations

Observations

Gen – well

Obs – NAD

Blood Pressure – xx/xx

Random BSL

done in office

RBSL =

Anthropometrics

Height

Weight

BMI

Waist circumference

Neck circumference

Cardiovascular system

Pulse Rate – xx regular

Heart Auscultation – HS I + II + O

Carotid pulse character  – NAD

Radial pulse character – NAD

Radio-radial delay – NAD

Lower Limb examination

Paedal pulses intact at dorsalis pedis and medial malleolus

Nil signs of peripheral neuropathy

Nil trophic changes

Nil ulcers

ABI =

Tone – NAD

Power – NAD

Reflexes – NAD

Coordination – NAD

Sensation – NAD

Upper Limb Examination

Nil signs of peripheral neuropathy

Nil trophic changes

Nil ulcers

Tone – NAD

Power – NAD

Reflexes – NAD

Coordination – NAD

Sensation – NAD

Ophthalmic Examination

Nil signs of diabetic retinopathy seen on fundoscopy

Nil arcus cornelius

Nil xantholasma

Nil signs of cataracts on red reflex examination

Skin

Nil bruising or bleeding

Nil skin tags

Nil spider naevi

No early signs of skin cancer

Abdo

Nil hepatosplenomegaly

Nil palpable liver

OFFICE INVESTIGATIONS

ECG

UWT

Fingerprick Glucose

ABI

AUSDRISK SCORE

The type 2 diabetes risk evaluation must include:

? evaluating a patient’s ‘high risk’ score as determined by the Australian Type 2

Diabetes Risk Assessment Tool, which has been completed by the patient within a

period of 3 months prior to undertaking the type 2 diabetes risk evaluation;

INVESTIGATIONS RESULTS

LFTs

Fasting Lipids

TC

HDL

LDL

TG

HBa1c

FBSL

IMPRESSION

Habitus – Obese with BMI x

T2DM risk = x

Cardiovascular risk factors = x

Lifestyle = x

Fracture risk =

CVD Risk =

PLAN

Refer for investigations

Advice regarding weight management provided

Advice regarding nutrition provided

Advice regarding lifestyle changes provided

Human papillomavirus (HPV) test every five years

Mammogram for women dependent on her individual degree of risk

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