Symptoms

Does the patient complain of abdominal pain?

If they present with abdominal pain then consider diabetic ketoacidosis.  

Does the patient complain of changes to their vision? 

If the patient is experiencing ameurosis fugax, loss of field of vision or visual neglect consider cerebral vascular disease

If the patient is experiencing blurred vision consider poorly controlled T1DM and T2DM

If the patient describes floaters (small coloured mobile patches in the visual field) consider vitreous haemorrhage

If the patient is experiencing a 'blind spot', or visual loss, in one eye consider vitreous haemorrhage

If the patient describes any sudden change in vision consider vitreous haemorrhage or hypoglycaemia

Does the patient complain of pain in the calf muscles on exertion? 

If the patient complains of pain on the back of their legs or buttocks consider peripheral vascular disease

Has the patient experienced confusion? 

If the patient has experienced sudden onset confusion, it is suggestive of hypoglycaemia

If the patient has experienced gradual onset confusion consider HHS

Is the patient also deaf? 

If the patient is deaf consider mitochondrial diabetes

Has the patient had difficulty speaking? 

If the patient has experienced dysphasia consider TIA or stroke.  

If the patient has experienced transient dysphasia and associated symptoms consider hypoglycaemia

Does the patient complain of diarrhoea? 

If a patient with T2DM complains of diarrhoea consider stopping their metformin.  

If a patient presents with long standing diarrhoea consider small bowel bacterial overgrowth associated with autonomic neuropathy and gastroparesis

Is the patient experiencing problems with their legs and/or feet? 

If the patient has evidence of foot ulceration consider neuropathy and peripheral vascular disease.

If the patient is complaining of pain in their feet and legs which is predominantly at night and of a burning or shooting nature consider neuropathy.

Does the patient complain of tiredness? 

If the patient complains of lethargy consider hyperglycaemia

Tiredness, cold intolerance and constipation are suggestive of associated hypothyroidism

Other causes to consider include B12 deficiency due to co-existent pernicious anaemia or due to metformin therapy, and iron deficiency dut to co existent coeliac disease.

Does the patient complain of numbness? 

If the onset is acute and the numbness is confined to one side of the body then consider TIA.

If the onset of numbness is gradual, the symptom has been present for a long time and is associated with pain or unpleasant alterations of sensation then consider neuropathy

Has the patient suffered weakness? 

If the patient has experienced transient weakness of the face, arm or leg consider TIA or hypoglycaemia.

Does the patient complain of excessive thirst? 

If the patient complains of excessive thirst, and the need to drink large volumes of fluid, the most likely cause is T1DM but also consider T2DM

Has the patient experienced seizures? 

If the patient complains of seizures consider hypoglycaemia

Has the patient experienced unconsciousness? 

If the patient complains of unconsciousness consider hypoglycaemia, HHS and DKA

Is the patient experiencing vomiting? 

If the patient is experiencing vomiting - in an acute situation - consider DKA.

If the patient has been vomiting over a long period consider diabetic gastroparesis

Does the patient describe weight loss? 

If the patient describes rapid weight loss consider T1DM

If the patient describes more modest weight loss consider LADA

Is the patient experiencing frequent and/or recurrent hypoglycaemia?

 This symptom can have many potential causes but important ones to consider are:

1) What is the HbA1c? if below target the total daily dose of insulin may be too high

2) Is there lipohypertrophy at the injection sites? - this can cause erratic absorption of insulin and these sites should be avoided

3) Is the patient self-adjusting insulin doses and what system are they using to do so? - patient education may need to be re-visited

4) Does the patient have co-existent autonomic neuropathy and gastroparesis? this is a particularly challenging set of circumstances to manage

5) Has addison's disease been excluded? - consider performing a short synacthen test

6) Has celiac disease been excluded? - TTg antibodies should be requested.

7) Is there a relationship to drinking alcohol?

8) Is there a relationship to exercise?

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