1. OPD follow up 1

2. General P/E Blood pressure Sites of insulin injection Deep tendon reflex 2

3. Physical examination Height and weight : Poor glycemic control Hypothyroidism Celiac 3

4. Blood pressure Physical examination 4

5. Pubertal assessment— puberty increases insulin resistance Thyroid — Check for thyroid enlargement Physical examination 5

6. Skin — Examination of injection sites for evidences of lipohypertrophy or atrophy Physical examination 6

7. Extremities — for evidence of limited joint mobility or peripheral neuropathy Annual foot examination in children ≥10 years of age Physical examination 7

8.  Eye Exam Time for screening? Before puberty :after 5 years of DM onset. After puberty:after 2 years of DM onset. Thereafter Annual ophthalmologic evaluation is needed. Physical examination 8

9. Laboratory evaluation  Hb A1C : every three months 9

10.  Age-specific goals for A1C are: <6 years of age: < % 8.5 6 to 12 years of age: < % 8 13 to 19 years of age: < % 7.5 Over 19 years of age: < % 7.0  Age-specific goals for A1C are: <6 years of age: < % 8.5 6 to 12 years of age: < % 8 13 to 19 years of age: < % 7.5 Over 19 years of age: < % 7.0 Laboratory evaluation 10

11.  Thyroid screening All children with type 1 diabetes should be screened regularly for thyroid disease at diagnosis and then every one to 2 year. Laboratory evaluation 11

12.  The best time for testing Several weeks after the diagnosis of type 1 diabetes( when metabolic control has been established) Laboratory evaluation 12

13.  Lab testing TSH Anti TPO & Anti TG Ab Laboratory evaluation 13

14.  If Abs are positive Patient should be monitored closely(6 mo). Repeat antibody testing is not needed. Laboratory evaluation 14

15.  Celiac screening All children with type 1 diabetes should be screened for celiac disease at diagnosis. Laboratory evaluation 15

16.  Best time for screening Soon after the diagnosis of type 1 diabetes Laboratory evaluation 16

17.  Best test ANTI TTG If the screening test is negative: rescreen every other year. Total IgA Laboratory evaluation 17

18.  Nephropathy screening The best time for screening? Before puberty :after 5 years of DM onset After puberty:after 2 years of DM onset There after Annual evaluation is needed. Laboratory evaluation 18

19.  Lab evaluation Random urine sample : microalbumin to creatinine ratio Laboratory evaluation 19

20.  Microalbuminuria A value of microalbumin to creatinine ratio ≥ 30 mg/g or μg/mg. Diagnosis of microalbuminuria requires an elevation in albumin excretion that persists over a three- to six-month period. Laboratory evaluation 20

21.  False positive test Urinary tract infection Hematuria Acute febrile illness Vigorous exercise Short-term pronounced hyperglycemia Uncontrolled hypertension Heart failure 21

22. Microalbuminuria and diabetic nephropathy The urine dipstick is a relatively insensitive marker for initial increases in protein excretion, not becoming positive until protein excretion exceeds 300 to 500 mg/day. 22

23. Microalb ; 40 mg/lit Urine creat ; 50 mg/dl Ratio : 40 × 1000 / 50 × 10 = 80 23

24. Monitoring of DM Lipid profile — Screen for dyslipidemia once puberty begins, and if normal, repeat the screen every five years. If abnormal, screen yearly. rescreening at the time of a prolonged episode of poor glycemic control. 24

25.  Screening for dyslipidemia After 2 years old ( after diagnosis) If the profile is within the accepted risk levels it should be repeated every five years. Because of poor control in our children we check lipid profile annaully. Laboratory evaluation 25

26.  Goal lipid levels LDL <100 mg/dl HDL >35 mg/dl TG <150 mg/dl 26

27. GLYCEMIC CONTROL Age-specific ADA blood glucose goals are: Bedtime - <6 years of age: 110 to 200 mg/dL - 6 to 12 years of age: 100 to 180 mg/dL - 13 to 19 years of age: 90 to 150 mg/dL 27

28. GLYCEMIC CONTROL Before meals - <6 years of age: 100 to 180 mg/dL - 6 to 12 years of age: 90 to 180 mg/dL - 13 to 19 years of age: 90 to 130 mg/dL 28

29. Monitoring of DM A1C, every three months. Celiac disease screening at diagnosis and every other year. Thyroid function testing —every one or two years. 29

30. Monitoring of DM Annual screening for microalbuminuria for children ≥10 years of age and five-year duration of diabetes Annual ophthalmologic examination for children ≥10 years of age and three- to five-year duration of diabetes — Screen for retinopathy Annual foot examination — Evaluate foot health and screen for neuropathy in children ≥10 years of age 30

31. Microalbuminuria and diabetic nephropathy Increased urinary protein excretion is the earliest clinical finding of diabetic nephropathy. 31

32. Microalbuminuria and diabetic nephropathy Persistent albumin excretion between 30 and 300 mg/day (20 to 200 µg/min) is called microalbuminuria Values above 300 mg/day (200 µg/min) are considered to represent overt proteinuria 32

33. Microalbuminuria and diabetic nephropathy Fever, exercise, heart failure, and poor glycemic control,HTN are among the factors that can cause transient microalbuminuria. 33

34. Microalbuminuria and diabetic nephropathy 24-hour urine collection was previously the gold standard for the detection of microalbuminuria. screening can be more simply achieved by a timed urine collection or an early morning specimen to minimize changes in urine volume that occur during the day. 34

35. Albumin-to-creatinine ratio A value above 30 mg/g (or 0.03 mg/mg) suggests that albumin excretion is above 30 mg/day and therefore that microalbuminuria is probably present. 35

36. Hypoglycemic reaction 36

37. Symptoms & signs :  Pallor  Cold sweating  Palpitation  Tachycardia  Hunger  haedache 37

38. Symptoms & signs :  Nervousness  Nightmare  Cerebral glucopenia  Convulsion  LOC 38

39. Etiology : Technical No feeding Activity Insulin Ab Adrenal insufficiency Celiac disease 39

40. Etiology : Hypothyroidism Lipodystrophy Renal failure Somogyi phenomenon Honeymoon period Hypoglycemia unawareness 40

41. Treatment of hypoglycemia :  Glucose 5 – 10 gr po  Glucagon 0.5 – 1 mg im 41