A first diabetes consultation is mostly history, examination and baseline tests. Three of those baseline checks belong at diagnosis itself rather than later, a dilated eye examination, kidney tests, and a complete foot examination, and each is repeated at least once a year afterwards (ICMR Guidelines for Management of Type 2 Diabetes 2018).
That is why a first visit takes longer than a prescription refill. ICMR's own instruction for the first visit is that "on the first clinic visit detailed history and a thorough examination with preliminary tests are essential" (ICMR, 2018, Section 8.2). Blood sugar is one line of that visit, not all of it.
One thing before the rest. AJSMC is an outpatient and day-care multi-specialty centre in Egmore, Chennai, open Monday to Saturday, 10am to 9pm. It has no casualty unit, no emergency department, no inpatient beds, no intensive care and no cardiologist. A person with diabetes who is vomiting, drowsy or confused, breathing rapidly, or unable to keep fluids down needs a hospital with a 24-hour emergency department — call 108 or go straight there, rather than waiting for an outpatient slot. The same applies to a foot that is ulcerated, infected, hot and swollen, or suddenly cold and painful. Those are not appointments to book for next week.
Low blood sugar is the other acute emergency, and it does not look like the one above. Sweating, shaking, sudden confusion or drowsiness in a person taking diabetes medicines means a low sugar until proved otherwise, and it is treated at once with sugar by mouth rather than waited out or driven to an outpatient clinic. If the person cannot swallow safely, cannot be roused, or has a fit, that is 108 or the nearest hospital with a 24-hour emergency department.
Which tests are done at diagnosis, and how often are they repeated?
ICMR sets three checks at the time of first diagnosis and then annually — eyes, kidneys and feet, and separately sets the rhythm for blood sugar monitoring. The intervals below are the guideline's, not a clinic's schedule, so they hold wherever in Chennai a person is seen.
| Check | When it is first done | How often it is repeated | Source |
|---|---|---|---|
| Dilated retinal examination by a trained ophthalmologist | At the time of first diagnosis | At least annually | ICMR 2018, recommendation 3.2 |
| Kidney assessment — urine albumin-creatinine ratio and serum creatinine, with calculated eGFR | At the time of diagnosis | At least annually | ICMR 2018, recommendation 3.3 |
| Comprehensive foot examination for nerve damage and reduced circulation | At the time of first diagnosis | At least annually, and more often by risk category | ICMR 2018, recommendation 3.4 |
| HbA1c | At the first visit, with whatever recent report exists | At least every 6 to 12 months; every 3 months if values are out of target or tight control is being attempted | ICMR 2018, Section 5.1 |
| Fasting and 2-hour post-prandial plasma glucose | Baseline | At least once a month, more often if out of target | ICMR 2018, Section 5.1 |
| Clinical examination, including blood pressure | First visit | Every visit, and at minimum every 3 months | ICMR 2018, Section 5.1 |
| Foot inspection and foot-care advice | First visit | Every visit | ICMR 2018, Section 5.1 |
| Annual panel — lipids, blood urea and serum creatinine, urine routine and urine albumin, haemogram, ECG | Baseline | At the annual check-up | ICMR 2018, Section 5.3 |
| Screening for retinopathy, nephropathy, neuropathy, peripheral vascular disease and coronary artery disease | Baseline, with the diagnosis-time checks above | At least once a year | ICMR 2018, Section 5.1 |
Some of these are done where the consultation happens and some are arranged elsewhere. Before travelling to AJSMC in Egmore, Chennai, call 044 2532 2021 and ask which of the tests named above can be given on the day and which will be arranged outside. That one call saves a second trip. AJSMC has an in-house laboratory.
Do I have to fast before the first visit?
Only if a fasting plasma glucose or an oral glucose tolerance test is planned. HbA1c does not need a fast. A post-prandial sample is deliberately taken after a meal, so fasting for it defeats the purpose. Ask when the appointment is made which sample is being planned, so the fast matches the test.
This matters more than it sounds for anyone already on treatment for diabetes. Coming in fasting when nobody asked for a fasting sample, while continuing the usual medication, risks a low sugar in the waiting room — sweating, shaking, sudden confusion or drowsiness, which is treated at once with sugar by mouth and not waited out. Do not stop, change or skip any medicine before the visit either — bring it with you instead and let the consultant decide. The one number to have with you is the time of the last dose and the last meal.
How often should HbA1c be checked?
At least every six to twelve months when the numbers are where they should be, and every three months when they are not, or when tighter control is being attempted (ICMR, 2018, Section 5.1). There is no guideline anywhere in that document for repeating it monthly, and no value in doing so, the test reflects a longer window than a month.
Between HbA1c tests, ICMR asks for fasting and two-hour post-prandial plasma glucose at least once a month, and more often when readings are out of target. Home monitoring with a glucometer is described as ideal for every patient and mandatory for anyone on insulin, anyone with brittle diabetes, anyone prone to ketosis or recurrent low sugars, and anyone who does not get the usual warning symptoms of a low sugar (ICMR, 2018, Section 5.2). That last group is the reason the warning signs are worth learning by heart: if the body has stopped announcing a low sugar, the meter and the people around you are the only warning left. Urine glucose testing is not recommended — if the household has been using urine strips, bring that up at the visit in Egmore rather than bringing the strips.
Why does the eye test have to be a dilated one?
Because the retina cannot be judged from the front of the eye or from a spectacle test. ICMR states plainly that "glasses testing/refraction should not be mistaken for retinal examination", and that a dilated retinal examination, preferably by a trained retina specialist, is mandatory (ICMR, 2018, Section 8.5.3).
The second reason is harder to accept and more important. ICMR warns in the same section that severe diabetic retinopathy can be present even with good vision. Someone reading a phone screen comfortably can still have changes at the back of the eye that only a dilated examination will find. Waiting until vision drops is waiting too long, and if vision does drop in a person with diabetes, ICMR treats that as vision-threatening retinopathy needing immediate referral.
| Situation | When the retina is first examined | Then |
|---|---|---|
| Type 2 diabetes | At the time of diagnosis | Annually |
| Type 1 diabetes | Within 5 years of diagnosis | Annually |
| Pre-existing diabetes and planning a pregnancy | Before conception, and referral to an ophthalmologist or retina specialist early in the first trimester | As advised by the specialist |
Source: ICMR Guidelines for Management of Type 2 Diabetes 2018, Section 8.5.3. Where a retinal examination cannot be performed at the place of consultation, ICMR makes referral for it mandatory rather than optional, so expect to be asked at the next visit whether it was done. AJSMC publishes an ophthalmology department with a consultant ophthalmologist; ask on the booking call how the dilated examination is arranged.
Why do they want to look at my feet every single time?
Because the examination is looking for loss of sensation, not for pain. ICMR asks for a complete foot examination at first diagnosis and at least annually, with palpation of the pulses at the top of the foot and behind the inner ankle, and testing of sensation with a monofilament and for vibration (ICMR, 2018, Sections 5.3 and 8.2.2). Foot inspection and foot-care education are then listed for every visit, not every year.
How often the detailed examination is repeated depends on what the first one finds. This is the guideline's own risk grid, and it is worth knowing which row you are in before you decide how seriously to take the next appointment.
| Risk category | What it means | How often the feet are examined |
|---|---|---|
| Low risk | Normal foot pulses, normal vibration and monofilament sensation, no history of ulceration, no significant deformity, no visual impairment | Annual |
| Moderate risk | Reduced vibration or monofilament sensation, or absent pulses in the foot | Annual or more often as required |
| High risk | Pain in the calves on walking or at rest, previous ulceration, or Charcot neuroarthropathy | Every 6 months or more often |
| Active foot disease | Ulceration, infection, suspected Charcot foot or poor blood supply | At least once weekly |
Source: ICMR Guidelines for Management of Type 2 Diabetes 2018, Table 8.1. Anyone with a previous foot ulcer, an amputation, or peripheral vascular disease needs the feet examined at every clinic visit, or at least every three months. Active foot disease, an ulcer, an infected foot, a foot that is hot, swollen or discoloured — is not an ordinary outpatient booking; AJSMC has no inpatient beds, no intensive care and no general surgeon on its roster, so that goes to a hospital equipped to admit and operate.
What will the doctor ask me?
More about the last few years than about today. ICMR's first-visit history has four parts, and knowing them in advance is the difference between a thorough first consultation and one that has to be repeated.
| Part of the history | What is asked |
|---|---|
| Present history | Symptoms suggesting organ involvement; how long the diabetes has been known; current medicines and their doses; how regularly they are actually taken; the latest blood glucose, HbA1c and other laboratory reports available |
| Past history | High blood pressure, heart disease, known kidney disease, tuberculosis, eye problems including any laser treatment, past surgery, any non-healing ulcer or amputation |
| Personal history | Smoking and other tobacco use, alcohol, what a normal day's eating looks like, physical activity |
| Family history | Diabetes and diabetic complications, high blood pressure, kidney disease, stroke, coronary artery disease |
Source: ICMR Guidelines for Management of Type 2 Diabetes 2018, Section 8.2.1. The examination that follows covers blood pressure sitting and standing, the heart and chest, the abdomen, the nervous system, the pulses in the legs and neck, swelling of the feet, and the feet themselves (ICMR, 2018, Section 8.2.2).
What should I bring to a first diabetes consultation?
Bring the objects, not the memory of them. Every item below maps to something ICMR's first visit explicitly requires, which is why a visit with the bag packed is worth more than a visit without it.
| What to bring | Why it is needed |
|---|---|
| Every medicine strip or box currently being taken — including those for blood pressure and cholesterol, not only the diabetes ones | The first-visit history requires medicines and doses, and how regularly they are taken. A strip settles both; a name half-remembered settles neither |
| The most recent laboratory reports — blood glucose, HbA1c, kidney and lipid reports, however old | ICMR asks for the latest blood glucose, HbA1c and other laboratory reports available |
| The glucometer itself, with its stored readings, or the notebook the readings are written in | Self-monitoring readings are part of the assessment (ICMR, Section 5.2), and the pattern across a week says more than one reading on the day |
| Any past eye reports, including any laser treatment | Eye problems including laser therapy are named in ICMR's past history |
| Discharge summaries from any hospital admission or surgery, and any record of a foot ulcer or amputation | All named in ICMR's past history |
| Any ECG or cardiac reports already done | Heart disease is named in ICMR's past history, and an ECG is part of the annual panel — an older tracing to compare against is worth having |
| What is known of the family history — diabetes, kidney disease, stroke, heart disease | Named as its own section of the first-visit history |
| Spectacles, and the footwear normally worn all day | The examination includes vision and a complete foot examination; everyday footwear tells the consultant more than a new pair kept for hospital visits |
If old reports are with a relative or in another clinic's file, bring photographs of them on a phone rather than nothing.
What numbers is the treatment aiming at?
ICMR publishes an ideal range for each, and immediately qualifies it: "any target is only a general guideline, and individualized targets are to be established", and targets are revised in older people and once complications appear (ICMR, 2018, Section 4). Read the table as the starting position for a conversation, not as a pass mark.
| What is measured | ICMR ideal range |
|---|---|
| Fasting plasma glucose | 80–110 mg/dl |
| 2-hour post-prandial glucose | 120–140 mg/dl |
| HbA1c | Below 7% |
| Blood pressure | Below 130/80 mmHg |
| Body mass index | 20–23 kg/m2 |
| Waist circumference | Below 90 cm in men, below 80 cm in women |
| Total cholesterol | Below 200 mg/dl |
| LDL cholesterol | Below 100 mg/dl; below 70 mg/dl in those at high risk |
| Non-HDL cholesterol | Below 130 mg/dl |
| Triglycerides | Below 150 mg/dl |
| HDL cholesterol | Above 40 mg/dl in men, above 50 mg/dl in women |
Source: ICMR Guidelines for Management of Type 2 Diabetes 2018, Tables 4.1 and 4.2, and summary recommendation 2.6. Which medicines, if any, are used to get there is a decision for the consultant with the individual patient in front of them, and it is not something a web page can or should set. Chasing a target harder than the person can safely manage is how low sugars start, which is the other half of the same conversation.
What happens after the first visit?
The non-medicine half of the plan is set at the first visit and reviewed at every later one. ICMR's stated lifestyle goals are optimum nutrition, energy intake matched to a reasonable body weight and normal growth, maintaining glycaemic control, achieving optimum blood lipid levels, a diet individualised to any complications and other illnesses present, optimal physical activity, behavioural change around tobacco and alcohol, and stress management (ICMR, 2018, Section 6.1). Discouraging tobacco in every form and excess alcohol is listed among the things done at each visit.
Follow-up itself is not a fixed calendar. Clinical examination happens at every visit and at minimum every three months; HbA1c every six to twelve months, or three-monthly if control is off target; and the complication screen — eyes, kidneys, nerves, circulation and heart — at least once a year (ICMR, 2018, Section 5.1). The annual check-up adds blood urea and serum creatinine, urine routine and urine albumin, lipids, a haemogram and an ECG, with chest X-ray, thyroid tests, liver tests, vitamin B12, uric acid, electrolytes or an abdominal ultrasound added only where the clinical picture calls for them (ICMR, 2018, Section 5.3).
Some results lead outward rather than back to the same room. ICMR names referral to a kidney specialist for severe or resistant high blood pressure, a high potassium level, heavy protein loss in the urine, protein in the urine without any retinopathy, a raised serum creatinine, an eGFR below 60, fluid overload or reduced urine output, and for diabetes in pregnancy with protein in the urine (ICMR, 2018, Section 8.4.4). A referral in that situation is the system working, not a setback.
The heart works the same way. ICMR's instruction is that "when patient is asymptomatic with abnormal E.C.G, refer to specialist / physician / cardiologist" (ICMR, 2018, Section 8.3). AJSMC has no cardiologist on its roster, so an abnormal ECG, or chest pain, or anything else cardiac — routes outward to a cardiologist or a hospital that has one, in the same way a foot needing admission does.
When is this not an outpatient problem at all?
When the picture is acute. Vomiting that will not stop, drowsiness or confusion, rapid or laboured breathing, or being unable to keep fluids down in a person with diabetes belongs in a hospital with a 24-hour emergency department, reached by calling 108 if needed. So does an ulcerated, infected, hot or swollen foot, and a foot that turns cold, pale and painful. So does chest pain.
A low sugar is its own emergency and needs naming separately, because it is the commonest acute problem in treated diabetes and it does not come with vomiting. Sweating, shaking, sudden confusion or drowsiness in a person on diabetes medicines is a low sugar until proved otherwise, and it is treated at once with sugar by mouth. If the person cannot swallow safely, cannot be roused, or has a fit, nothing is given by mouth. That is 108 or the nearest hospital with a 24-hour emergency department, straight away.
AJSMC has no casualty unit, no emergency department, no inpatient beds, no intensive care, no cardiologist and no general surgeon, and there is no outpatient service in Egmore outside Monday to Saturday, 10am to 9pm, nothing at all on a Sunday. If any of the above happens at night or on a Sunday, do not wait for AJSMC to open. What an outpatient diabetology consultation is for is the baseline assessment, the yearly complication screen, and keeping the plan on track between those.
When should you see a doctor?
See a diabetology or general medicine consultant at diagnosis, and then on the interval you are given — with the strips, the reports and the glucometer in the bag. Come sooner than the appointment if vision changes in either eye, if any break in the skin of the foot is not healing, if there is new numbness, burning or tingling in the feet, if home readings are consistently outside the range you were given, or if low sugars have been happening and settling with sugar by mouth, the treatment plan needs revisiting before the next one is worse.
Go to a hospital with a 24-hour emergency department instead, or call 108, for drowsiness, confusion, unrousability or a fit; for vomiting that will not stop or an inability to keep fluids down; for breathing that has become rapid or laboured; for chest pain; or for a foot that is infected, hot and swollen, or suddenly cold and painful. In anyone taking diabetes medicines, sweating, shaking, confusion or drowsiness means a low sugar first — treat it at once with sugar by mouth, and if the person cannot swallow safely, cannot be roused or has a fit, call 108 rather than booking an outpatient slot.
Outpatient consultations in General Medicine and Diabetology at AJSMC, Police Commissioner Office Road, Egmore, Chennai 600008 run Monday to Saturday, 10am to 9pm. Call 044 2532 2021 to book, and ask on that call which of the baseline tests in this article can be given on the day.
