Medical Practice Guidelines

Initial Visit

Medical History
Physical Examination
Laboratory Evaluation
Management Plan

Medical History           (back to top)
The comprehensive medical history can uncover symptoms that will help establish the diagnosis in the patient with previously unrecognized diabetes. If the diagnosis of diabetes has already been made, the history should confirm the diagnosis, review the previous treatment, allow evaluation of the past and present degrees of glycemic control, determine the presence or absence of the chronic complications of diabetes, assist in formulating a management plan, and provide a basis for continuing care. Elements of the medical history of particular concern in patients with diabetes include the following

	Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes
	Prior HbA1c records
	Eating patterns, nutritional status, and weight history; growth and development in children and adolescents
	Details of previous treatment programs, including nutrition and diabetes self-management education
	Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and patients' use of the data
	Exercise history
	Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia
	Prior or current infections, particularly skin, foot, dental, and genitourinary infections
	Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function; heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes
	Other medications that may affect blood glucose levels
	Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history
	History and treatment of other conditions, including endocrine and eating disorders
	Family history of diabetes and other endocrine disorders
	Gestational history: hyperglycemia, delivery of an infant weighing >9 lb, toxemia, stillbirth, polyhydramnios, or other complications of pregnancy
	Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
	Tobacco and alcohol use

 

Physical examination           (back to top)
A physical examination should be performed during the initial evaluation. People with diabetes have a high risk of developing eye, kidney, foot, nerve, cardiac, and vascular complications. Patients with type 1 diabetes have an increased frequency of autoimmune disorders, especially thyroid disease. All individuals with poorly controlled diabetes are at increased risk for infections. Children with poorly controlled diabetes may have delayed growth and maturation. Therefore, certain aspects of the detailed physical examination require particular attention. These include the following:

	Height and weight measurement (and comparison to norms in children and adolescents)
	Sexual maturation staging (during peripubertal period)
	Blood pressure determination (with orthostatic measurements when indicated) and comparison to age-related norms
	Ophthalmoscopic examination (preferably with dilation)
	Oral examination
	Thyroid palpation
	Cardiac examination
	Abdominal examination (e.g., for hepatomegaly)
	Evaluation of pulses (by palpation and auscultation)
	Hand/finger examination
	Foot examination
	Skin examination (including insulin-injection sites)
	Neurological examination
The clinician should also be alert for signs of diseases that can cause secondary diabetes, e.g., hemochromatosis, pancreatic disease, and endocrine disorders such as acromegaly, pheochromocytoma, and Cushing's syndrome.

 

Laboratory evaluation           (back to top)
Blood glucose testing and urine ketone testing should be available in the office for immediate use as needed. In addition, each patient should undergo laboratory tests that are appropriate to the evaluation of the individual's general medical condition. Certain tests should be performed to establish the diagnosis of diabetes (see the American Diabetes Association's "Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus" for a complete discussion on this subject), determine the degree of glycemic control, and define associated complications and risk factors. These include the following:

	Fasting plasma glucose (a random plasma glucose test may be performed in an undiagnosed symptomatic patient for diagnostic purposes)
	HbA1c
	Fasting lipid profile: total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol
	Serum creatinine in adults; in children if proteinuria is present
	Urinalysis: glucose, ketones, protein, sediment
	Test for microalbuminuria (e.g., timed specimen or the albumin-to-creatinine ratio) in pubertal and postpubertal type 1 patients who have had diabetes for at least 5 years and in all patients with type 2 diabetes. However, some evidence suggests that the prepubertal duration of diabetes may be important in the development of microvascular complications; therefore, clinical judgment should be used when applying these recommendations to individual patients.
	Urine culture if sediment is abnormal or symptoms are present
	Thyroid-stimulating hormone (TSH) in all type 1 patients
	Electrocardiogram in adults

 

Management Plan           (back to top)
A complete, organized medical record system is essential to providing ongoing care of people with diabetes. The records must always be accessible to the diabetes treatment team and organized so that they not only document what has occurred but also serve as a reminder of what should be done at appropriate intervals.

The management plan should be formulated as an individualized therapeutic alliance among the patient and family, the physician, and other members of the health care team skilled in the management of diabetes to achieve the desired level of diabetes control.

Patient self-management should be emphasized. To this end, the management plan should be formulated in collaboration with the patient, and the plan should emphasize the involvement of the patient in problem solving as much as possible. A variety of strategies and techniques should be employed to provide adequate education and development of problem-solving skills in the various aspects of diabetes management. In formulating this management plan, consideration should be given to the patient's age, school or work schedule and conditions, physical activity, eating patterns, social situation and personality, cultural factors, and presence of complications of diabetes or other medical conditions. Implementation of the management plan requires that each aspect be understood and agreed on by the patient and the care providers and that the goals and treatment plan are reasonable. The management plan should include the following:

	Statement of short- and long-term goals
	Medications (insulin, oral glucose- lowering agents, glucagon, antihypertensive and lipid-lowering agents, aspirin therapy, other endocrine drugs, and other medications)
	Individualized nutrition recommendations and instructions, preferably by a registered dietitian familiar with the components of diabetes MNT
	Recommendations for appropriate lifestyle changes (e.g., exercise, smoking cessation)
	Patient and family education for self-management that is consistent with the National Standards for Diabetes Self-Management Education Programs
	Monitoring instructions: SMBG, urine ketones, and use of a record system. Frequency of SMBG should be individualized according to clinical circumstances, the form of treatment employed, and the response to treatment. Urine glucose may be considered as an alternative only if the patient is unable or unwilling to perform blood glucose testing or if the only goal is avoidance of symptomatic hyperglycemia.
	Annual comprehensive dilated eye and visual examinations by an ophthalmologist or optometrist for all patients of age 10 years and older who have had diabetes for 3-5 years, all patients diagnosed after age 30 years, and any patient with visual symptoms and/or abnormalities. However, some evidence suggests that the prepubertal duration of diabetes may be important in the development of microvascular complications; therefore, clinical judgment should be used when applying these recommendations to individual patients.
	Consultation for podiatry services as indicated
	Consultation for specialized services as indicated
	Agreement on continuing support, follow-up, and return appointments
	Instructions on when and how to contact the physician or other members of the health care team when the patient has not been able to solve problems and when management of acute problems is required
	For women of childbearing age, discussion of contraception and emphasis on the necessity of optimal blood glucose control before conception and during pregnancy
	Dental hygiene
	Pneumococcal vaccine; influenza vaccine annually