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Home / Resources / Clinical Gems / Joslin’s Diabetes Deskbook, Updated 2nd Ed., Excerpt #40: Multiple Treatments for a Multicomponent Condition, Part 2

Joslin’s Diabetes Deskbook, Updated 2nd Ed., Excerpt #40: Multiple Treatments for a Multicomponent Condition, Part 2

Richard S. Beaser, MD

Joslin_Diabetes_Deskbook

This week’s excerpt addresses the following topics:
  • How to develop a medical care plan
  • How to develop the initial assessment
  • What the medical history should detail
  • What the physical exam should include   

Developing a Medical Care Plan

Before initiating any specific therapeutic interventions for a person with type 2 diabetes, a careful assessment of the person’s general condition, related issues such as socioeconomic, cultural and lifestyle considerations are important. Preparing such an inventory in one place as part of the initial diabetes evaluation record can be helpful in visualizing the scope of interventions that will be necessary.

Development of this initial assessment begins with a careful and comprehensive history and physical examination. While many of the components of this assessment are similar to those that might be used for people with type 1 diabetes, the focus should be on issues related to treatment concerns for type 2.

Medical History 

The history should detail the following information:

1. History of diagnosis and treatment of diabetes

  • When was diagnosis made?
  • Estimate of how long the person might have had diabetes prior to diagnosis, suggested by:
    • suggestive symptoms
    • presence of complications at presentation
    • history of gestational diabetes or large babies
    • past impairment of glucose tolerance or fasting glucose
    • abnormal glucose levels in old records that may not have been acted upon
  • How the diagnosis was made?
    • acute presentation/presentation due to symptoms
    • discovery by accident
    • discovery concurrent with another illness
    • gestational diabetes
  • Treatment history
    • initiation of lifestyle changes (when, what, and how successful)
    • initiation of pharmacologic intervention (when, what medications, degree of control achieved and for how long, medication changes/combinations, insulin initiation and dosing pattern history)
    • initiation of treatments to reduce macrovascular risk factors and/or provide direct vascular protection targeting hypertension, dyslipidemia, hypercoagulation and weight management
    • weight changes before and since treatment initiation
    • treatment complications (hypoglycemia, hyperosmolar coma or diabetic ketoacidosis (DKA), adverse events relating to medication use)
2. Diabetes educational history
  • Instruction on medical nutritional therapy (MNT)
    • when (initial and refresher visits)
    • with whom (dietitian/nutritionist, nurse educator, physician, written or electronic, other)
    • details of calorie recommendations or other parameters
    • adherence to program
    • weight changes resulting from MNT
  • Basic diabetes education
    • when (initial and refresher visits)
    • with whom (certified diabetes educator [CDE], other educator, physician, written or electronic, other)
    • subjects covered and current educational deficits. Of particular importance to those people with type 2 diabetes would be:
      • Self blood glucose monitoring (SBGM) (what method/equipment taught, frequency of testing recommendation and adherence to recommendation, method and frequency of recordkeeping and adherence to recommendation, interpretation and use of results)
      • foot care
      • eye care
      • recognition of signs and symptoms of macrovascular disease
      • effects, impact, and treatment adjustments for activity
  • Instruction on exercise or physical activity
    • when (initial and refresher visits)
    • with whom (diabetes nurse educator, exercise physiologist, trainer, written or electronic, other)
    • factors limiting activity (other medical conditions, etc.)
    • initial activity recommendations
    • current type and frequency of activity
  • Current potential for further education
    • level of interest or readiness to make lifestyle changes
    • financial obstacles
    • logistical obstacles (time constraints, difficulty with access to educational resources, etc.)

3. History of conditions related to diabetes, the time of their diagnosis, and treatment history

  • Cardiovascular risk factors
    • dyslipidemia
    • hypertension
    • microalbuminuria
    • hypercoagulability with prophylactic treatment
    • smoking
    • family history of premature cardiovascular disease
    • lifestyle (obesity, activity)
  • Cardiovascular end-organ effects (when, extent of impact, treatment initiated and its success, recurrences/chronic impact, current functional status)
    • coronary artery disease
    • peripheral vascular disease
    • cerebrovascular disease
    • other (renovascular, etc.)
  • Microvascular status
    • frequency and most recent eye examination by qualified diabetes eye care professional, with results
    • hypertension treatment
    • microalbuminuria — presence, treatment, results of treatment
    • renal function status (microalbuminuria history, creatinine/creatinine clearance)
  • Neuropathic complication assessment and treatment history
    • history suggestive of peripheral neuropathic changes (pain/hypesthesia, anesthesia, neuropathic ulcers, Charcot changes)
    • monotherapies
    • Male: erectile dysfunction and/or signs/symptoms suggestive of hypoandrogenism
    • Female: reproductive problems, sexual function problems
    • bladder dysfunction
    • GI symptoms suggestive of gastropathy (early satiety, etc.) or diabetic diarrhea (diarrhea alternating with constipation)
    • orthostatic hypotension
    • cardiac neuropathy (absence of respiratory rhythm variations)
  • Other foot issues
    • podiatry consultations (if ever, frequency, most recent, issues such as toe care, calluses, deformities)
    • shoe use (types, frequency of shoe rotation/change) – foot pain or discomfort (onset, duration, severity, precipitating factors and time of day most likely to occur)
    • past foot injury/surgery
    • foot deformities
4. Current medications in use
  • Treating existing conditions
  • Preventing macrovascular disease or protecting vascular health
  • Birth control
  • Prophylaxis (aspirin, vitamins, osteoporosis/menopausal, etc.)
  • "Over-the-counter" medication habits
5. Family medical history
  • Of diabetes
  • Of macrovascular risk factors (especially dyslipidemia, hypertension)
  • Of macrovascular end organ disease
  • Of obesity
  • Of early non-accidental death
  • Of other genetic/endocrine disorders (thyroid disorders, etc.)
  • General family medical history
6. Personal/social history
  • Marital status
  • Family issues/stresses (ill relatives, marital discord, etc.)
  • Domestic violence
  • Living arrangement status (with whom, type of dwelling, who does cooking, etc.)
  • Occupational history
    • type of work
    • activity level at work
    • work schedule (hours, meal times, variability of schedule/swing shifts, predictability of schedule, overnight travel requirements, dining out and entertainment requirements)
  • Daily schedule for arising, meals, activity, bedtime
  • Substance use/abuse, current and past, with status of efforts to control (tobacco, alcohol, recreational drugs)

7. Other issues as part of a general medical history

Physical Examination 

The physical examination should include the basics of a comprehensive medical examination. For people with type 2 diabetes, focus should be, in particular, on:

  1. Height/weight/waist circumference and/or BMI
  2. Blood pressure lying/standing (checking for orthostatic changes)
  3. Ophthalmologic examination (funduscopy)
  4. Examine for bruits (carotid, femoral)
  5. Feet
    • General appearance of feet
      • color (dusky look or dependent rubor? — suggestive of ischemia)
      • presence of hair (presence of hair suggests adequate circulation, however, absence does not necessarily suggest ischemia)
      • deformities
      • ulcers or other signs of infection
      • presence of calluses or potential pressure points
    • Peripheral pulses
    • Signs of peripheral neuropathy
      • light touch (monofilament)
      • vibration (tuning fork)
      • pin prick (pin or pin wheel)
    • Shoes
      • unusual or uneven wear
      • support
      • are they custom made or have special features?
  6. Cardiopulmonary examination
    • General examination
    • Cardiac rhythm abnormalities
    • Congestion or congestive heart failure
    • Presence or absence of respiratory variations of cardiac rhythm
  7. Abdominal examination
    • General examination
    • Hepatic status
    • Signs suggestive of abdominal aneurysms
    • GI sounds
  8. Male genitalia (if history of sexual or reproductive dysfunction)
    • General examination (normal anatomy? findings suggestive of hypogonadism?)
    • Presence of signs of past injury, Peyronie’s disease, etc.
  9. Female
    • Loss of lubrication for sexual activity

Copyright © 2010 by Joslin Diabetes Center. All rights reserved. Reprinted with permission. Neither this book nor any part thereof may be reproduced or distributed in any form or by any means without permission in writing from Joslin. Note: Joslin does not endorse products or services.

You can purchase the updated 2nd Edition of JOSLIN’S DIABETES DESKBOOK at:

https://www.joslin.org/jstore/books_for_healthcare_professionals.html

Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.

Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.

This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.