Devin Pinaroc, FNP-C

 

On a typical day, primary care physicians run from exam room to exam room, completing various tasks and to-do’s for each patient as well as fielding questions from support staff and helping run the operations of the clinic. To add a layer of complexity, visit times are limited, and chief complaints require knowledge on the management of any number of chronic illnesses and acute symptoms. These difficulties can make chronic disease management overwhelming given that comprehensive care requires evaluation of the current status of disease as well as preventing any further complications or progression. For Type 2 Diabetes Mellitus (T2DM), specifically, this is quite the list. 

There are many specific care requirements that must be confirmed and monitored when managing patients with T2DM. Organization of T2DM follow-up visits ensure completion of unique steps that prevent the disease progression and reduce risk of complications and comorbidities. By creating a checklist, charting templates, and/or standardizing visits as much as possible, clinicians can deliver complete, holistic management and fulfill all routine screenings and methods to reduce progression and risk for associated comorbidities (Wexler, 2021).

 

Special Screenings 

Yearly Eye Exam. Patients with T2DM have increased risk for vision loss, cataracts, glaucoma, and retinopathy. Asking about visual acuity or any visual impairment during routine visits can help detect these issues and promote further evaluation. Regardless, an annual referral for a dilated eye exam is necessary for all diabetes to aid in early detection (Wexler, 2021).

Routine Foot Examination. Visualize the feet at every routine visit to assess for evidence of neglect or loss of sensation, like toenail infections or non-healing wounds. The medical assistant (MA) can ask the patient to remove their shoes and socks during intake and vital signs measurement. A more comprehensive foot exam can occur yearly in the primary care setting and should include pedal pulses and testing for loss of sensation with monofilament and one of the following: vibration using 128 Hz tuning fork, pinprick sensation, ankle reflex, and VPT (vibratory perception threshold) testing. An abnormal foot examination warrants a podiatrist or expert in diabetic foot care referral (Wexler, 2021).

Urinary albumin. Urinary albumin and eGFR should be screened annually to detect elevation and possible chronic kidney disease (American Diabetes Association [ADA], 2021).  

 

Glycemic Control Assessment

Glucose log and Hemoglobin A1C. An A1C value of ≤7.0 percent shows adequately controlled glucose levels.  This means target blood glucose levels should be between 80 to 130mg/dL, fasting status, and a postprandial glucose less than 180mg/dL (Wexler, 2021).The patient may have a glucose log book or a glucometer that displays daily blood glucose readings, usually in relation to time of day or meals. Asking the patient to present the average of their glucose log or directing the MA to calculate the average may be most helpful for quick assessment. The glucose log is usually necessary and more helpful with medication adjustment for insulin dependent diabetics. 

 

Reducing Cardiovascular Risk 

The American Diabetes Association recommends different statin dose therapies depending on CVSD risk stratification (2021). In general all patients with T2DM should be placed on AT LEAST a moderate intensity statin. A lipid panel should be taken at time of diagnosis, with every medication change, and at least yearly when stable. If the patient is under 40 yrs old, screening can occur every 5 years (ADA, 2021). 

Blood pressure should be assessed at every visit, and elevated blood pressure (≥140/90 mmHg) readings re-assessed. If hypertension is discovered, ACE inhibitors or angiotensin receptor blockers (ARBs) are recommended as first-line therapy. (ADA, 2021).  

Patients should also be on aspirin therapy (75-162md/day) to prevent secondary ASCVD (ADA, 2021).

 

Important Health Maintenance Topics

As with all chronic conditions, discussing healthy diet and physical activity completes a comprehensive visit. For patients with T2DM and hypertension, specifically recommend a DASH style diet (reducing sodium and potassium, moderating alcohol, and increasing physical activity) (ADA, 2021). Given these topics can be time intensive, pre-prepared handouts on how to incorporate physical activity throughout daily life and diabetic friendly meals help effectively provide information.

Address smoking cessation and highly encourage patients to quit smoking all forms of nicotine and tobacco. Studies have shown that smoking cessation has a much greater effect on overall survival than most other interventions (Wexler, 2021).

Routine vaccinations should be kept up-to-date and assessed yearly, at least. T2DM puts patients more at risk for complications from otherwise simple respiratory illness. These especially include the COVID 19 vaccine, yearly flu vaccine, and pneumonia series as per the CDC vaccine schedule. 

 

Learn More & Earn CE

Visit our Learning Center for courses related to Diabetes.

 

Other helpful links…

​​Disease Management: Diabetes — FPM Toolbox

Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

 

References

American Diabetes Association (2021). Standards of Medical Care in Diabetes-2021 Abridged for Primary Care Providers. Clinical diabetes : a publication of the American Diabetes Association, 39(1), 14–43. https://doi.org/10.2337/cd21-as01

Wexler, D. (2021, January 13). Overview of general medical care in nonpregnant adults with diabetes mellitus. UpToDate. Retrieved October 22, 2021, from https://www.uptodate.com/contents/overview-of-general-medical-care-in-nonpregnant-adults-with-diabetes-mellitus?source=autocomplete&index=2~3&search=Diabetes+mellitus+management.