Standards of Medical Care for Patients with Diabetes Mellitus
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POSITION STATEMENT Standards of Medical Care for Patients With Diabetes Mellitus iabetes is a chronic illness that requires contin- Dietary habits, nutritional status, and weight history; uing medical care and education to prevent acute growth and development in children complications and to reduce the risk of long- Details of previous treatment programs, including Dterm complications. People with diabetes should diabetes education receive their treatment and care from physicians with Current treatment of diabetes, including medications, expertise and a special interest in diabetes. The follow- diet, and results of glucose monitoring ing standards define basic (minimum) medical care for Exercise history people with diabetes. These standards are not intended Frequency, severity, and cause of acute complica- to preclude more extensive evaluation and management tions such as ketoacidosis and hypoglycemia of the patient. For more detailed information refer to Prior or current infections, particularly skin, foot, den- Physician's Guide to Insulin-Dependent (Type I) Dia- tal, and genitourinary betes: Diagnosis and Treatment and Physician's Guide Symptoms and treatment of chronic complications to Non-Insulin-Dependent (Type II) Diabetes: Diagnosis associated with diabetes: eye, heart, kidney, nerve, and Treatment. sexual function, peripheral vascular, and cerebral vascular Other medications that may affect blood glucose INITIAL VISIT concentration Risk factors for atherosclerosis: smoking, hyperten- Medical history. The comprehensive medical history sion, obesity, hyperlipidemia, and family history can uncover symptoms that will help establish the di- Psychosocial and economic factors that might influ- agnosis in the patient with previously unrecognized di- ence the management of diabetes abetes. If the diagnosis of diabetes has already been Family history of diabetes and other endocrine dis- made, the history should confirm the diagnosis, review orders the previous treatment, help evaluate the present degree Gestational history: hyperglycemia, delivery of an in- of glycemic control, determine the presence or absence fant weighing >9 Ib, toxemia, stillbirth, polyhydram- of the chronic complications of diabetes, assist in for- nios, or other complications of pregnancy mulating a management plan, and provide a basis for continuing care. Elements of the medical history of par- ticular concern in patients with diabetes include: Physical examination. A complete physical examina- tion should be performed during the initial evaluation. • Symptoms and laboratory test results related to the Individuals with diabetes are at high risk of developing diagnosis of diabetes eye, kidney, nerve, cardiac, and vascular complica- tions. Patients with type I (insulin-dependent) diabetes also have an increased frequency of thyroid disease, and Originally approved October 1988. Reprinted from Diabetes Care 12:365-68, 1989. all individuals with diabetes are at increased risk of in- Copyright 1989 by the American Diabetes Association. fections. Children may have delayed growth and mat- 10 DIABETES CARE, VOL. 14, SUPPL. 2, MARCH 1991 POSITION STATEMENT uration. Therefore, certain aspects of the physical ex- providing written material appropriate to the patient/ amination require special attention. These include: family educational level. The management plan should include: • Height and weight measurement (and comparison to norms in children) • Statement of goals • Sexual maturation staging • Medications: insulin, oral glucose-lowering agents, • Blood pressure determination (with orthostatic mea- antihypertensive, lipid-lowering agents, or other surements) medications as needed • Ophthalmoscopic examination, if possible with dila- • Individualized nutrition recommendations and in- tion structions, preferably by a dietitian • Thyroid palpation • Recommendations for life-style changes (e.g., exer- • Cardiac examination cise, smoking cessation) • Evaluation of pulses (with auscultation) • Patient and family education: assessment of knowl- • Foot examination edge and understanding of diabetes and diabetes • Skin examination (including insulin-injection sites) management skills; plan for education consistent with • Neurological examination the National Standards for Diabetes Patient Education • Dental and periodontal examination of the American Diabetes Association • Monitoring instructions: self-monitoring of blood and/ The examiner should also be alert for signs of diseases or urine glucose, urine ketones, and use of a record that can cause secondary diabetes, e.g., hemochroma- system tosis, pancreatic disease, and endocrine disorders such • Referral to an eye doctor for a comprehensive eye and as acromegaly and Cushing's syndrome. visual examination: all patients aged 12-30 yr with Laboratory evaluation. Each patient should undergo a diagnosis of diabetes of at least 5 yr duration or over laboratory tests that are appropriate to the evaluation of age 30 yr at time of diagnosis or any patient with the individual's general medical condition. In addi- visual symptoms and/or abnormalities tion, certain tests should be obtained to establish the • Consultation for specialized services as indicated diagnosis of diabetes, determine the degree of glycemic • Agreement on ongoing support and follow-up: return control, and define associated complications and risk appointment and when and how to contact the phy- factors. These include: sician or other members of the health-care team for • Fasting plasma glucose: a random plasma glucose may problem-solving and crisis management be obtained in an undiagnosed symptomatic patient • For women of childbearing age: discussion of contra- for diagnostic purposes ception and review of program of diabetes care before • Glycosylated hemoglobin (HbA! or HbAlc) and during pregnancy • Fasting lipid profile: total cholesterol, high-density li- poprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides CONTINUING CARE • Serum creatinine in adults or if proteinuria is present • Urinalysis: ketones, glucose, protein, microscopic if A continuing-care plan is an essential feature in the indicated; after 5 yr of diabetes or after puberty, total management plan of every patient with diabetes. At each urinary protein excretion should be measured by a visit, the patient's progress in achieving treatment goals microalbuminuria method if available should be evaluated, and problems that have occurred • Urine culture: if microscopic is abnormal or symp- should be reviewed. If goals are not being met, both the toms are present goals and the treatment plan need to be reassessed. • Thyroid function tests (T4 or thyroid-stimulating hor- mone) VISIT FREQUENCY • ECG (in adults) The frequency of patient visits depends on the type of Management plan. The management plan should be diabetes, degree of blood glucose control achieved, formulated as an individualized therapeutic alliance be- changes in the treatment regimen, and presence of com- tween the patient/family, the physician, and other mem- plications of diabetes or other medical conditions. bers of the health-care team (e.g., RN, RD) to achieve Patients starting insulin or having a major change in the desired level of diabetes control. Consideration must their insulin program may need to be in contact with be given to the age of the patient, school or work sched- their care provider as often as daily until glucose control ules and conditions, physical activity, eating habits, so- is achieved, the risk of hypoglycemia is low, and the cial situation and personality, and presence of compli- patient is competent to conduct the treatment program. cations of diabetes or other medical conditions. Some patients may require hospitalization for initiation Implementation of the management plan requires that or change of therapy. Contact with the patient after a each aspect be understood by the patient and the care major modification of the treatment plan should not be provider and that the goals and means be considered delayed >1 wk. realistic. Instructions and plans should be reinforced by Patients beginning treatment by diet or oral glucose- DIABETES CARE, VOL. 14, SUPPL. 2, MARCH 1991 POSITION STATEMENT lowering agents may need to be contacted weekly until tions should be measured and glomerular filtration as- reasonable glucose control is achieved and the patient sessed. is competent to conduct the treatment program. Contact Management plan. The plan should be reviewed at with these patients after a major modification of the each regular visit to determine progress in meeting goals treatment plan should be no more than 1 mo later. and to identify problems. This review should include Regular visits should be scheduled for insulin-treated nutritional evaluation and weight control, the exercise patients at least quarterly and for other patients at least regimen, the control of blood glucose and desired lipid semiannually. All patients must be taught some method levels, frequency of hypoglycemia, adherence to all as- of monitoring glycemic control. In insulin-treated pa- pects of self-care, assessment of complications, follow- tients, and in non-insulin-treated patients with poor up of referrals, and psychological adjustment. In addi- metabolic control, this should be blood glucose testing; tion, knowledge of diabetes and self-management skills in other patients, blood glucose testing may be useful. should be reassessed at least annually. Patients must be taught to recognize