2.0.0.0 COM­PRE­HEN­SIVE MED­I­CAL EVAL­U­A­TION

Rec­om­men­da­tions

4.3 A com­plete med­i­cal eval­u­a­tion should be per­formed at the ini­tial visit to:

Confirm the di­ag­no­sis and clas­si­fy di­a­betes. B

Eval­u­ate for di­a­betes com­pli­ca­tions and po­ten­tial co­mor­bid con­di­tions. B

Re­view pre­vi­ous treat­ment and risk fac­tor con­trol in pa­tients with es­tab­lished di­a­betes. B

Begin pa­tient en­gage­ment in the for­mu­la­tion of a care man­age­ment plan. B

De­vel­op a plan for con­tin­u­ing care. B

4.4 A fol­low-‍up visit should in­clude most com­po­nents of the ini­tial com­pre­hen­sive med­i­cal eval­u­a­tion in­clud­ing: in­ter­val med­i­cal his­to­ry, as­sessment of med­i­ca­tion-‍tak­ing be­hav­ior and intol­er­ance/‍ side ef­fects, phys­i­cal ex­am­i­na­tion, lab­o­ra­to­ry eval­u­a­tion as ap­pro­pri­ate to as­sess at­tain­ment of A1C and metabol­ic tar­gets, and as­sessment of risk for com­pli­ca­tions, di­a­betes self-‍man­age­ment be­hav­iors, nu­tri­tion, psychoso­cial health, and the need for re­fer­rals, im­mu­niza­tions, or other rou­tine health main­te­nance screen­ing. B

4.5 On­go­ing man­age­ment should be guid­ed by the as­sessment of di­a­betes com­pli­ca­tions and shared de­ci­sion mak­ing to set ther­a­peu­tic goals. B

4.6 The 10-year risk of a first atheroscle­rot­ic car­dio­vas­cu­lar dis­ease event should be as­sessed using the race- and sex-‍specific Pooled Co­hort Equa­tions to bet­ter strat­i­fy atheroscle­rot­ic car­dio­vas­cu­lar dis­ease risk. B

The com­pre­hen­sive med­i­cal eval­u­a­tion in­cludes the ini­tial and fol­low-‍up eval­u­a­tions, as­sessment of com­pli­ca­tions, psychoso­cial as­sessment, man­age­ment of co­mor­bid con­di­tions, and en­gage­ment of the pa­tient through­out the pro­cess. While a com­pre­hen­sive list is pro­vided in Table 4.1, in clin­i­cal prac­tice, the pro­vider may need to pri­or­i­tize the com­po­nents of the med­i­cal eval­u­a­tion given the avail­able re­sources and time. The goal is to pro­vide the health care team in­formation to op­ti­mally sup­port a pa­tient. In ad­di­tion to the med­i­cal his­to­ry, phys­i­cal ex­am­i­na­tion, and lab­o­ra­to­ry tests, pro­viders should as­sess di­a­betes self-‍man­age­ment be­hav­iors, nu­tri­tion, and psychoso­cial health (see Sec­tion 5 “Lifestyle Man­age­ment”) and give guid­ance on rou­tine im­mu­niza­tions. The as­sessment of sleep pat­tern and du­ra­tion should be con­sid­ered; a re­cent meta­-anal­y­sis found that poor sleep qual­i­ty, short sleep, and long sleep were as­so­ci­at­ed with high­er A1C in peo­ple with type 2 di­a­betes (15). In­ter­val fol­low-‍up vis­its should occur at least every 3–6 months, in­di­vid­u­alized to the pa­tient, and then an­nu­al­ly.

Lifestyle man­age­ment and psychoso­cial care are the cor­ner­stones of di­a­betes man­age­ment. Pa­tients should be re­ferred for di­a­betes self-‍man­age­ment ed­u­ca­tion and sup­port, med­i­cal nu­tri­tion ther­a­py, and as­sessment of psychoso­cial/emotional health con­cerns if in­di­cat­ed. Pa­tients should re­ceive rec­om­mend­ed pre­ventive care ser­vices (e.g., im­mu­niza­tions, can­cer screen­ing, etc.), smok­ing ces­sa­tion coun­sel­ing, and oph­thal­mo­log­i­cal, den­tal, and po­di­atric re­fer­rals.

The as­sessment of risk of acute and chron­ic di­a­betes com­pli­ca­tions and treat­ment plan­ning are key com­po­nents of ini­tial and fol­low-‍up vis­its (Table 4.2). The risk of atheroscle­rot­ic car­dio­vas­cu­lar dis­ease and heart fail­ure (Sec­tion 10 “Car­dio­vas­cu­lar Dis­ease and Risk Man­age­ment”), chron­ic kid­ney dis­ease stag­ing (Sec­tion 11 “Mi­crovas­cu­lar Com­pli­ca­tions and Foot Care”), and risk of treat­ment-‍as­so­ci­at­ed hy­po­glycemia (Table 4.3) should be used to in­di­vid­u­alize tar­gets for glycemia (Sec­tion 6 “Glycemic Tar­gets”), blood pres­sure, and lipids and to se­lect specific glu­cose-‍low­er­ing med­i­ca­tion (Sec­tion 9 “Phar­ma­co­log­ic Ap­proach­es to Glycemic Treat­ment”), an­ti­hy­per­ten­sion med­i­ca­tion, or statin treat­ment in­ten­sity.

Ad­di­tion­al re­fer­rals should be ar­ranged as nec­es­sary (Table 4.4). Clin­i­cians should en­sure that in­di­vid­u­als with di­a­betes are ap­pro­pri­ately screened for com­pli­ca­tions and co­mor­bidi­ties. Dis­cussing and im­ple­ment­ing an ap­proach to glycemic con­trol with the pa­tient is a part, not the sole goal, of the pa­tient en­counter.

Table 4.1 Com­po­nents of the com­pre­hen­sive di­a­betes med­i­cal eval­u­a­tion at ini­tial, fol­low-‍up, and an­nu­al vis­its

ABI, ankle-brachial pressure index: ARBs, angiotensin receptor blockers; CGM, continuous glucose monitors; OSA, obstructive sleep apnea; PAD, peripheral arterial disease

'at 65 years of age or older

+may be needed more frequently in patients with known chronic kidney disease or with changes in medications that affect kidney function and serum potassium (see Table 11.2)

#may also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications)

^in people without dyslipidemia and not on cholesterol lowering therapy, testing may be less frequent.

**should be performed at every visit in patients with sensory loss, previous foot ulcers, or amputations

Table 4.2—As­sess­ment and treat­ment plan*

ASCVD, atherosclerotic cardiovascular disease.

*Assessment and treatment planning is an essential component of initial and all follow-up visits.

Table 4.3—As­sess­ment of hy­po­glycemia risk

See references 114–118.

Table 4.4—Re­fer­rals for ini­tial care man­age­ment