6: 57-year-old woman diabetes care visit Flashcards
Physician tasks for diabetes care:
- -Work to detect diabetes complications and potential comorbid conditions
- -Review previous treatment and risk factor control
- -Begin patient engagement in the formulation of a care management plan
- -Review and discuss prevention of complications
- -Develop a plan for continuing care
Relevant medical history for a patient with diabetes:
- Age at onset and characteristics of onset of diabetes
- Asymptomatic laboratory finding or retinopathy detected on exam
- Symptomatic hyperglycemia (i.e. frequent urination, thirst, fatigue, weight loss)
- Metabolic crisis (i.e. diabetic ketoacidosis (DKA) or hyperosmolar, hyperglycemic state (HHS))
- Nutrition history (eating patterns, nutritional status, weight history, nutrition education, food insecurity screening)
- Level of physical activity
- Complementary and alternative medicine use
- Presence of common comorbidities and dental disease
- Screen for psychosocial problems and other barriers to self-management (e.g. cognitive dysfunction, financial/logistical/support resources)
- Screen for depression, anxiety, and disordered eating
- History of smoking, alcohol consumption, and substance use
- Diabetes education, self-management, and support history and needs
- Review of previous treatment regimens and response to therapy (A1C records)
- Assess medication-taking behaviors and barriers to medication adherence
- Results of glucose monitoring and patient’s use of data
- DKA or HHS episodes (frequency, severity, and cause)
- Hypoglycemia episodes and awareness (frequency, severity, and cause)
- History of increased blood pressure or increased cholesterol
- Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
- Macrovascular complications: coronary heart disease, cerebrovascular disease, and peripheral arterial disease
- For women with childbearing capacity, review contraception and preconception planning
Pathophysiology of Diabetes
Type 1 diabetes mellitus
The pancreas is damaged, and the beta cells don’t produce enough insulin. (Immunologic etiology)
Type 2 diabetes mellitus
The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion may initially compensate, but over time, beta cells fail.
Complications
Both types of diabetes cause the same end-damage. High blood glucose eventually affects blood vessels and therefore organs throughout the entire body. The heart, brain, kidneys, and eyes and the nerves that control sensation and autonomic function are affected.
Remember: High blood pressure, which many patients with diabetes have, makes the vascular disease much worse.
Diabetes: Common Manifestations of End-Organ Damage
> > Cardiovascular disease, including both coronary heart disease and cerebrovascular disease
The leading cause of death in patients with diabetes. People with diabetes are 2-4 times more likely to have heart disease or stroke than people without diabetes. Patients with diabetes who have a myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of cardiovascular risk factors so commonly found in diabetes is therefore essential in preventing morbidity and mortality in these patients.
> > Retinopathy
Diabetes is the most common cause of new cases of blindness among adults of working age. Five years after diagnosis of type 2 diabetes, patients with more severe or uncontrolled disease that requires insulin have a 40% prevalence of retinopathy while those on oral hypoglycemic agents have a 24% prevalence. After 15 years of diabetes, almost all patients with type 1 diabetes and two thirds of patients with type 2 diabetes have background retinopathy. By the time the patient’s vision is affected, substantial retinal damage may have already occurred. Proliferative retinopathy is prevalent in 25% of the diabetes population with 25 or more years of diabetes.
> > Neuropathy
Neuropathy is a heterogeneous condition that is associated with nerve pathology. The condition is classified according to the nerves affected. The classification of neuropathy includes focal, diffuse, sensory, motor and autonomic neuropathy. The prevalence of neuropathy defined by loss of ankle jerk reflexes is 7% at 1 year increasing to 50% at 25 years for both type 1 and type 2 diabetes.
> > Nephropathy
Nephropathy is common in diabetes. 20-40% of people with diabetes develop diabetic nephropathy. Diabetes was listed as the primary cause of kidney failure in 44% of all new cases in 2014.
While hyperthyroidism is not an end organ result of diabetes, this hypermetabolic state can unmask underlying glucose intolerance, and adversely affect glucose control and lipid management in patients with diabetes. Hypothyroidism can cause fatigue, depression, and dyslipidemia, all of which complicate management of diabetes. Type 1 diabetes, being an autoimmune illness, is associated with both Graves disease and Hashimoto disease.
Acute Diabetic Decompensations (DKA and HHS)
Type 1 Diabetes
In patients with type 1 diabetes, without sufficient insulin, blood sugar runs high, and diabetic ketoacidosis (DKA)
can develop.
Type 2 Diabetes
Type 2 patients with hyperglycemia more often develop hyperosmolar hyperglycemic state (HHS) .
Typically it is the patient with type 1 diabetes who is most at risk for developing DKA; however, patients with type 2 diabetes can also develop DKA. This happens because over time, type 2 diabetes starts to resemble type 1 diabetes as pancreatic function dwindles and patients with type 2 diabetes may begin to require insulin. If the insulin deficiency is severe enough, a patient with type 2 diabetes may produce ketones and develop hyperglycemia. For example, an elderly patient with longstanding type 2 diabetes who becomes acutely ill with pneumonia could easily develop DKA.
Screening Recommendations for Type 2 Diabetes:
American Diabetes Association Recommendations
- Overweight or obese patients (BMI ≥ 25 kg/m2 or ≥ 23 kg/m 2 in Asian Americans) who have one or more of the following additional risk factors:
- -Physical inactivity
- -High-risk race/ethnicity (e.g. Native American, Pacific Islander, Latino, African American, Asian American)
- -First-degree relative with diabetes
- -Previously diagnosed impaired fasting glucose (100-125 mg/dL) or impaired glucose tolerance (2-hour plasma glucose > 140 mg/dL following a 75 gram glucose load)
- -Stage 2 hypertension (≥140/90 mmHg or on therapy for hypertension)
- -HDL cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL (2.83 mmol/L)
- -History of gestational diabetes mellitus
- -Polycystic ovarian syndrome
- -History of cardiovascular disease
- -A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
- -Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans, severe obesity) - In the absence of the above risk factors, screening should begin at 45 years of age.
- If results are normal, testing should be repeated at least at three-year intervals, with consideration of more
frequent testing depending on risk status and initial results.
Screening Recommendations for Type 2 Diabetes: United States Preventive Services Task Force (USPSTF) Recommendations
For adults aged 40 to 70 years who are overweight or obese, screen for abnormal blood glucose as part of cardiovascular risk assessment. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Rating: “B” recommendation.
Diagnostic Criteria for Diabetes Mellitus
- A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia like polyuria or unexplained weight loss, or hyperglycemic crisis.
- A fasting plasma glucose of greater than or equal to 126 mg/dL. Fasting is defined as no caloric intake for at least eight hours.
- A hemoglobin A1C greater than or equal to 6.5%.
- Two-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an Oral Glucose Tolerance Test (OGTT).
The fasting glucose, OGTT and the A1C need to be confirmed on a different day unless the patient has unequivocal or unquestionable symptoms of hyperglycemia.
Who Gets Diabetes? Prevalence of diagnosed and undiagnosed diabetes in the United States, all ages, 2015:
Total: 30.3 million people (9.4% of the population) have diabetes.
Diagnosed: 23.0 million people
Undiagnosed: 7.2 million people (23.8% of the population)
Prevalence of diabetes (diagnosed and undiagnosed) among people aged 18 years or older, United States, 2015:
Age 18 years or older: 30.2 million or 12.2% of all people in this age group have diabetes.
Age 65 years or older: 12.0 million or 25.2% of all people in this age group have diabetes.
After adjusting for population age differences, 2013-2015 national survey data for U.S. adults aged 18 years or older indicate that the following percentages have diagnosed diabetes:
- 4% of non-Hispanic whites
- 0% of Asian Americans
- 1% of Hispanics
- 7% of non-Hispanic blacks
- 1% American Indians/Alaska natives
Among Hispanics, rates were:
- 5% for Central/South Americans
- 0% for Cubans
- 0% for Puerto Ricans
- 8% for Mexican Americans
Diabetic Retinopathy
The most frequent cause of new blindness among adults (aged 20-74 years). Laser photocoagulation treatment can slow the progression of retinopathy and reduce vision loss, but it doesn’t restore lost vision. Since the treatment is aimed at preventing vision loss, and retinopathy is asymptomatic for its initial course; it’s important to identify and treat patients early in the course of disease.
In severe, non-proliferative retinopathy, look for the following findings on fundoscopic exam:
»Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction.
»Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages.
»Microaneurysms are more punctate dark lesions that indicate vascular dilatation.
Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.
Diabetes Education: Blood Glucose
Optimal range for blood glucose:
»fasting blood glucose should be 80 -120 mg/dl
»postprandial blood glucose between 1-2 hours after a meal should be < 180 mg/dl
Conditions that contribute to hyperglycemia:
Overeating, missing doses of medication, dehydration, infection and illness, and stress.
Often in practice, providers use one-way communication to describe the biomedical explanation for the disease and the recommended treatment. The LEARN model, developed by Berlin and Fowkes, is a simple way to remember the importance of two-way dialogue with your patient about their understanding of their own disease.
Listen with empathy and understanding to the patient’s perception of the problem.
Explain your perceptions of the problem and your strategy for treatment.
Acknowledge and discuss the differences and similarities between these perceptions.
Recommend treatment while remembering the patient’s cultural parameters.
Negotiate agreement. It is important to understand the patient’s explanatory model so that medical treatment fits in their cultural framework.
Annual Foot Exam for Patients with Diabetes
The American Diabetes Association recommends that all patients with diabetes have an annual foot exam and provides standard of care guidelines for this exam, including testing for neuropathy.
Foot ulceration is the result of impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral vascular disease), both of which are independent, strong risk factors for foot ulceration and amputation.
The early recognition and appropriate management of neuropathy in the patient with diabetes is important because:
1. Up to 50% of diabetic peripheral neuropathy (DPN) may be asymptomatic but leave patients at risk of foot ulceration
2. nondiabetic neuropathies may be present in patients with diabetes and may be treatable
3. while specific treatment for the underlying nerve damage is currently not available, other than improved
glycemic control, which may slow progression but not reverse neuronal loss – effective symptomatic treatments are available for some manifestations of DPN.
The foot exam should include:
> > testing for loss of protective sensation
Sensory testing, according to the ADA, should be conducted with a 10-gram monofilament PLUS any one of the following:
- vibration using 128-Hz tuning fork
- pinprick sensation
- ankle reflexes (Achilles necessary, but patellar not needed)
> > Assessment of pedal pulses(dorsalis pedis and posterior tibial arteries). Assessing the arterial supply to the lower limbs and feet is essential in evaluation for peripheral vascular disease, the strongest risk factor for delayed ulcer healing and amputation in diabetes patients.
> > Inspection. Skin changes such as hair loss and temperature changes may signal vascular insufficiency. Since foot ulceration is usually caused by breaks in the skin due to accidental trauma or poorly-fitted footwear, at each visit the patient’s feet should be inspected for breaks in the skin, pressure calluses that precede ulceration, existing ulceration and infection, and bony abnormalities that lead to abnormal pressure distribution and ulceration. The patient’s footwear should also be inspected for abnormal patterns of wear and appropriate sizing.
