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Q 65What is the recommended initial assessment plan for newly diagnosed adults with stable Type 1 diabetes?

Author / Title / Reference / YrDepartment of Veterans Affairs. The management of diabetes mellitus in the primary care setting. 1999.
N=N/A
Research DesignGuidelines
AimTo make recommendations on the management of diabetes mellitus in the primary care setting 1999.
PopulationBoth Type 1 and Type 2 diabetics included
InterventionCore module of management
ComparisonN/A
OutcomeN/A
CharacteristicsN/A
ResultsIdentify comorbid conditions DM may not be the patient’s only disease, nor is it necessarily the condition that needs to be prioritised for immediate treatment. Persons with DM are at risk of multiple comorbid conditions including
Coronary artery disease
Peripheral vascular disease
Hypertension
Hyperlipidemia.
The following are examples of conditions that affect the management of DM
Chronic obstructive pulmonary disease
Substance use disorder
Depression
Among the more frequently encountered precipitating factors resulting in secondary diabetes are
Pancreatic disease
Drug induced disease
Is the Patient Medically, Psychologically, and sociaIy stable?
Identify / update related diabetes problems from the medical record, history, physical examination, laboratory tests, nutritional and educational assessment.
Review systems and set priorities for care
Hierarchy of Evidence GradingIV
Comments6 references for this section of the guideline
No details of evidence base profile
Not specific to newly diagnosed people
Reference / Citation283
Author / Title / Reference / YrDiabetes UK 2000, Recommendations for the management of diabetes in primary care.
N=N/A
Research DesignGuideline
AimTo make recommendations for the management of diabetes in primary care
PopulationType 1 and Type 2 diabetics
InterventionInitial assessment
ComparisonN/A
OutcomeN/A
CharacteristicsN/A
ResultsA management plan should be developed with each individual patient so that the responsibility for the various aspects of care is clear.
The components of the management plan should be discussed and agreed with each patient. ( A patient-held record can help to facilitate this process. New approaches are also being developed, including the remote printing of computerised records held by the health professionals the unified medical record and smart cards.
A planned programme of diabetes care should include systems for ensuring assessment and acute management of all newly diagnosed people
Initial assessment at diagnosis If the patient is clearly unwell, ketonuria is present or if the blood glucose is greater than 20.0 mmol/1, urgent telephone referral to hospital is generally required. Chi Pregnant women presenting with diabetes require urgent specialist care.
People not included in the above categories may be managed in the primary care setting.
Initial discussion
History of illness, including enquiry about possible underlying causes of diabetes.
Simple explanation of diabetes, including nature and significance of diabetes – taking account of any fears and anxieties
Lifestyle in relation to diabetes – including advice to stop smoking.
Explanation of the practice organisation, the roles of each PHCT member and how to obtain advice when needed.
Information about Diabetes UK
Examination
Weight and height – calculation of body mass index Blood pressure
Full clinical examination to exclude underlying causes of diabetes and the presence of complications
Investigations
Urinalysis for glucose, ketones and protein – MSU if protein detected
Blood test for baseline measurements – local practice will vary, but may include:
-

Plasma glucose

-

full blood count

-

serum creatinine

-

liver function tests

-

serum cholesterol and triglycerides

-

thyroid function tests 3.

Further investigations, as indicated.
Management
Initial dietary assessment and advice
Referral to state registered dietician
Referral to specialist diabetes team, if indicated
Referral to state registered podiatrist, ophthalmologist or other specialist, if necessary Discussion and agreement of initial management plan
Discussion and agreement of individual management targets
Next appointment – regular reviews will initially be required
Recording of findings
Written and/or computerised medical record
Patient-held record
Practice diabetes register
District diabetes register, where this exists
Hierarchy of Evidence GradingIV
CommentsBoth Type 1 and Type 2 diabetics
Specific to newly diagnosed people
The emphasis in this document is primarily on the organisation of care, rather than on the clinical management of diabetes.
Reference / Citation282
Author / Title / Reference / Yr2002, Inpatient management guidelines for people with diabetes., American Healthways., Nashville (TN).
N=N/A
Research DesignGuidelines
AimN/A
PopulationType 1 and Type 2 diabetics
InterventionInitial assessment and exam
ComparisonN/A
OutcomeN/A
CharacteristicsN/A
ResultsA history of diabetes management and assessment of standards of are status to be taken on admission/ pre-admission
Initial Questions.
Type of diabetes
Duration of diabetes
Primary care physician
Primary diabetes physician if different from PCP
Medical Nutrition Assessment
Physical Activity
Medications Taken
Assessment of Control
Acute Symptoms of Diabetes
Reproductive Assessment
Substance Abuse
Barriers to Care
Chronic Complications / Co-Morbidities
Documentation of symptoms of diabetes-related co-morbidities or complications
Hierarchy of Evidence GradingIV
Comments45 references but uncited
Produced by an incorporated organisation
The Inpatient Management Guidelines contained in this document represent the consensus of the conference participants.
Specific to newly diagnosed people
Both Type 1 and type 2 target population
Reference / Citation284
Author / Title / Reference / Yr2003, "Standards of Medical Care for Patients With Diabetes Mellitus", Diabetes Care, vol. 26, p. S33–S50.
N=N/A
Research DesignGuideline
AimTo establish standards of medical care for people with diabetes mellitus
PopulationType 1 and t Type 2 diabetics
InterventionInitial evaluation
ComparisonN/A
OutcomeN/A
CharacteristicsN/A
ResultsA complete medical evaluation should be performed to classify the patient, detect the presence or absence of diabetes complications, assist in formulating a management plan, and provide a basis for continuing care. If the diagnosis of diabetes has already been made, the evaluation should review the previous treatment and the past and present degrees of glycaemic control. Laboratory tests appropriate to -» the evaluation of each patient’s general medical condition should be performed. A focus on the components of comprehensive care (Table 5) will assist the health care team to ensure optimal management of the patient with diabetes.

Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes
  • Prior A1C records
  • Eating patterns, nutritional status, and weight history; growth and development in children and adolescents
  • Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs
  • Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and people’ use of data
  • Exercise history
  • Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia
  • Prior or current infections, particularly skin, foot, dental, and genitourinary infections
  • Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function (including symptoms of celiac disease in type 1 diabetic people); heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes
  • Other medications that may affect blood glucose levels
  • Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history
  • History and treatment of other conditions, including endocrine and eating disorders
  • Family history of diabetes and other endocrine disorders
  • Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
  • Tobacco, alcohol and/or controlled substance use
  • Contraception and reproductive and sexual history
Physical examination
  • Height and weight measurement (and comparison to norms in children and adolescents)
  • Sexual maturation staging (during pubertal period)
  • Blood pressure determination, including orthostatic measurements when indicated, and comparison to age-related norms
  • Fundoscopic examination
  • Oral examination
  • Thyroid palpation
  • Cardiac examination
  • Abdominal examination (e.g., for hepatomegaly)
  • Evaluation of pulses by palpation and with auscultation
  • Hand/finger examination
  • Foot examination
  • Skin examination (for acanthosis nigricans and insulin-injection sites)
  • Neurological examination
  • Signs of diseases that can cause secondary diabetes (e.g., hemochromatosis, pancreatic disease)
Laboratory evaluation
  • A1C
  • Fasting lipid profile, including total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol
  • Test for microalbuminuria in type 1 diabetic people who have had diabetes for at least 5 years and in all people with type 2 diabetes. Some advocate beginning screening of pubertal children before 5 years of diabetes.
  • Serum creatinine in adults (in children if proteinuria is present)
  • Thyroid-stimulating hormone (TSH) in all type 1 diabetic people; in type 2 if clinically indicated
  • Electrocardiogram in adults
  • Urinalysis for ketones, protein, sediment
Referrals
  • Eye exam, if indicated
  • Family planning for women of reproductive age
  • MNT, as indicated
  • Diabetes educator, if not provided by physician or practice staff
  • Behavioural specialist, as indicated
  • Foot specialist, as indicated
  • Other specialties and services as appropriate
Hierarchy of Evidence GradingIV
Comments104 refs
Evidence based guidelines
Both Type 1 and Type 2 diabetes target population
Not specific to newly diagnosed person
Reference / Citation285

From: Appendix D, Evidence tables

Cover of Type 1 Diabetes in Adults
Type 1 Diabetes in Adults: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 15.1.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2004, Royal College of Physicians of London.

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