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Ongoing Management Recommendations

 

Components of Care Visits for Adults with Type 2 Diabetes
Vitals

q     Weight                         q Re-calculate BMI

q     Measure height if not on chart

q     Compare with previous weights and BMI to monitor trends

Blood Pressure Assessment

q     Assess at every visit

q       Monitor and adjust therapy to keep BP < 130/80 mmHg

 

Glycemic Control Assessment

q     A1c if indicated.  Goal: <7% (e.g., <6.5%, can be considered for some patients)

q     Review log of patient’s Self Blood Glucose Monitor (SBGM) results

q     Point-of-care capillary blood glucose check if indicated

q     Monitor and adjust therapy to attain glycemic goals

Chronic Kidney Disease Assessment

q Annual for screening

q More frequently for monitoring of CKD

q     Estimated GFR:

q       Serum creatinine (needed for calculation of GFR)

q     Albumin to Creatinine Ratio (UACR) [review diagnosis]

q     Preserve kidney function:

q       Consider ACE inhibitor or ARB

q       Lower targets for BP control: <120/70 mmHg

q     If GFR < 60:

q     Hemoglobin/Hematocrit for presence of anemia

q     Ca, PO4, and PTH to assess metabolic bone disease

Lipids Assessment

At least annually, more frequently if monitoring therapy:

q     Fasting lipoprotein panel (Total cholesterol, LDL, HDL, and triglyceride)

q     If fasting lipids not possible/reasonable, consider direct LDL, total cholesterol and HDL

q     Additional lipid testing may be needed to adjust pharmacologic therapy

Antiplatelet Therapy q     Aspirin or other antiplatelet agent prescribed in appropriate clinical setting
Visit Exams

q     Directed exam according to review of systems

q     Routine Foot Check 

q     Annual comprehensive neurovascular foot exam to include 10 g monofilament exam

Immunization Status Review

q     Influenza immunization annually,

q     PneumoVax at diagnosis.  Re-immunization if age 65 or older and first dose was given before age 65 

q     Tetanus and diphtheria every 10 years

q     HBV immunization if kidney status is compromised and GFR < 60 or at high risk for HBV

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