A. Initial evaluation
A 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 glycemic control. Laboratory tests appropriate to the evaluation of each patient??n 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 patients?? 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, liver function tests with further evaluation for fatty liver or hepatitis if abnormal
* Test for microalbuminuria in type 1 diabetic patients who have had diabetes for at least 5 years and in all patients with type 2 diabetes; some advocate beginning screening of pubertal children before 5 years of diabetes
* Serum creatinine and calculated GFR in adults (check creatinine in children if proteinuria is present)
* Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated
* Electrocardiogram in adults, if clinically indicated
* 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
* Behavioral specialist, as indicated
* Foot specialist, as indicated
* Other specialties and services as appropriate
B. Management
People with diabetes should receive medical care from a physician-coordinated team. Such teams may include, but are not limited to, physicians, nurse practitioners, physician?? the patient and family, the physician, and other members of the health care team. Any plan should recognize diabetes self-management education (DSME) as an integral component of care. In developing the plan, consideration should be given to the patient?? * For patients using less frequent insulin injections or oral agents or medical nutrition therapy (MNT) alone, SMBG is useful in achieving glycemic goals. (E)
* To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)
* Instruct the patient in SMBG and routinely evaluate the patient??ngelgau ME, Narayan KMV, Herman WH: Screening for type 2 diabetes (Technical Review). Diabetes Care 23:1563-1580, 2000 [erratum appears in Diabetes Care 23:1868 -1869, 2000]
13. American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement). Diabetes Care 23:381-389, 2000
14. American Diabetes Association: Gestational diabetes mellitus (Position Statement). Diabetes Care 27 (Suppl. 1):S88 – S90, 2004
15. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. N Engl J Med 329: 977-986, 1993
16. The UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352: 837- 853, 1998
17. The UK Prospective Diabetes Study Group: Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854 -865, 1998
