General practice management of type 2 diabetes


Initial evaluation
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The aim of the initial assessment is to provide a whole-person evaluation, and determine and understand which factors are affecting the patient’s health and quality of life. Many people with diabetes are dealing with multiple medical conditions (not necessarily related to diabetes) and family, work or financial stresses. Some are also dealing with other factors including poor sleep, smoking, lack of exercise and pain that affects their priorities for management.91 This can have an impact on the individualised approach to diabetes management and outcomes.

A detailed assessment, including appraisal of CVD risk and end-organ damage, should be made at first diagnosis.
 

ABORIGINAL AND TORRES STRAIT ISLANDER POINT

In Aboriginal and Torres Strait Islander patients, the development of rapport may take precedence over a detailed assessment in a single consultation. An assessment could be done over several visits.92

Developing a doctor–patient (or patient–healthcare worker) relationship based on trust and respect is the best way of overcoming cultural barriers and ensuring effective care in the long term. 

 


History


Ascertain symptoms supportive of a diagnosis of diabetes, including a history regarding the onset of symptoms (including obstetric history).
Factors in a specific diabetes enquiry:

  • Symptoms of hyperglycaemia: polyuria, polydipsia, polyphagia, weight loss, nocturia.
  • Sequelae of hyperglycaemia and complications of diabetes: malaise/fatigue, cardiovascular symptoms, neurological and autonomic symptoms, altered vision, bladder and sexual function, foot and toe numbness and pain, and any recurrent infections (especially urinary and skin with delayed wound healing) and gastrointestinal dysfunction (such as gastroparesis and nausea). Include specific enquiry about dental hygiene and gingivitis.

Enquire about specific issues that may provide the aetiology or predisposition to diabetes, including:

  • age, family history, cultural group, overweight, physical inactivity, hypertension
  • obstetric history of macrosomic babies or gestational diabetes
  • medication causing hyperglycaemia (refer to Chapter 8. Managing glycaemia)
  • personal or family history of haemochromatosis
  • personal or family history of other autoimmune diseases (eg hypothyroidism or hyperthyroidism)
  • pancreatic disease, Cushing’s disease
  • obstructive sleep apnoea.

Perform a general health enquiry for:

  • presence of risk factors for diabetes complications or known comorbidities (including personal or family history of CVD), smoking, hypertension, dyslipidaemia, and also include a history of past or current mental health problems such as depression
  • health literacy and knowledge about diabetes and related complications
  • emotional and mental health (use the Patient Health Questionnaire-2 [PHQ-2] tool to assess depressive symptoms and problem areas in diabetes [PAID] tool to assess diabetes-specific distress – refer to Appendix C. Problem areas in diabetes questionnaire and Appendix D. Patient health questionnaire-2 tool)
  • living situation (eg alone/with family, employment, financial worries).

It is important to confirm the patient’s immunisation currency. The following vaccinations are recommended for patients with type 2 diabetes:

  • Influenza – once per year
  • Pneumococcal
    • Non-Indigenous Australians: <65 years of age – single dose and revaccinate at 65 years of age or after 10 years, whichever is later; >65 years of age – single dose and revaccinate after five years
    • Aboriginal and Torres Strait Islander peoples: <50 years of age – single dose and revaccinate at 50 years of age or after 10 years, whichever is later; >50 years of age – single dose and revaccinate after five years
  • Tetanus – booster at 50 years of age (unless booster has been given within 10 years). Tetanus vaccination in adults is best given with a multivalent vaccine such as dTpa.
  • Other vaccinations as required on an individual basis according to the Australian immunisation handbook, 10th edn.


Full physical assessment


This should be focused on determining current overall health status to provide information that helps establish management strategies including treatment options.


Assess cardiovascular status and risks


Visceral fat accumulation and obesity increase the risks of developing diabetes, and complications arising from diabetes and comorbidities such as hypertension, dyslipidaemia and pancreatitis.
Hypertension is more common in diabetes, but autonomic neuropathy conversely may arise and lead to postural hypotension. Macrovascular disease may be evident on peripheral arterial examination including the presence of carotid bruits. Dysrhythmias may indicate the presence of existing CVD.

Assess:

  • weight: BMI = weight (kg) divided by height2 (m2)
  • waist: waist circumference (cm)
  • BP, central and peripheral vascular systems
  • absolute CVD risk assessment (this may require calculation and investigations)
  • for symptoms of ischaemic disease or dysrhythmia, in which case an ECG may be considered.


Assess for the presence or absence of diabetes complications


Eyes: Visual acuity (with correction); screen for retinopathy (retinal photography or examine with pupil dilation and ophthalmoscope) – it is prudent to assess for retinopathy and maculopathy with diabetes, as they are the leading causes of blindness and may occur asymptomatically.

Feet: Stratify the risk of developing foot complications (refer to Section 10.5. Foot complications) – sensation and circulation, skin condition, pressure areas, interdigital problems, abnormal bone architecture.

Peripheral nerves: Tendon reflexes, sensation – touch (eg 10 g monofilament) and vibration (eg 128 Hz tuning fork) – existence of peripheral neuropathic changes indicates the onset of microvascular diabetes complications.

Urinalysis: Testing for albumin, ketones, nitrites and/or leucocytes. The presence of proteinuria on clinic testing may necessitate further albumin-to-creatinine ratio (ACR) investigation to exclude existing diabetes nephropathy.

  • Microalbuminuria  ACR ≥2.5 mg/mmol (men) or ≥3.5 mg/mmol (women), or albumin concentration ≥20 mg/L.
  • Proteinuria ACR ≥25 mg/mmol (men) or ≥35 mg/mmol (women; refer to Figure 5).
  • Elevated leucocytes and nitrites may indicate genitourinary infection, which occurs at a higher prevalence and severity in diabetes.

Investigations

To help determine CVD risks, and as clinically indicated, obtain levels of:

  • urine microalbumin, calculated estimated glomerular filtration rate (eGFR)
  • lipids – low-density lipoprotein-cholesterol (LDL-C), high-density lipoproteincholesterol (HDL-C), total cholesterol, triglycerides
  • HbA1c (mmol/mol or %).

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  1. Johnson B, Abraham M, Conway J, et al. Partnering with patients and families to design a patient- and family-centered health care system: Recommendations and promising practices. Bethesda, MD: Institute for Patient- and Family-Centered Care, 2008.
  2. Delahanty LM, Grant RW, Wittenberg E, et al. Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes. Diabet Med 2007;24(1):48–54.
  3. McBain-Rigg KE, Veitch C. Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa. Aust J Rural Health 2011;19(2):70–74.