Next Steps in Managing a Patient's Health
For optimal patient management, conduct a comprehensive follow-up visit that includes assessment of medication adherence, physical examination, laboratory evaluation, and assessment of diabetes self-management behaviors, as recommended by the American Diabetes Association. 1
Key Components of Follow-Up Visit
Medical History Assessment
- Review interval medical history since last visit
- Assess medication-taking behavior and any side effects/intolerances
- Evaluate frequency, cause, and severity of any hypoglycemic episodes
- Screen for depression, anxiety, and disordered eating
Physical Examination
- Measure height, weight, BMI, and waist circumference
- Check blood pressure (consider orthostatic measurements if indicated)
- Perform comprehensive foot examination:
- Visual inspection for skin integrity, calluses, deformities, ulcers
- Check pedal pulses (refer for ankle-brachial index if diminished)
- Test temperature, vibration, pinprick sensation, and 10-g monofilament exam
- Examine skin for acanthosis nigricans and insulin injection/insertion sites
Laboratory Evaluation
- Check A1C if not available within past 3 months
- Annual tests (if not performed within past year):
- Lipid profile (total, LDL, HDL cholesterol, triglycerides)
- Liver function tests
- Spot urinary albumin-to-creatinine ratio
- Serum creatinine and estimated GFR
- Thyroid-stimulating hormone in type 1 diabetes
- Vitamin B12 levels if patient is on metformin
- Complete blood count with platelets
- Serum potassium if on ACE inhibitors, ARBs, or diuretics
Risk Assessment and Prevention
- Assess 10-year cardiovascular risk using appropriate risk calculator
- Ensure vaccination status is up-to-date:
- Annual influenza vaccine
- Pneumococcal vaccines (PCV13 and PPSV23 as age-appropriate)
- Hepatitis B vaccine series for unvaccinated adults
- COVID-19 vaccination
Self-Management Assessment
- Review diabetes self-management behaviors
- Assess nutritional status and dietary patterns
- Evaluate physical activity levels
- Check sleep patterns and duration (poor sleep quality associated with higher A1C) 1
- Assess social determinants of health that may impact care
Goal Setting and Treatment Planning
- Engage in shared decision-making to establish treatment goals
- Set individualized A1C targets based on patient factors
- Develop action plans for addressing any identified issues
- Prioritize interventions based on potential impact on morbidity and mortality
Follow-Up Scheduling
- Schedule next visit at appropriate interval (typically every 3-6 months)
- Ensure annual comprehensive evaluations are completed
- Consider more frequent follow-up if treatment changes are made or goals not met
Common Pitfalls to Avoid
- Focusing only on glucose control while neglecting other cardiovascular risk factors
- Overlooking social determinants of health that may impact care
- Failing to address psychological aspects of diabetes management
- Not providing adequate self-management support between visits
- Missing opportunities for preventive care like vaccinations
By systematically addressing these components during follow-up visits, you can provide comprehensive care that reduces morbidity and mortality while improving quality of life for patients with diabetes.