What are the key components of a good History of Present Illness (HPI), Review of Systems (ROS), and physical examination for a diabetic patient follow-up?

Key Components of a Diabetic Patient Follow-Up Visit

A comprehensive diabetic follow-up should include a focused history of present illness (HPI), targeted review of systems (ROS), and systematic physical examination to effectively monitor disease progression, prevent complications, and optimize treatment outcomes. 1

History of Present Illness (HPI)

Glycemic Control Assessment

• Inquire about blood glucose monitoring results, patterns of hyperglycemia or hypoglycemia, and frequency/severity/timing of any hypoglycemic episodes 1
• Review medication adherence, including any medication rationing, side effects, or barriers to taking medications as prescribed 1
• Assess technology use including glucose meters, CGM data, insulin pump settings, and connected pen data if applicable 1

Interval History

• Document changes in medical or family history since the last visit 1
• Review previous treatment plans and patient's response to therapy 1
• Assess eating patterns, weight history, and familiarity with carbohydrate counting if relevant 1

Complication Screening

• Ask about symptoms related to microvascular complications (vision changes, numbness/tingling in extremities, foot problems, sexual dysfunction) 1
• Inquire about macrovascular symptoms (chest pain, shortness of breath, claudication) 1
• Document any diabetes-related hospitalizations or emergency visits since last appointment 1

Lifestyle Factors

• Assess physical activity patterns and sleep behaviors (screen for obstructive sleep apnea) 1
• Document tobacco, alcohol, and substance use 1
• Review vaccination history and needs 1

Review of Systems (ROS)

Cardiovascular

• Chest pain, palpitations, dyspnea on exertion, orthopnea, edema 1
• Symptoms of orthostatic hypotension (dizziness when standing) 1

Neurological

• Numbness, tingling, burning sensations in extremities (peripheral neuropathy) 1
• Changes in vision, night vision difficulties (autonomic neuropathy) 1
• Dizziness, fainting, gastroparesis symptoms (autonomic neuropathy) 1

Renal

• Changes in urination patterns, frequency, or appearance 1
• Edema or fluid retention 1

Integumentary

• Skin changes, particularly on feet and insulin injection sites 1
• Delayed wound healing or infections 2

Psychological

• Screen for depression, anxiety, diabetes distress, and fear of hypoglycemia 1
• Assess cognitive function, especially in older adults 1

Gastrointestinal

• Symptoms of gastroparesis (early satiety, nausea, vomiting, bloating) 1
• Changes in bowel habits (autonomic neuropathy) 1

Physical Examination

Vital Signs

• Height, weight, BMI calculation 1
• Blood pressure (including orthostatic measurements when indicated) 1

Cardiovascular Examination

• Heart rate and rhythm, murmurs, peripheral pulses 1
• Signs of heart failure (JVD, edema, crackles) 1

Comprehensive Foot Examination

• Visual inspection for skin integrity, callus formation, deformities, or ulcers 1
• Assessment of pedal pulses (screen for peripheral arterial disease) 1
• Neurological testing including temperature sensation, vibration or pinprick sensation, and 10-g monofilament exam 1

Skin Examination

• Inspect for acanthosis nigricans (insulin resistance) 1
• Check insulin injection or insertion sites for lipodystrophy 1
• Evaluate for any skin infections or poor wound healing 2

Neurological Examination

• Assess for sensory deficits, particularly in lower extremities 1
• Check deep tendon reflexes (patellar and Achilles) 1
• Evaluate proprioception 1

Ophthalmologic Screening

• Fundoscopic examination or referral to eye specialist 1

Thyroid Examination

• Thyroid palpation, especially in type 1 diabetes 1

Common Pitfalls to Avoid

• Overlooking hypoglycemia assessment: Always inquire about hypoglycemic episodes, as they may indicate need for medication adjustment and are associated with medication nonadherence 3
• Neglecting psychosocial evaluation: Depression and diabetes distress significantly impact self-management and outcomes 1
• Incomplete foot examination: Diabetic foot complications are preventable with thorough regular examination 1, 2
• Missing medication adherence issues: Poor adherence is directly linked to worse glycemic control 4, 5
• Forgetting vaccination status: Diabetic patients have increased risk of complications from preventable infections 1

By systematically addressing these components during diabetic follow-up visits, clinicians can effectively monitor disease progression, prevent complications, and optimize treatment outcomes for patients with diabetes.