Ambulatory Exam 2

Define diabetes mellitus and differentiate between types.

Diabetes mellitus: a condition in which the body struggles to metabolize glucose because of insufficient insulin or from a decreased response to it.

• Type I DM: Congenital/unmodifiable, absolute lack of insulin, more frequent in childhood, must administer insulin (insulin-dependent)

• Type II DM: acquired/modifiable, genetically-linked, usually adult-onset

• Gestational: during/after pregnancy, complications include increased birth weight and preeclampsia, half of people develop T2DM later in life

Know the USPSTF criteria for screening for diabetes and prediabetes in an adult patient

• USPSTF: screening for prediabetes/T2DM in adults 35-70 who have overweight/obesity (BMI>25)

• Consider earlier screening for those with risk factors

  • In addition to weight: older age, family history, history of PCOS, dietary/lifestyle factors

• Gestational diabetes: screen at 24 weeks or later (grade B)

 Identify the risk of diabetes in pregnant people

• increased risk of developing T2DM later in life for both mother and child

  • Obesity, sedentary lifestyle

  • Older age

  • Family history

 Identify the risk of diabetes in children and adolescents

Increasing rates of obesity and sedentary behavior (plus usual risk factors)

 Identify the risk of diabetes in the elderly

• Age-related decreased insulin sensitivity 

• Increased abdominal fat and loss of muscle mass

• Physical inactivity

• Poor diet and nutritional deficiencies

• Polypharmacy 

• Other comorbidities

What is the impact of DM on the heart?

• Atherosclerosis leading to CAD

• HTN

• Increased risk of HF and MI

• Must manage lipid levels, keep under certain ranges

• Minimize glucose swings and control BP

What is the impact of DM on the brain?

• infarcts/bleeds

• Ischemic stroke

• Cognitive decline and dementia 

• Diabetic neuropathy

• Must manage blood pressure and lipid levels

• Diabetes-related dementia

What is the impact of DM on the kidneys?

• Glomerular damage, CKD

• HTN/fluid retention 

• Monitor eGFR/labs, albumin if necessary

• Glucose management necessary

Primary prevention for diabetes

• Diet: Mediterranean, DASH, Diabetes focused Medical Nutrition Therapy (MNT)

• active lifestyle

• education

Secondary prevention for diabetes

• Screenings (USAPTF recommendations)

  • Gestational diabetes: screen at 24 wks or later (grade B)

  • Prediabetes: Monitor for T2DM at least annually

  • Pre-symptomatic Type 1: monitor HgbA1C every 6 mo.

  • Monitor for central obesity/metabolic syndrome, activity levels, and sleep apnea

Tertiary prevention for diabetes

• Continuous glucose monitor – especially for T1DM, Blood glucose meters

• Insulin pump, smart insulin pens

• Education: S/S of hyper+hypoglycemia, immediate care, and sustained control with meals

• Foot exams to screen for peripheral neuropathy, education about how to prevent

• Monitor lipid levels and BP to prevent end-organ damage

What are the primary ways to monitor and manage blood glucose?

• Continuous glucose monitor

• Insulin pump

• Blood glucose meters

• Smart insulin pens

What does a continuous glucose monitor do?

continuously measures and displays blood glucose levels in real-time, sensor just under skin

How does an insulin pump work?

delivers insulin continuously or in bolus doses, cannula inserted into skin

What are blood glucose meters?

portable device to measure blood glucose using finger stick method

How do smart insulin pens work?

automatically record insulin injection data (time, dose) and can connect to mobile apps to help manage diabetes, can help calculate appropriate dose

What education about DM should you provide?

• S/S of hypoglycemia: sweating, tremors, pallor, sweating, irritability, dizziness

• S/S of hyperglycemia: polyphagia, polydipsia, polyuria, lethargy, confusion

• Immediate treatment of hypoglycemia: something to bring the blood sugar up – OJ, simple carbs

• Sustained control: something to keep the sugar from rebounding down – peanut butter, complex carbs or protein

What does HbA1C (Hemoglobin A1C) measure and what is its disadvantage?

• a blood test that measures the average blood glucose levels over the past 2-3 months by determining the percentage of hemoglobin that has glucose attached to it

• An average HbA1C that is improved doesn’t necessarily mean the person kept their BG at a good level: it doesn’t catch the possible highs and lows

education about foot care in DM

• Footwear: well-fitting, cushioned shoes and socks to prevent blisters and ulcers; avoid walking barefoot

• Toenails: train straight across

• Importance of keeping intact skin– daily foot inspection

• Wash with lukewarm water and soap, dry thoroughly 

• Foot exam at least annually: includes inspection, pulses, and monofilament test

Discuss barriers to treatment adherence and methods to address them

• Age: children or elderly 

  • Tailor education and care to age group

• Unable to make certain lifestyle changes (cost, time, education, access, motivation, cultural considerations)

  • Provide education

  • Set SMART goals

  • Culturally competent care

• High cost of medications and equipment 

  • Cost-saving programs

  • Community care

Metformin administration and side effects

• generally the first line for T2DM

• take same time every day, with food, increase water intake

• Side effects: gastric issues – abdominal discomfort, diarrhea, loss of appetite

Insulin information and side effects

• Administration: injection, can be automatic or manual

• Pricing and storage considerations: store in fridge, expensive 

• Side effects: possible hypoglycemia

What are the risk factors, both modifiable and non-modifiable, for hypertension?

• Modifiable: smoking, DM, dyslipidemia/high cholesterol, weight, sedentary lifestyle, excess alcohol, high fat and sodium diet

• Non-modifiable: age, family hx, male sex, sleep apnea, psychosocial stress, CKD, low socioeconomic status

What are the values of normal, elevated, Stage 1, and Stage 2 hypertension?

• Normal: SBP under 120 and DBP under 80

• Elevated: SBP 120-129 and DBP under 80

• Stage 1: SBP 130-139 and DBP 80-89

• Stage 2: SBP 140+ and DBP 90+

Explain the physiologic effects of sustained chronic hypertension on the kidneys

ischemia from narrowed lumen of blood vessels that can cause end-stage renal disease

Explain the physiologic effects of sustained chronic hypertension on the eyes

retinopathy, hemorrhages or exudates

Explain the physiologic effects of sustained chronic hypertension on the brain

cerebral vascular disease from cerebral atherosclerosis, TIA/stroke

Explain the physiologic effects of sustained chronic hypertension on the heart

CAD, angina, MI, LV hypertrophy and heart failure

What are the key labs and assessments that identify end organ damage? What are the recommendations for tertiary prevention: how often and how to monitor for organ damage?

• Kidneys: serum creatine, proteinuria, microalbuminuria, eGFR

  • 6-12 months

• Eye exam

• Neuro exam

• UA; CBC; Uric acid

• BMP (glucose, Na, K, CL, CO2 BUN, Creatinine)

• Lipid profile (Total lipids, Triglycerides, HDL, LDL, Cholesterol, Total-to-HDL cholesterol ratio)

  • 6-12 months

• ECG for left ventricular hypertrophy, ischemia, or arrhythmias.

  • 1-2 years

USPSTF recommendation for hypertension screening in asymptomatic individuals

BP readings every 3-5 years (18-39 years)

Describe how to use the 5A’s

Ask: open ended questions

Advise: Provide Clear, Personalized Recommendations

Assess: Evaluate Readiness for Change

Assist: Help the patient set realistic, small goals

Arrange: Follow-Up & Monitor Progress

Describe methods used to accurately measure blood pressure in the ambulatory care setting: preparation

• Avoid caffeine, exercise, smoking at least 30 minutes before  

• Empty bladder 

• No talking while measurement is taken 

• Remove clothing covering cuff placement 

• Patient should sit on chair, feet on floor and back supported for > 5 min before taking pressure (not lying or sitting on an exam table)

Describe methods used to accurately measure blood pressure in the ambulatory care setting: technique

• Validated device 

• Support arm 

• Middle of cuff on upper arm at level of atrium (midpoint of the sternum) 

• Cuff size: Bladder should encircle 80% of the arm  

• Can use either stethoscope diaphragm or bell

Describe methods used to accurately measure blood pressure in the ambulatory care setting: taking the measurement

• First visit: Record BP in both arms and use arm with higher reading for subsequent measurements  

• Separate measurement by 1 to 2 minutes 

• Deflate cuff pressure 2 mmHg per second

• Note time of most recent BP medication before taking measurements  

• Average the readings to estimate BP 

• Use average of ≥ 2 readings obtained on ≥ 2 occasions

Understand the class of medications that are used to initially treat hypertension

• Diuretics: decrease fluid volume

• Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs): preventing vasoconstriction or promote vasodilation to lower BP

• Beta-blockers: not first-line, better for post MI/CHF

• Calcium channel blockers: first-line, block calcium influx into vascular smooth muscle and cardiac cells, leading to vasodilation, reduced heart workload, and lower BP

• Vasodilators: alpha-blockers; relax and widen blood vessels, reducing blood pressure and improving blood flow

• Centrally-acting agents: lower blood pressure by working within the central nervous system (CNS) to reduce sympathetic outflow, leading to decreased heart rate, cardiac output, and vascular resistance

important information to tell an adult just starting antihypertensive medications

medication adherence, lifestyle modifications, potential side effects, and monitoring

side effects of diuretics

fluid/electrolyte imbalances (monitor for hypokalemia)

side effects of beta blockers

decreased heart rate, fatigue, mask hypoglycemia

side effects of ACE Inhibitors

cough, angioedema, hyperkalemia

What questions would you ask the patient to determine if they are experiencing side effects of anti-hypertensive medications?

• General well-being

• About feeling dizzy, lightheaded, or faint

• Fatigue and weakness

• Swelling, breathing difficulties

• About specific side effects of medications

Understand the four aspects of Motivational Interviewing as reflected in the OARS acronym

Motivational Interviewing (MI) is a patient-centered, goal-oriented counseling style designed to help individuals resolve ambivalence and increase motivation for behavior change

• O – Open-Ended Questions

• A – Affirmations

• R – Reflective Listening

• S – Summarizing

Know the stages of change/transtheoretical model. Be able to identify actions that reflect each stage of change

1. Precontemplation: no intention of change, may be unaware

2. Contemplation: aware of problem, thinking of changing, no commitment to take action 

3. Preparation: intend to take action soon

4. Action: modify behavior 

5. Maintenance: maintain behavior and work to prevent relapse

Understand the principles of effective teaching as reflected in the NIH Clear and Simple Communication.

• designed to ensure that health information is understandable, accessible, and actionable for diverse audiences

• principles focus on simple language, clarity, and active engagement with the patient

1. Define target audience

2. Conduct target audience research

3. Develop concept for product

4. Develop content and visual design features

5. Pretest and revise draft materials

SMART goals

• Specific

• Measurable

• Achievable

• relevant

• time-bound

definition of culture

shared values, beliefs, customs, behaviors, practices, language, traditions, and artifacts that characterize a group of people or society

definition of race

a social construct that categorizes people based on physical characteristics

definition of ethnicity

the shared cultural traits and traditions of a group, often linked to a common ancestry, language, history, and sometimes geographic origin