Chronic conditions (Type 2 DM) care – Clinical Connectathon Narrative

Objectives: use of FHIR clinical resources to capture and view data (including use of Care Plan) relevant to care of patient with chronic health conditions (Type 2 DM and associated health risks/concerns)

Description

The purpose of this use case is to describe a series of events related to the generation, capture and retrieval of clinical data relevant to the care of patient with chronic health conditions (Type 2 DM and cardiovascular risks/concerns).

Exclusions

Emergency conditions such as acute complications of Type 2 DM

Actors

PCP: Dr Patricia Primary

Nurse: Ms Nancy Nightingale

Patient: Mr Adam Everyman

Pre-condition

Mr Adam Everyman with known medical history of hypercholesterolemia and moderate hypertension presents to his PCP with complaints suggestive of Type 2 Diabetes Mellitus

Trigger

Patient arrives at PCP clinic seeking medical consultation and care for a set of complaints

Narrative of Events

November, 12– First consultation

The patient: On 12 November, Mr Adam Everyman, a 52 year old male patient known to the clinic presented at Dr Patricia Primary’s (PCP) clinic with a set of complaints suggestive of Type 2 Diabetes Mellitus. These signs and symptoms appeared about 3 months ago before he decided that they were bad enough for him to seek medical help.

Clinic Nurse: The patient was escorted by the clinical nurse, Nancy Nightingale, to the examination room where routine nursing assessments were performed, which included:

Height (5.6 feet or 170 cm), weight (215.6 pounds or 98 kg; fully clothed), waist circumference(102.5 cm; 40.35 in)

Blood pressure measured on left upper arm with patient in sitting position (179/98; second reading 10 min later = 162/92. Patient is obese. Arm circumference=37.6cm/14.8in. A large adult cuff was used).

Based on the height and weight, the BMI calculation (=33 [30+ = obese]) indicated that the patient was obese. The waist circumference (102.5 cm; 40.35 in) is >50% of his height. These observations were documented.

And the nurse also documented that the blood pressure indicated that patient was still moderately hypertensive (sitting blood pressure is 162/92) despite the prescribed medications of a thiazide diuretic and ACE inhibitor he is taking.

The nurse performed urine dipstix test and recorded that the result showed mild glycosuria (glucose 1+; ketone –ve; RBC –ve; albumin –ve), SG = 1024

Spot blood sugar test showed a reading of11.7mmol/L(210mg/dl)

PCP: The patient was next seen by Dr Primary.

A review of his medical record revealed:

Family history: biological father sufferedhypercholesterolemia, hypertension. His father suffered first acute myocardial infarction at age of 44 and died from a third attack at age of 57. No family history of DM. No known allergy/intolerance record in his EMR. The allergy/intolerance history is checked and confirmed.

Lifestyle/social history: Patient was asmoker (12.75 pack year [15 cigarettes per day for 17 years: 15/20 x 17]; current cigarette consumption = 5-10 cigarettes/day). Previous attempts to quit smoking (including participation in quit smoking programs and use of nicotine patches) produced ineffective results. He tends to smoke more when stressed.

He is a social drinker(4 standard drinks per week [1 Australian standard drink = 10gm alcohol]).

Medical history:patient was diagnosed with hypertension 6 years ago. Medication treatment: (Telmisartan80mgdaily)

Patient indicated that occasionally skipped a dose of the anti-hypertensive medications prescription by his PCP.

Dr Primary recorded the patient’s chief complaints, conducted a thorough physical examination which revealed no abnormality of most body systems.

Examination of the feet revealed very mild decrease in sensation and temperature of patient’s both feet.

Dr Primary explained to the patient that based on his presenting signs and symptoms, the spot urine and blood sugar levels, he might be suffering from Type 2 diabetes and recorded that as a provisional diagnosis in the medical record.

The PCP discussed with the patient and created an initial generalcare plan to manage his health issues before the next visit:

Health Concern / Health Goal / Care Activity
Difficulty in weight management / 5-10% (of 98kg) weight loss
(milestone: 0.5kg/week)
Waist circumference <94cm /
  • Diet order: low kilojoule (e.g. 5025kJ-6670kJ [1200-1600kcal] /day); low glycaemic index; low saturated fat; high fibre diet
  • Regular exercise: walking (1.5km in 15 min), jogging, riding push bike, or swimming, e.g. for 15-30 min 3 times/week

Increased CVS risk from smoking / Cigarette consumption reduced to 0 per day /
  • Referral to cardiac rehabilitation nurse to initiate smoking cessation counselling sessions
  • Re-enroll in smoking cessation program
  • Medication: Varenicline tartrate days 1–3: 0.5mg daily; days 4–7: increase to 0.5mg twice daily; then 1mg twice daily from day8 to the end of a 12-week treatment course

Poor BP control related to possible non-adherence to treatments / To determine median BP to guide medication and diet adjustment /
  • BP monitoring: patient to measure his blood pressure twice daily at home for a week before next follow-up visit
  • Medication education:clinic nurse to initiate medication compliance education sessions

Potential case of Type 2 DM / To confirm/rule out that patient has Type 2 DM / Diagnostic order:
  • Fasting blood glucose
  • Oral glucose tolerance test[1]
  • HbA1c
  • Fasting blood lipids (cholesterol, triglyceride, HDL, LDL)

PCP reviewed care plan with the patient, and the patient agreed with the goals and planned care activities.

Blood pressure measurement:

  • As patient is obese (BMI=33, arm circumference=37.6cm/14.8in), he is advised to use a large adult cuff when measuring his BP
  • He receives instruction from the clinic nurse on how to correctly perform the BP measurement including: rest and relax in seated position for 10 mins[2] and correct application of the cuff

The patient fasted after dinner on 12 November and went next morning to his preferred path laboratory for blood specimens to be taken for the ordered tests.

The results were sent back to the PCP electronically two days later.

At the meanwhile, the patient measured his blood pressure at home twice daily (morning and evening). He recorded on a paper chart given by his PCP: the BP readings, the extremity used, cuff size and position.

November, 19– Follow-up visit

The patient: Mr Everyman returns to the PCP clinic in the morning of 19 November for the follow-up consultation. He brings with him the BP observation chart that recorded the week of his blood pressure measurement.

The nurse: Nancy Nightingale measures the patient’s body weight, waist circumference which records a 0.3 kg decrease in weight (98kg on 12 September) with no change in waist circumference.

His blood pressure reading is: 168/92

PCP: Dr Primary reviews the patient’s clinical status and records in the EMR with updated signs and symptoms.

She reviews the patient’s blood test results:

  • Fasting blood glucose = [10.3mmol/L];[(185 mg/dl)]
  • 2 hours post glucose load(75 gm) = [13.9mmol/L];[(230mg/dl)][3]
  • The HbA1c level= 7.5% (≥ 6.5% (48 mmol/mol) = cut off for diagnosing diabetes).
  • His fasting lipid profile:
  • Cholesterol = [6.5 mmol/L (reference range3.9 – 5.5)];[251.4mg/dl];
  • Triglyceride = [2.9 mmol/L (reference range 0.6 – 2.0)];[256.9mg/dl];
  • HDL = [1.32 mmol/L (reference range 0.90 – 1.50)];[51.0mg/dl]
  • Total cholesterol/HDL ration =[4.9:1 (reference <3.5:1)]

Based on the clinical assessment of the patient’s signs and symptoms and the blood results, Dr Primary confirms and informs the patient of the diagnosis of Type 2 Diabetes Mellitus and hypercholesterolaemia. The assessment findings and new diagnoses are recorded in the patient’s EMR.

Dr Primary reviews the patient’s 1 week blood pressure readings – the readings range from 149/82 to 182/98, the median/average reading being 158/92. The higher readings are recorded in the morning.

Dr Primary explains to the patient that Type 2 Diabetes is a complex problem. It has implications (risks) for his existing cardiovascular comorbidities: hypercholestrolaemia and hypertension. Both conditions (hypertension and diabetes mellitus) must be managed carefully.

Dr Primary discusses with the patient oral anti-diabetic drugs and prescribes an extended release biguanides (Metformin/Glucophage: 500mg daily after evening meal) with a plan to review in 2 weeks to titrate the drug dose)

She discusses with the patient the benefits of initiating a Type 2 DM care plan. The care plan could be used to effectively monitor and manage a number of health concerns related to the diagnoses, and to coordinate the care with other providers such as diabetic educator, dietitian, etc The patient agrees and a care plan is created.

The PCP emphasizes the importance of adherence to anti-hypertensive medications for blood pressure control and reduction of CVS risks especially with the addition risks arising from the newly diagnosed DM.

Type 2 DM and CVS Care Plan:

Health Concern

/

Health Goal and Review

/

Care Activity

Confirmed: Type 2 DM

Problem in effective glycaemic control

/

Goal/Targets:

BSL:

6–8 mmol/L fasting (108-144mg/dl); and

8–10 mmol/L postprandial; (108-180mg/dl)

HbA1c: ≤7% (range 6.5–7.5) [≤53 mmol/mol (ref range 48–58)]

/

Medication: Metformin/Glucophage 500mg after evening meal; and review in 2 weeks to titrate drug dose based on BSL results

Diet: low kilojoule (e.g. 5025kJ-6670kJ [1200-1600kcal] /day); low glycaemic index; low saturated fat; high fibre diet (for review and adjustment by dietitian)

Exercise: Regular exercise: walking (1.5km in 15 min), jogging, riding push bike, or swimming, e.g. for 15-30 min 3 times/week

Referral: to dietitian for diabetic diet plan

Increased CVS risks (hypertension, AMI) associated with Type 2 DM and poor BP control (due to non -adherence to treatment)

/

[Goal/milestone review– average BP shows sustained moderate hypertensive state: 1 week average BP reading being 158/92]

Short term goal: reduce BP readings to below 140/90

Long term goal to reduce BP readings to 130/80 (RCAGP Type 2 DM guideline)

[US JNC 8 guideline: hypertensive persons 30 - 59 years of age: diastolic goal of less than 90 mmHg][4]

/

Medications: Telmisartan80mg daily

Diet: low salt diet (total daily salt = 5-6g/day); low sodium foods (<120mg/100g)

Patient education: clinic nurse to provide education on (a) adherence to medications as prescribed (urine frequency will decrease with effective BSL control),(b) importance of reduced salt intake; and their importance in reducing CVS and Neuro-vascular risks

Referral: to community pharmacy for medication management education (not in US)

Hypercholesterolemia

/

[Goal/milestone review–hypercholesterolemia despite prescribed medications & diet]

Targets (RACGP 2014 guideline)

Total cholesterol: <4.0 mmol/L;(<154.5 mg/dl)

HDL-C: ≥1.0 mmol/L;(≥38.5mg/dl)

LDL-C: ≤2.0 mmol/L[5] (≤77.0mg/dl)

Non HDL-C: <2.5 mmol/L

Triglycerides: <2.0mmol/L;(<177mg/dl)

/

Medication: Atorvastatin 40mg/day in the evening (increased from 20mg)

Diet: low saturated fat

Referral: dietitian for better cholesterol control / lowering diet plan

Difficulty in weight management / [Goal/milestone review – 0.3 kg reduction in BW in 1 week; no change in waist circumference]
Targets:
  • 5-10% (of 98kg) weight loss(milestone: 0.5kg/week)
  • Waist circumference <94cm
/
  • Diet order: low kilojoule (e.g. 5025kJ-6670kJ [1200-1600kcal] /day); low glycaemic index; low saturated fat; high fibre diet (for review and adjustment by dietitian)
  • Regular exercise: walking (1.5km in 15 min), jogging, riding push bike, or swimming, e.g. for 15-30 min 3 times/week
  • Referral: to exercise physiology for weight reduction exercise plan

Increased CVS risk from smoking / [Goal/milestone review– cigarette smoked dropped to 3-6/day]
Target:
  • Cigarette consumption reduced to 0 per day
/
  • Patient education: patient advised to continue with cardiac rehabilitation nurse for smoking cessation counselling andsmoking cessation program
  • Medication: Varenicline tartrate days 1–3: 0.5mg daily; days 4–7: increase to 0.5mg twice daily; then 1mg twice daily from day8 to the end of a 12-week treatment course
Review medication at next follow-up

PCP documents in the EMR the plan to review the patient’s hypertension in 2 weeks and decide whether the patient requires a referral to see a cardiologist for blood pressure management.

Referral

Example referral to dietitian/nutrition services (outside PCP practice)

[Referral] Date: 19 November

From: Dr Patricia Primary; Address: 111 Any Street, Any Suburb, Any State, Postcode 123456; Phone: (123) 1234 567

Patient: Mr Adam Everyman; Sex: male; Date of birth: 10 August 1962; Age: 52

To: Ms Nutri Deli, Address: 222 Near Street, Near Suburb, Near State, Postcode 12345; Phone (123) 2234 789

Discipline: Nutrition Services

Priority: Normal

Referral Reason: newly diagnosed Type 2 Diabetes Mellitus patient with blood glucose control, cholesterol and weight control problems

Services Requested: (1) nutrition assessment; (2) Develop and coach patient on implementation of a diet plan for diabetic, cholesterol reduction and weight reduction; (3) diet counselling and educate patient on importance of and strategies on effective blood glucose control, cholesterol and weight reduction

Supporting information:

Medical history: patient has a medical history of hypertension, hypercholesterolaemia, and obesity. He is newly diagnosed with Type 2 DM

Social/lifestyle:

  • Current smoker with cigarette consumption approximately 5-10 cigarettes/day
  • Social drinker: consumes approximately 4 standard drinks per week

Uses smoking as means to help reduce anxiety/stress and reduce weight

Recent Laboratory test (reported on 17 November) results showed:

Lipid Profile:

  • Cholesterol = [6.5 mmol/L (reference range3.9 – 5.5)];[251.4mg/dl]
  • Triglyceride = [2.9 mmol/L (reference range 0.6 – 2.0)];[256.9mg/dl]
  • HDL = [1.32 mmol/L (reference range 0.90 – 1.50)];[51.0mg/dl]
  • Total cholesterol/HDL ration =[4.9:1 (reference <3.5:1)]

Glucose Challenge Test:

  • Fasting blood glucose = [10.3 mmol/L];[(185 mg/dl)]
  • 2 hours post glucose load(75 gm) = [13.9 mmol/L];[(230mg/dl)] (see footnote 1)

The HbA1c level = 7.5%

Physical Measurements:

  • Height (5.6 feet or 170 cm)
  • Weight (214.9 pounds or 97.7 kg; fully clothed): reduced 0.3kg (0.7 lb) from a week before
  • BMI (33)
  • Waist circumference(102.5 cm; 40.35 in): >50% of his height

Blood Pressure: 168/92 (measured at clinic on 19 November)

[1] NOTE – Glucose challenge test is no longer a recommended diagnostic test for Diabetes Mellitus. As of 1 November 2014, the recommended diagnostic tests are: fasting blood glucose and HbA1c (

[2]Journal of Human Hypertension(2014)28,56–61; doi:10.1038/jhh.2013.38; published online 30 May 2013[Office BP recorded after 10 min is more representative of true BP reading] (

[3] No longer used as DM diagnostic test in Australia as of 1 November 2014 (

[4]There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. [JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427]

[5] American College of Cardiology and Circulation 2013 guideline – makes no recommendation for specific LDL and non-HDL targets as there is no evidence of benefit from randomized controlled clinical trials to support treatment to such targets, (Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association.J Am CollCardiol2013.Circulation2013)