Download Chronic conditions (Type 2 DM) care – Clinical

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
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.
And the nurse also noted 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 medication list also indicated that the patient was prescribed statin for cholesterol control.
Urine dipstix test revealed mild glycosuria (glucose 1+; ketone –ve; RBC –ve; albumin –ve), SG = 1024
Spot blood sugar test showed a reading of 11.7 mmol/L (210mg/dl)
PCP: The patient was next seen by Dr Primary.
A review of his medical record revealed:
Family history: biological father suffered hypercholesterolemia, 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.
Lifestyle/social history: Patient was a smoker (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
very ineffective results. He tended to smoke more when stressed
He was a social drinker (4 standard drinks per week [1 Australian standard drink = 10gm alcohol]).
Medical history: patient was diagnosed with hypercholestrolaemia and hypertension 6 years ago.
Medication treatment: (Simvastatin 20mg daily; Telmisartan 80mg daily)
Patient indicated that he occasionally skipped a dose of the anti-hypertensive medications
prescription by his PCP.
He admitted that he was relatively stressed by his work and also the recent ill health. He also did not
cut down on the amount of daily salt intake as instructed.
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 general care plan to manage his health
issues before the next visit:
Health Concern
Difficulty in weight
management
Health Goal
5-10% (of 98kg) weight loss
(milestone: 0.5kg/week)

Waist circumference <94cm

Non-adherence to
dietary salt reduction
target
Reduction of total dietary
sodium intake to =<6g/day


Increased CVS risk from
smoking
Cigarette consumption
reduced to 0 per day

Care Activity
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
Diet order: low salt diet (total daily
salt = 5-6g/day); low sodium foods
(<120mg/100g)
Patient education: clinic nurse to
counsel patient on importance of
low salt diet and salt substitution
strategies
Referral to cardiac rehabilitation
nurse to initiate smoking cessation
counselling sessions

Poor BP control related
to possible nonadherence to
treatments
To determine median BP to
guide medication and diet
adjustment
Anxiety/stress disorder
Reduce anxiety/stress level
Potential case of Type 2
DM
To confirm/rule out that
patient has Type 2 DM
Re-enrol in smoking cessation
program
 Medication: Varenicline tartrate
days 1–3: 0.5 mg daily; days 4–7:
increase to 0.5 mg twice daily; then
1 mg twice daily from day 8 to the
end of a 12-week treatment course
 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
 Counselling and relaxation
therapy: clinic nurse to provide
counselling on how to deal with
stress and anxiety; recommends
relaxation therapies such as
mediation, tai chi, etc
 Review at next follow-up
Diagnostic order:



Fasting blood glucose
Oral glucose tolerance test1
Fasting blood lipids (cholesterol,
triglyceride, HDL, LDL)

HbA1c
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 mins2 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.
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
(http://www.comlaw.gov.au/Details/F2014L01441/Explanatory%20Statement/Text)
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]
(http://www.nature.com/jhh/journal/v28/n1/full/jhh201338a.html)
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.
Mr Everyman informs Dr Primary that over the past week he had trouble falling asleep, woke up
most of the nights in the middle of the night and stayed awake for 1-2 hours. He feels anxious,
stressed and his mood has worsened on waking up in the morning and when the day draws towards
the evening. He also has mild difficulty in concentrating.
He still experienced those signs and symptoms that appeared since 12 November
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 = [10.3 mmol/L]; [(185 mg/dl)]
 2 hours post glucose load (75 gm) = [13.9 mmol/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 records
the assessment findings in the EMR.
She also assesses the patient’s psychological/mood changes symptoms and records the diagnosis of
anxiety and depression symptoms (including mood changes, stress and insomnia) related to Type 2
diabetes.
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.
Upon further questioning of the patient’s medications and diet, the patient tells Dr Primary that he
forgets taking his blood pressure tablets 2-3 times per week. But he has cut down on the amount of
daily salt intake.
Dr Primary explained to the patient that Type 2 Diabetes is a complex problem. It has implications
(risks) for his existing cardiovascular comorbidities: hypercholestrolaemia and hypertension. Both
3
No longer used as DM diagnostic test in Australia as of 1 November 2014
(http://www.comlaw.gov.au/Details/F2014L01441/Explanatory%20Statement/Text)
conditions and the psychological issues (sleep and mood disturbances) require to be managed
carefully.
Dr Primary discusses with the patient about 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 to 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
Confirmed: Type 2
DM
Problem in effective
glycaemic control
Health Goal and Review
Goal/Targets:

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. 5025kJ6670kJ [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 1530 min 3 times/week

Referral: to dietitian for diabetic diet
plan

Medications: Telmisartan 80mg
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
BSL:

6–8 mmol/L fasting (108144mg/dl); and

8–10 mmol/L
postprandial; (108180mg/dl)
HbA1c: ≤7% (range 6.5–7.5)
[≤53 mmol/mol (ref range 48–
58)]
Increased CVS risks
(hypertension, AMI)
associated with Type
2 DM and poor BP
control (due to non adherence to
treatment)
Care Activity
[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
Referral: to community pharmacy for
years of age: diastolic goal of
less than 90 mmHg]4

Medication: Atorvastatin 40mg/day
in the evening (increased from
20mg)

Diet: low saturated fat

Referral: dietitian for better
cholesterol control / lowering diet
plan
[Goal/milestone review –
anxiety/stress worsen with
mood and sleep disturbance
despite sedative medication]

Medication: Lexapro 5 mg daily for
4 weeks

Recommend enrol into relaxation
therapy/meditation sessions
Target:

Referral: to psychologist for stress
management and cognitive
behavioural therapy
[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

[Goal/milestone review –
cigarette smoked dropped to 3-

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
Patient education: patient advised
to continue with cardiac
Persistent
[Goal/milestone review –
hypercholesterolemia hypercholesterolemia despite
prescribed medications & diet]
Targets (RACGP 2014 guideline)
Worsening
anxiety/stress
disorder
Difficulty in weight
management
Increased CVS risk
from smoking
4
medication management education (not
in US)

Total cholesterol: <4.0
mmol/L; (<154.5 mg/dl)

HDL-C: ≥1.0 mmol/L;
(≥38.5mg/dl)

LDL-C: ≤2.0 mmol/L5
(≤77.0mg/dl)

Non HDL-C: <2.5 mmol/L

Triglycerides: <2.0mmol/L;
(<177mg/dl)

Reduce anxiety/stress

Improved sleep at night


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 Coll Cardiol 2013. Circulation 2013)
6/day]
Target:
 Cigarette consumption
reduced to 0 per day

rehabilitation nurse for smoking
cessation counselling and smoking
cessation program
Medication: Varenicline tartrate
days 1–3: 0.5 mg daily; days 4–7:
increase to 0.5 mg twice daily; then
1 mg twice daily from day 8 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 standards 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)