Managing Type 2 Diabetes

1. John's Patient profile and Key Points

1.1. 1. Initial Diagnosis from GP

1.1.1. Medication and Treatment:

1.1.2. HbA1c 8.5%

1.1.3. Metformin + lifestyle changes

1.1.4. Follow-up: 3-month

1.2. 2. Check-in & Referral

1.2.1. Adjusted medication

1.2.2. 7.8% (above target)

1.2.3. Metformin

1.2.4. Dietitian referral

1.3. 3. Dietitian

1.3.1. Portion control & carbohydrate management

1.3.2. Routine follow-ups

1.4. 4. Enocrinologist

1.4.1. Implemented exercise plan

1.4.2. addition of GLP-1 + metformin

1.4.3. Follow-up: 3 month

1.5. 5. Emergency Room Visit

1.5.1. Endocrinology consultation

1.5.2. (insulin, IV fluids, needed electrolytes)

1.5.3. Stabilized & discharged with new medication

1.6. 6. Prevention and On-going Care (DMP)

1.6.1. (foot examination, retinopathy & nephropathy, needed lipids)

1.6.2. Educational Services and Supportive Resources

1.6.3. Glucose and lab monitization

2. Goals and Outcomes for John

2.1. Weight management

2.2. Blood Pressure

2.3. Avoid medical complications

2.4. HbA1c needs to be 7.0%

2.5. Improve overall quality of life

3. Healthcare Establishments

3.1. Community and Support Resources

3.2. Dietitian

3.3. Diabetes Management Program (DMP)

3.4. Hospital

3.5. Outpatient Clinic

3.6. Primary Care Clinic (GP)

4. John's Healthcare Providers

4.1. Case Manager

4.2. Diabetes Educator

4.3. Edocrinologist

4.4. General Practitioner (GP)

4.5. Dietitian

4.6. Primary Care Team

4.7. Emergency Room Phyician (or ER team)

5. Decision Milestones

5.1. Diagnosis -> HbA1c 8.5%

5.2. Suboptimal Control -> HbA1c 7.8%

5.3. Addition of GLP-1 -> HbA1c > 8.0% after 6 months

5.4. DKA Management

5.5. Adjusted medications

5.6. Adjusted Follow-up plans