Manage most diabetes, including Type I and Type II, including facilitate patient perioperative care for patients with difficult to manage diabetes. …
SIERRA NEVADA MEDICAL ASSOCIATES, INC IPA
UTILIZATION GUIDELINES
PRIMARY CARE MANAGEMENT GUIDELINES
ENDOCRINOLOGY
DIABETES MELLITUS:
The Primary Care Physician should:
1 Manage most diabetes, including Type I and Type II, including
facilitate patient education, supervision of home testing, medication
management, regular examinations including at least yearly retinal
examination and renal function testing and evaluation of
complications The glycohemoglobin should be checked at each visit
b Routine follow up by the PCP should be as follows:
iii Type I - every three to six months once controlled
iv Type II - every six months once controlled
5 Manage most cases of diabetic ketoacidosis and nonketotic hyperosmolar
states
f Consider referral if:
vii compliant patient with glycohemoglobin greater than 2 above
normal
viii unstable glycemic control characterized by frequent or severe
hypoglycemia and hyperglycemia complications such as nephrology,
retinopathy, or
neuropathy
ix diabetic ketoacidosis or hyperosmolar state occurs
x pregnant diabetics or gestational diabetics
xi patients who desire intensive insulin therapy or those for whom
it is indicated
xii patients who are candidates for insulin pump therapy
xiii perioperative care for patients with difficult to manage
diabetes
xiv coma in a diabetic not rapidly reversible by glucose
xv instability in an established management program
p Refer for a retinal examination after pupil dilatation by an
ophthalmologist:
xvii Type I - at least yearly, beginning five years after diagnosis
xviii Type II - yearly beginning at time of diagnosis
GROWTH AND GONADAL DISORDERS
The Primary Care Physician should:
1 Consider referral for:
ii menstrual disorders
iii menopausal disorders
4 Refer for:
v accelerated or abnormal growth velocity, growth failure or
failure to thrive
vi delayed or precocious puberty
vii precocious thelarche and pubarche
viii under-virilization
ix sexual ambiguity ambiguous genitalia
x cryptorchidism galactorrhea amenorrhea
xi congenital adrenal hyperplasia, hirsutism, and virilization
LIPID AND NUTRITIONAL DISORDERS
The Primary Care Physician should:
1 Hyperlipidemia:
b Initiate evaluation, education and first line treatment,
including diet, exercise and single drug therapy Consider
referral if patient not responding to first line treatment
c Consider referral for:
iv morbid and metabolic obesity
v hormonal complication associated with eating and nutritional
disorders
vi the diagnosis, evaluation, treatment of hypoglycemia
vii inborn errors of metabolism
METABOLIC BONE DISEASE
The Primary Care Physician should:
1 Osteoporosis
ii Educate patients on risk factors for development of
osteoporosis, prevention of osteoporosis, and prevention of
falling especially elderly Treat with adequate calcium and
Vitamin D intake, hormonal replacement therapy if appropriate,
and exercise Consider bone mineral density measurement in high
risk patients, especially those with early menopause or chronic
steroids, and for those with an established
diagnosis of
osteoporosis who will be starting HRT or non-hormonal therapy
for osteoporosis in general, patients need no more than a
baseline BMD measurement and a follow-up BMD 18-24 months after
starting therapy
iii Consider endocrinology or rheumatology referral for high risk
patients and those with moderate to severe osteoporosis
iv Pagets Disease Of Bone
5 Consider referral for initial evaluation of severity and
possible need for treatment, symptomatic patients or those with
complications from the Pagets Disease
vi Disorders of Vitamin D metabolism, including Rickets and osteomalacia,
should be referred to an endocrinologist for evaluation and initiation
of treatment
vii Other metabolic bone disorders should be referred for evaluation and
initiation of treatment
PITUITARY AND ADRENAL CONDITIONS
The Primary Care Physician should refer for:
a Pituitary and hypothalamic tumors
b Cushing disease, acromegaly, hyperprolactinemia and other disorders of
pituitary and hypothalamic function
c Hypopituitarism
d Diabetes insipidus and SIADH
e
Difficult and/or unexplained electrolyte disorders
f Adrenal tumors including pheochromocytoma, adenomas, carcinomas and
Cushing syndrome
g Addison disease
h Endocrine hypertension
i Ectopic hormone secretion
THYROID DISORDERS
The Primary Care Physician should:
1 Diagnose and treat thyroid disorders
b Hyperthyroidism
iii Consider referral for:
severely hyperthyroid patient
thyroid storm
consideration of thyroidectomy or thyroid ablation
continued symptoms despite optimal care and patient
compliance
h Hypothyroidism
ix Consider referral for:
assessment, treatment and management of
hypothyroidism which is unusually complicated or
with difficult to interpret thyroid function tests
hypothyroidism with normal TSH
l Ophthalmopathy related to thyroid disease should be referred to
an ophthalmologist and endocrinologist
m Refer for evaluation, biopsy and management of thyroid nodules
n
Consider referral for patients with unexplained abnormal thyroid
exam or thyroid function test
o Patients with thyroid cancer should be referred for initial
evaluation and treatment and then seen at least yearly by the
endocrinologist
p Consider referral for acute and subacute thyroiditis
q Refer infants with abnormal neonatal thyroid screening test,
children under the age of three with hypothyroidism or
questionable thyroid function, or thyroglossal duct cyst
Source:co.franklin.oh.us
