Diabetes

HISTORY:

 Type 2  diabetes follow-up

Complications of diabetes: ‍ ‍none



Blood sugar monitoring: ‍not monitored

Fasting: ‍ ‍normal

Postprandial: ‍ ‍normal

Hypoglycemic episodes: ‍ ‍nonemildsevere ‍infrequentfrequent, ‍aware of hypoglycemia management



Current symptoms: ‍none

‍increased thirst

‍frequent urination

‍increased hunger

‍fatigue

‍blurred vision

‍foot sores

‍paresthesias

‍frequent infections

‍chest pain

‍shortness of breath



Medications:

‍Insulins, ‍Metformin, ‍Sulfonylureas, ‍Meglitinides, ‍Thiazolidinediones, ‍DPP-4 inhibitors, ‍GLP-1 receptor agonists, ‍SGLT2 inhibitors, ‍combinations

Adherence: ‍goodaveragepoor, ‍adverse effects



Social history:

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



Weight: ‍ ‍lbskg, ‍gainunchangedloss

Blood pressure monitoring: ‍ ‍not monitored (target ‍130/80)

Foot examination: ‍ ‍normal

Eye examination: ‍ ‍normal



Labs:

HbA1c: ‍ ‍normal

Fasting blood glucose: ‍ ‍normal

Creatinine: ‍ ‍normal

Na: ‍ ‍normal, K: ‍ ‍normal

Hb: ‍ ‍normal

Lipids: ‍normal, Cholesterol: ‍, LDL: ‍, HDL: ‍, Triglycerides: ‍

TSH: ‍ ‍normal

Microalbuminuria: ‍ ‍normal

Urinalysis: ‍ ‍normalproteinsglucose



Vaccinations:

Pneumococcal: ‍up-to-dateincompleteunvaccinated

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated



EXAM:

General appearance:  well-appearing 

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Measurements: weight: ‍ kg, height: ‍ cm, waist: ‍ cm, BMI: ‍

Eyes: -R:  normal , -L:  normal , ‍

Neck:  normal 

Heart:  RRR ,  normal S1 and S2 

Lungs:  clear , ‍retractions

Extremities:  no wounds , ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Sensation:  normal  to  fine touch 

Neurologic: cranial nerves  normal , strength  5/5 throughout , sensation  normal , reflexes  2+ throughout , cerebellar function  normal , gait  stable 



ASSESSMENT:

 Type 2 Diabetes , ‍well-managed



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍HbA1c, ‍lipid profil, ‍TSH

- Urine: ‍urinalysis, ‍urine microalbumin

- ECG

- Healthy diet (low in salt, carbs and fat)

- Regular exercise

- Weight loss counseling

- Medication renewal for ‍61224 months

- ‍Metformin

- ‍Sulfonylureas

- ‍DPP-4 inhibitors

- ‍GLP-1 receptor agonists

- ‍SGLT2 inhibitors

- ‍Insulin

- ‍Aspirin

- ‍Statin

- ‍ACEs

- ‍ARBs

- Advise on foot inspection and care

- Home blood glucose monitoring

- Home blood pressure monitoring

- Repeat HbA1c in ‍ ‍monthsyears

- Referral to diabetes educator

- Referral to dietitian

- Referral to podiatrist

- Referral to ‍ophthalmologistoptometrist

- Referral to endocrinologist

- Follow-up in ‍ months

- Return if blood glucose levels are consistently above target or if new symptoms develop such as frequent urination, increased thirst, unexplained weight loss, fatigue, blurred vision, slow-healing sores or frequent infections