Type 2 Diabetes follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a type 2 diabetes follow-up

Complications of diabetes: ‍ ‍none

Last visit was ‍ ‍days ago



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, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍shortness of breath



Medications:

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

Adherence: ‍goodaveragepoor, ‍adverse effects



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

Physical activity: ‍adequateaveragesedentary

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonereasonableexcessive, ‍ 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: ‍unremarkable

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, ‍apparent distress

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

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Type 2 Diabetes, ‍well-managed





PLAN:

Investigations:

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

- Urine: ‍urinalysis, ‍urine microalbumin

- ECG

Treatments:

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

- Regular exercise

- Weight loss counseling

- ‍Metformin

- ‍Sulfonylureas

- ‍DPP-4 inhibitors

- ‍GLP-1 receptor agonists

- ‍SGLT2 inhibitors

- ‍Insulin

- ‍Aspirin

- ‍Statin

- ‍ACEs

- ‍ARBs

- Advise on foot inspection and care

Further care:

- Home blood glucose monitoring

- Home blodd pressure monitoring

- Repeat HbA1c in ‍ ‍monthsyears

- Referral to diabetes educator

- Referral to dietitian

- Referral to podiatrist

- Referal 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