Diabetes Consult

Chief Complaint

Assessment and management of diabetes.

Template

Dear Dr. [name], Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of diabetes. The patient was seen [in person or via telemedicine]. We spoke in [English or Mandarin]. [They were accompanied by]. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that Empathia saves a copy of our conversation on their website for the purpose of generating a note, and that this software is FDA approved. DIABETES HISTORY: Type of diabetes: [Type 1 or Type 2] Date of diagnosis: [date] Most recent A1c: [number] CAD: [present or absent, and relevant details] CVD: [present or absent, and relevant details] PAD: [present or absent, and relevant details] CKD: [present or absent] [albuminuria absent or present] Retinopathy: [present or absent] [last eye exam] Neuropathy: [present or absent, and relevant details] Prior DKA/HHS: [number] Hypoglycemia awareness: [intact or not intact] Therapies tried: [drug_name] CURRENT DIABETES MEDICATIONS: 1. [drug_name] 2. [drug_name] [List numerically with each having its own line] HISTORY OF PRESENTING ILLNESS: [History of Presenting Illness:] BLOOD GLUCOSE READINGS: [number] OTHER MEDICAL HISTORY: 1. [medical_history] 2. [medical_history] [List numerically with each having its own line] OTHER MEDICATIONS: 1. [drug_name] 2. [drug_name] [List numerically with each having its own line] ALLERGIES: 1. [allergies] 2. [allergies] [List numerically with each having its own line] SOCIAL HISTORY: Exercise: [exercise] Meals: [meals] Work: [work] Extended coverage: [coverage] Alcohol: [alcohol] Cigarettes: [cigarettes] Drugs: [drugs] FAMILY HISTORY: [family_history] EXAM: Weight: [weight] Height: [height] Blood pressure: [blood pressure] Heart rate: [heart rate] [general exam] [cardiac exam] [pulmonary exam] [pedal edema] (Give each exam finding its own line) INVESTIGATIONS: [Date of investigation] [investigations] (Give each lab value finding its own line but do not list it numerically) IMPRESSION AND PLAN: [name] is a [age] year old [gender] with [type 1 or type 2 diabetes] diagnosed [brief history of diagnosis]. [He/She] has risk factors for diabetes, including [risk factors]. He has [list of complications or no complications of diabetes]. [He/She] is [at target or not at target] for [his/her] A1c and requires [maintenance or further escalation] of [his/her] nonpharmacologic and pharmacologic therapies. Other metabolic parameters, such as lipids and blood pressure, are [not at target or well controlled]. We discussed the importance of maintaining an A1c in the target range (<7%, ideally <6.5%), as this would minimize the risk of developing or worsening diabetic complications. [He/She] was understanding of this and seems motivated to achieve good glycemic control today. We had a lengthy discussion today around the pathophysiology of diabetes and the nonphamacologic and pharmacologic ways to manage it. 1. Diabetes: [at target or not at target] A1c of <7% (ideally <6.5%) - [List detailed action plans using the correct person tone] 2. Dyslipidemia: [at target or not at target] of LDL <2 or nonHDL <2.6 - [List detailed action plans using the correct person tone] 3. Hypertension: [at target or not at target] of BP <130/80 - [List detailed action plans using the correct person tone] 4. Diabetes complications: - I have recommended annual eye exam. - I have provided bloodwork for nephropathy. - Patient has no symptoms to suggest CAD, CVD, PAD, or neuropathy. 5. Lifestyle factors: - I recommended limiting carbohydrate intake to at most 25% of meal sizes and to substitute high glycemic index carbohydrates for lower glycemic index alternatives - I recommended achieving 150 minutes per week of moderate to intense activity, through both aerobic and resistance exercises [- Smoking cessation] [- Weight loss of 10% over 6 months] [List detailed action plans using the correct person tone] 6. Follow-up - I have arranged for follow-up in [time] PATIENT COUNSELING: I counseled the patient on sick day management for their diabetes medications. I recommended holding metformin and SGLT2-i if feeling unwell or if febrile, and to restart once feeling back to normal. Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Dr. Leo Hu, MD, FRCPC Elida Medical Centre