Diabetes follow-up

Chief Complaint

Diabetes follow-up consultation

Template

Dear Dr. [Last Name], I spoke with [Patient Name], a [Age] year old [Gender], who was seen on [Date] for follow-up of diabetes. The patient was seen [in person or via telemedicine]. We spoke in [English or Mandarin]. [They were accompanied by]. INTERVAL HISTORY: [Brief update since last visit] MOST RECENT A1C: [Number] CURRENT DIABETES MEDICATIONS: [Drug Name] OTHER MEDICATIONS: [Drug Name] NEW DIABETES COMPLICATIONS: [None or list new complication] BLOOD GLUCOSE READINGS: [Number] EXAM: [General exam, weight, height, vitals, cardiac exam, pulmonary exam] Blood pressure: [Value] Heart rate: [Value] (Arrange exam findings by organ system and list each system in its own line) INVESTIGATIONS: [Date of investigation] (List each in its own line, not numerically) IMPRESSION AND PLAN: 1. Diabetes: [at target or not at target] A1c of <7% (ideally <6.5%) (List detailed action plans using the correct person tone, e.g., '- I have started [drug_name] for diabetes control' or '- The family doctor has initiated...') 2. Dyslipidemia: [at target or not at target] of LDL <2 or nonHDL <2.6 3. Hypertension: [at target or not at target] of BP <130/80 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, e.g., '- I have started dapagliflozin for diabetes control' or '- The family doctor has initiated...)' 6. FOLLOW-UP: - I have arranged follow-up for [Insert follow-up details] Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Sincerely, Dr. Leo Hu, MD, FRCPC Elida Medical Center