EDM Diabetes Consult Note

OVERALL_INSTRUCTIONS

Chief Complaint

[Insert chief complaint or reason for referral]

Template

Date: [Insert Date] Referring Physician: Dr. [Insert Referring Physician Name] Dear Dr. [Insert Last Name], Thank you for asking me to see your patient. HISTORY OF PRESENT ILLNESS: Diabetes diagnosis: - Diet: BF: [Insert breakfast details]; Lunch: [Insert lunch details]; Dinner: [Insert dinner details]; Snacks: [Insert snack details]; Exercise: [Insert frequency]/week; Weight: {stable|gained|lost|[Insert amount][lbs|kgs]} Diabetes complications: Neuropathy: {present;|absent;} Erectile Dysfunction: {|yes|no} Macrovascular: {no CAD| no stroke| no PVD}. Last ECG - [Insert ECG details] MASH: [present|absent|not evaluated]; Fibroscan [Insert result|not performed]; Fib-4 [Insert result|not performed] ROS: No chest discomfort or dyspnea. No headaches, abdominal pain, urinary or bowel complaints Lifestyle Notes: [Insert lifestyle notes or 'None Recorded'] Family History: [Insert family history or 'None Recorded'] PHYSICAL EXAMINATION: Head and neck exam was normal. Thyroid was palpable without nodularity. Chest was clear to auscultation. Cardiovascular examination showed normal heart sounds, regular rate and rhythm, no audible murmurs or bruits. Abdomen was soft with no palpable organomegaly. Feet were clear to inspection. Pedal pulses palpable. Peripheral fine touch sensation was intact to 10gm monofilament. ASSESSMENT AND PLAN: 1. Type 2 diabetes Course: [Insert patient name] was diagnosed with DM in [Insert year] {on routine lab testing|when patient presented with [Insert presentation]}. {Pt progressed to insulin use in [Insert year].| } Pt is currently on [Insert current therapy]. [Reports|Denies] polyuria. [Reports|Denies] polydipsia SMBG: {acB|pcB|acL|pcL|acD|pcD|Random|HS}; Hypoglycemia: [Insert details] { |Insulin Profile:|Basal:|Lantus|Toujeo|Levemir|Tresiba|Basaglar|Semglee| units|qHS;|qAM;|Bolus:|Humalog|Novorapid|Apidra|Trurapi|Kirsty|Admelog} control [at|above] target based on A1c. - continue [Metformin|Glumetza|Janumet|Janumet XR|Komboglyze|Jentadueto] - continue [Januvia|Trajenta|Onglyza|Victoza|Trulicty|Ozempic|Rybelsus|Mounjaro] - continue [Invokana|Jardiance|Forxiga|Synjardy|Xigduo|Invokamet] - continue [Diamicron MR (Gliclazide MR)] - discussed diet, lifestyle modification and weight management. [Recommended reducing carb intake and snacking in between meals| ] {-Rx given for [Insert medication] | } - structured SMBG; [I will review SMBGs at next visit to determine need for additional pharmacotherapy| ] - driving and hypoglycemia precautions discussed 2. Lipids: LDL-C target < 2 discussed. LDL [at|above] target. - {Continue Crestor.|Continue Lipitor.|Statin therapy indicated as per Diabetes Canada guidelines.|Statin therapy not indicated.|I will reassess lipid profile with next set of labs|Patient hesitant to start a statin at this time.} 3 a) BP target < 130/80 discussed. BP [at|above] target. b) Renal function - Normal. [ |Continue to follow with nephrologist, Dr [Insert name]] c) UACR - [Normal|elevated] Continue [Coversyl|Ramipril|Telmisartan|Irbesartan|Valsartan|Amlodipine|HCTZ|indapamide] [- ACEi/ARB not indicated in absence of microvascular / macrovascular complications per Diabetes Canada 2018| ] 4. Last dilated eye exam: [Insert date] - Retinopathy: {unknown|none|OD|OS|OU|s/p|laser therapy|and|intravitreal injections}. Counseled re: annual dilated eye exam 5. Immunization: follow with you for flu and pneumonia vaccines (as applicable based on patient's age and risk factors). Discuss shingles vaccination (if applicable) 6. Recommended follow-up with you for screening ECG every 3-5 years as per Diabetes Canada 2018 guidelines {- Reviewed Sick Day management to reduce risk of acute renal injury: consider holding SUs, ACEIs, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors (SAD MANS) if patient becomes ill and/or dehydrated (eg vomiting or diarrhea).| - adverse impact of smoking on CV disease and death reviewed. Various options for smoking cessation discussed| - Appropriate family planning was emphasized, including use of reliable contraception (barrier or hormonal), and optimizing HbA1c and folate supplementation before conception.| - We reviewed pregnancy planning including the importance of maintaining an HbA1c < 7.0% and using appropriate folate supplementation in advance of conception. | - We reviewed diabetes and pregnancy including the importance of a structured self-monitoring program to achieve pregnancy-specific glycemic targets. Maternal health discussion points included regular assessment of blood pressure, renal and retinal surveillance. Fetal health discussion included the value of a structural ultrasound and echocardiogram at 18-20 weeks, the potential role of serum markers for neural tube defects in second trimester, and ultrasound monitoring of size for gestational age in third trimester. | } FOLLOW-UP: {Follow up: Appointment planned in| [Insert interval] weeks|2 months|3 months|4 months|5 months|6 months|1 year|2 years|Follow up: Patient is being discharged to your continuing care. I remain available for future reassessment at your discretion.|Follow up: Appointment planned in [Insert interval]|Follow up: Brief appointment planned in [Insert interval]|Follow up: Per your request, we haven’t booked a follow–up visit but I would be happy to see your patient again, for continuing support, at your discretion.|Follow up: With your permission, I would like to schedule 1-2 further follow up visits to assess the outcomes of the above steps. I’ll then remain available for future reassessment at your discretion.|Follow up: patient will be contacted for follow-up} Thank you very much for the opportunity to share in the care of your patient. Sincerely, [Insert Your Name], [Insert Credentials] [Insert Contact Information]