Telehealth Template

Patient's identity verified  
Informed consent to proceed with the telehealth consultation obtained from the patient/carer  
Limitations of telehealth explained to patient/carer

Subjective:
Mr. David presents for follow-up of type 2 diabetes mellitus and hypertension. He reports that he has been trying to keep his blood sugars and blood pressure under control by eating better and increasing his physical activity, specifically walking more. He denies any medication side effects. He monitors his blood glucose at home approximately three times per week, usually in the morning.

Past medical history:
- Type 2 diabetes mellitus
- Hypertension

Medications:
- Metformin daily
- Ramipril daily

Allergies:
- No known drug allergies

Objective:
- Blood pressure is 138/84 mmHg
- Weight is 84 kg
- BMI is 28.3
- Heart sounds are normal
- No ankle swelling observed
- Lungs are clear to auscultation
- Abdomen is soft and non-tender
- Foot sensation is intact
- No ulcers or skin issues noted
- Fasting glucose is 7.8 mmol/L
- Recent HbA1c is 7.2%
- LDL cholesterol is 2.4 mmol/L
- Triglycerides are 1.8 mmol/L

Assessment and Plan:
1. Type 2 diabetes mellitus  
- Type 2 diabetes mellitus without complications  
- Repeat laboratory tests in 3 months  
- Continue metformin  
- Advise high-fibre, low-glycemic diet and avoidance of sugary drinks  
- Encourage continued walking and light strength training twice weekly  
- Refer to dietitian for personalized dietary guidance  
- Instruct patient to keep a log of home blood glucose readings and bring it to next visit

2. Essential (primary) hypertension  
- Essential (primary) hypertension  
- Continue ramipril  
- Advise reduction of sodium intake to approximately 1 teaspoon per day including processed and restaurant foods  
- Reinforce importance of maintaining blood pressure under 130/80 mmHg

3. Other hyperlipidemia  
- Other hyperlipidemia  
- Reinforce importance of maintaining LDL under 2.0 mmol/L