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 walking more. He denies any side effects from his current medications. He monitors his blood glucose at home approximately three times per week, usually in the morning. He reports that his younger brother was recently diagnosed with diabetes.

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
- Lungs are clear to auscultation
- No peripheral edema
- Abdomen is soft and non-tender
- Foot examination reveals intact sensation with no ulcers or skin abnormalities

Investigations with results:
- Fasting glucose 7.8 mmol/L
- HbA1c 7.2%
- LDL cholesterol 2.4 mmol/L
- Triglycerides 1.8 mmol/L

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

2. Essential (primary) hypertension  
- Essential (primary) hypertension  
- Treatments planned:  
  - Continue ramipril  
  - Advise reduction of sodium intake to approximately 1 teaspoon per day

3. Other hyperlipidemia  
- Other hyperlipidemia  
- Treatments planned:  
  - Lifestyle modifications as above including diet and exercise  
- Investigations planned:  
  - Repeat lipid profile with other labs in 3 months