Diabetes Check-up

Patient Name: Arthur Pendelton Date of Birth: 14/05/1962 Date of Visit: 24/10/2023 Medical Record Number: MRN-8492014

Visit Type: Diabetes Review

Medical History

Diabetes Classification

• Category: T2DM
• Treatment Currently Used: Oral hypoglycaemics and diet modification

Prior Health History

• Relevant Long-Term Conditions: HTN, dyslipidaemia, OA knees
• Allergies: Penicillin (rash)

Family History

• Diabetes in the Family: Mother had T2DM
• Other Relevant Familial Conditions: Father had IHD (MI at age 64)

Medicines in Use

• Medication List: metformin (Diabex®) 1,000 mg PO BID, perindopril (Coversyl®) 5 mg PO daily, atorvastatin (Lipitor®) 20 mg PO nocte

Clinical Data

• Glucose Readings:
  • Fasting Reading: 7.8 mmol/L
  • After-Meal Reading: 10.2 mmol/L
• HbA1c Result: 7.6 % (60 mmol/mol)
• Blood Pressure Reading: 136/84 mmHg
• Body Mass Index: 31.2 kg/m²
• Body Weight: 94.5 kg
• Foot Check: Skin intact, no ulcers/calluses. DP and PT pulses palpable bilaterally. 10 g monofilament sensation intact all sites.

Examination Findings

• Overall Appearance: Well, NAD, alert and oriented.
• Cardiovascular Assessment: HS dual, no murmurs. No peripheral oedema.
• Respiratory Assessment: Chest clear to auscultation bilaterally, no wheeze or crepitations.
• Neurological Assessment: Normal gait, lower limb power 5/5, ankle jerks present, vibration sense intact at hallux.

Investigations

Recent Laboratory Findings

• Lipid Testing:
  • Total Cholesterol: 4.5 mmol/L
  • HDL Cholesterol: 1.1 mmol/L
  • LDL Cholesterol: 2.4 mmol/L
  • Triglycerides: 2.2 mmol/L
• Renal Function Testing:
  • Creatinine: 88 µmol/L
  • eGFR: 78 mL/min/1.73m²

Management Plan

Glycaemic Management

• Regimen and Revisions: Continue metformin 1,000 mg PO BID. Add SGLT2 inhibitor due to suboptimal HbA1c.
• HbA1c Goal: < 7.0 % (53 mmol/mol)

Lifestyle Measures

• Nutrition: Reduce refined carbohydrates and portion sizes; refer to dietitian under GP Management Plan.
• Physical Activity: Aim for 30 mins brisk walking 5 days/week, as tolerated by knee OA.

Medication Changes

• Adjustments: Continue current doses of metformin, perindopril, and atorvastatin.
• Newly Commenced Medicines: empagliflozin (Jardiance®) 10 mg PO daily (counselled on mycotic genital infections, euglycaemic DKA, and sick day management)

Monitoring and Follow-Up

• Follow-Up Date: 24/01/2024
• Glucose Monitoring Plan: Check fasting BGL 3 times weekly.
• Further Testing: Repeat HbA1c, UEC, LFT, lipids, and urine ACR in 3 months. Refer to optometrist for annual diabetic retinal screen.

Signature

Dr Sarah Jenkins General Practitioner Bayside Family Medical Centre, 120 Marine Parade, St Kilda VIC 3182 | Ph: (03) 9555 0199

Date: 24/10/2023