GP Comprehensive Clinical Overview

Patient Demographics

• Name: Arthur Pendelton
• Date of Birth: 14/05/1956 (68 yo)
• Gender: Male
• Identification Number: IHI: 8003608166690503 / Medicare: 2459 83710 1

Medical History

• Past Medical History: T2DM (diagnosed 2015), HTN, dyslipidaemia, GORD, OA bilateral knees. Laparoscopic cholecystectomy (2010, uncomplicated).
• Family History: Father died of AMI at 64 yo; Mother had T2DM and HTN.
• Social History: Retired accountant, lives with wife in single-storey home. Ex-smoker (ceased 2005, 20 pack-year hx). ETOH: 2–3 std drinks/week. Sedentary lifestyle.
• Allergies: Penicillin (maculopapular rash).

Current Clinical Status

• Chief Complaint: Bilateral foot paraesthesia and suboptimally controlled blood glucose levels.
• History of Present Illness: 3-month history of progressive "pins and needles" in both feet, stocking distribution to ankles, worse at night. Denies weakness, falls, or foot ulcers. Home BGLs averaging 9.5–12.0 mmol/L fasting. Admits to poor dietary compliance recently. No polyuria, polydipsia, chest pain, or SOB. O/E: BP 146/88 mmHg, HR 76 bpm reg, BMI 31.2 kg/m². Foot exam: Dorsalis pedis and posterior tibial pulses palpable bilaterally. Reduced monofilament sensation (6/10) plantar aspects bilaterally. No skin breakdown.
• Medications:
  • metformin (Diabex®) 1,000 mg PO BID
  • perindopril (Coversyl®) 5 mg PO daily
  • atorvastatin (Lipitor®) 40 mg PO daily
  • esomeprazole (Nexium®) 20 mg PO daily
  • paracetamol (Panadol Osteo®) 1,330 mg PO TID PRN

Diagnostic Findings

• Laboratory Tests: (10/10/2023) HbA1c 8.4 % (68 mmol/mol); FBG 10.2 mmol/L; eGFR 68 mL/min/1.73m²; UACR 4.2 mg/mmol (microalbuminuria); TC 4.8 mmol/L, LDL 2.6 mmol/L, HDL 1.1 mmol/L, TG 2.4 mmol/L; FBE and LFTs NAD; B12 340 pmol/L.
• Imaging Studies: Bilateral knee XR (12/02/2023): Moderate medial compartment joint space narrowing and osteophytosis.
• Specialist Consultations: Optometry (05/09/2023): Mild non-proliferative diabetic retinopathy (NPDR) bilaterally, no maculopathy.

Assessment

• Diagnoses: T2DM with peripheral neuropathy, mild NPDR, and early diabetic nephropathy (microalbuminuria); Uncontrolled HTN.
• Problem List:
  1. Suboptimal glycaemic control with microvascular complications.
  2. Diabetic peripheral neuropathy.
  3. Elevated BP / microalbuminuria.
  4. Obesity and physical inactivity.

Plan of Care

• Treatment Plan: Commence empagliflozin (Jardiance®) 10 mg PO daily. Increase perindopril (Coversyl®) to 10 mg PO daily for BP and renal protection. Counselled on daily foot checks, euglycaemic DKA red flags, and genitourinary hygiene.
• Rehabilitation Plan: GP Management Plan (GPMP) and Team Care Arrangements (TCA) initiated. Referred to Podiatry for neurovascular assessment and footwear advice, Dietitian for carbohydrate management, and Exercise Physiologist for tailored low-impact strengthening program.
• Prognosis: Guardedly optimistic; good potential to halt progression of microvascular complications if glycaemic and BP targets are achieved.

Progress Notes

• Clinical Progress: Review at 4 weeks post-initiation of SGLT2i. Patient tolerating empagliflozin well, no polyuria or thrush. Home FBG improved to 7.0–8.2 mmol/L. Repeat clinic BP 132/78 mmHg. Neuropathic symptoms stable, not interfering with sleep. Attended initial dietitian and podiatry reviews.
• Updates to Plan of Care: Continue current pharmacotherapy unchanged. Pregabalin not required at this stage as neuropathy is non-painful and tolerable.

Summary and Recommendations

• Executive Summary: 68 yo male with T2DM presenting with poor glycaemic control (HbA1c 8.4 %), peripheral neuropathy, microalbuminuria, and HTN. Commenced on empagliflozin 10 mg daily and uptitrated perindopril to 10 mg daily, with early improvements in home BGLs and clinic BP. Multidisciplinary allied health care initiated via GPMP/TCA.
• Recommendations: Repeat HbA1c, UEC, and UACR in 2 months. Review in GP clinic with results. Annual optometry review to monitor mild NPDR. Patient to present earlier if neuropathic pain develops or if any foot lesions occur.