Diabetes Management Clinic

Diabetes mellitus [select value="Type 2|Type 1"], diagnosed in [text default="yyyy"]

In reviewing the history, the patient is followed [select value="by a primary care physician|by the diabetes clinic|by primary care physician and diabetes clinic|by the family medicine team|other" name="provider"][conditional field="provider" condition="(provider).is('other')"] [text size=30 default="other provider"][/conditional].

In the past year the patient has had the following diabetic visits: [select value="no|one|two|three|four|five|more than five"] visits in the hospital, [select value="no|one|two|three|four|five|more than five"] visits to the ER, and [select value="no|one|two|three|four|five|more than five"] outpatient visits.

The patient [select value="is following an optimal diet|is having difficulties following the diet|is not following a diet|would like further education on their diet"].  The patient has [select value="no|some" name="diet_concerns"] specific concerns about diet. [conditional field="diet_concerns" condition="(diet_concerns).is('some')"] [textarea default="specific diet concern details..."][/conditional].

The patient routinely exercises [select value="never|once a week|2 times a week|3 times a week|4 times a week|5 times a week|6 times a week|7 times a week"].  The type of exercise is [text size=50].  Overall, the patient is exercising [select value="approximately|more than|less than"] 150 minutes per week.

The patient has a history of the following diabetes complications:
[select value="NO|YES" name="DKA"] <-- Diabetic ketoacidosis [conditional field="DKA" condition="(DKA).is('YES')"] [text default="diabetic ketoacidosis details" size=140][/conditional]
[select value="NO|YES" name="HHS"] <-- Hyperosmolar hyperglycemic state [conditional field="HHS" condition="(HHS).is('YES')"] [text default="hyperosmolar hyperglycemic state details" size=140][/conditional]
[select value="NO|YES" name="hypoglycemia"] <-- Hypoglycemic episodes [conditional field="hypoglycemia" condition="(hypoglycemia).is('YES')"] [text default="hypoglycemic episode details" size=140][/conditional]
[select value="NO|YES" name="eye"] <-- Eye complications [conditional field="eye" condition="(eye).is('YES')"] [text default="eye complication details" size=140][/conditional]
[select value="NO|YES" name="kidney"] <-- Nephropathy [conditional field="kidney" condition="(kidney).is('YES')"] [text default="nephropathy details" size=140][/conditional]
[select value="NO|YES" name="neuro"] <-- Neuropathy [conditional field="neuro" condition="(neuro).is('YES')"] [text default="neuropathy details" size=140][/conditional]
[select value="NO|YES|N/A" name="OB"] <-- Obstetric complications [conditional field="OB" condition="(OB).is('YES')"] [text default="obstetric complication details" size=140][/conditional]

The following prevention program has been set up and includes: 
[checkbox value="one time Pneumovax|yearly vaccination with Influenza|foot care instruction|preconception counseling"]

MONITORING:
The patient performs monitoring of blood glucose [select value="once a day|twice a day|three times a day|four times a day|once a week|twice a week|three times a week|at no specific times|at clinic visits"].
The patient's goals for diabetes control are:
[checkbox value="MORNING (FASTING) BLOOD SUGAR LESS THAN 130.  "]
[checkbox value="BLOOD SUGAR PRIOR TO MEALS OF 80-120.  "]
[checkbox value="BEDTIME BLOOD SUGAR LESS THAN 120.  "]
[checkbox value="HEMOGLOBIN A1C LESS THAN 7 WITHOUT SIGNIFICANT SYMPTOMS.  "]
[checkbox value="HEMOGLOBIN A1C LESS THAN 8.  "]
[checkbox name="control" value="Other: "] [conditional field="control" condition="(control).is('Other: ')"] [text default="diabetes control details" size=140][/conditional].

INSULIN
The patient [select name="insulin" value="does not use insulin|uses long-acting insulin only|uses short-acting insulin only|uses long- and short-acting insulins"].
[conditional field="insulin" condition="(insulin).is('uses long-acting insulin only')||(insulin).is('uses short-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient does not adjust insulin.  "][/conditional]
[conditional field="insulin" condition="(insulin).is('uses short-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient adjusts short-acting insulin based on glucose checks before meals.  "][/conditional]
[conditional field="insulin" condition="(insulin).is('uses short-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient adjusts short-acting insulin based on carbohydrate counting.  "][/conditional]
[conditional field="insulin" condition="(insulin).is('uses long-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient adjusts long-acting insulin based on fasting glucose trend. "]  [link url="//soapnote.org/endocrine-metabolic/long-acting-insulin-self-3-3/" memo="3 by 3 long-acting insulin adjustment instruction for patients"][/conditional]
Diabetes Follow-up (250 K030):

Wt: • kg Ht: • cm WC: • «BMI:» BP: •  HR: • 
Monofilament R:•/10 L:•/10 missed

Logbook:« no, forgot»« no, does not check sugars regularly»
«-FBS: •
-Lunch: •
-Dinner: •
-QHS: •
»«
-Hyperglycemia: highest in last • month(s) = • (explanation:)
-Hypoglycemia: lowest in last • month(s) = • (explanation:)
-Hypoglycemic symptoms occur at a threshold of: •
-Frequency of BG <4.0: 
-Severe low?  «no»»

Lifestyle:
-Smoking: •
-EtOH: •
-Diet: •
-Exercise: •

Complications:
-Macrovascular:« No chest pain, TIA/strokes, claudication.» 
-Erectile dysfunction: •
-Gastroparesis: •
-Peripheral neuropathy: •
-Ulcers: •

Current DM meds: Reviewed and updated medications in chart, denies s/e

Physical exam:« NAD, looks well».« Obese.»« No acanthosis nigricans.»
-HN: «Thyroid not enlarged, no nodules palpated, no lymphadenopathy»
-CVS: «NHS, no murmurs»
-Resp: «GAEB, no c/w»
-Fundi: «Grossly normal» 
-Foot exam: «No »PPP, monofilament R:•/10 L:•/10 missed, «no foot lesions», calluses/toenails: •

A+P: «DMI»«DMII», «well»«poorly»«not» controlled

1. Glycemic control 


2. Microvascular complications
Retinopathy:« No»« YES»
Neuropathy:« No»« YES»
Nephropathy:« No»« YES»

Latest Ophthalmology Consult = «never done»
Latest Optometry Consult = «never done»
Latest Podiatry Consult = «never done»
Latest A1c (q3m):
Latest Cr (q6m):
Latest ACR (q12m):
Latest ECG (q24m):

3. Macrovascular complications -« ABSENT»« YES:« CAD»« MI»« Stroke»« TIA»« PVD»»

ASA:« Yes.»« No, not indicated for primary prevention.»
ACE/ARB:« Yes.»« No, not indicated as BP at target and no nephropathy.»
Statin:« Yes.»« No, not indicated as <40 years and no macro- or microvascular complications.»

4. Immunizations: 

Influenza:
Pneumovax:
Zostavax:

-Most recent labs: 

A1C 
Date:[date name="variable_1"
default="04/02/2021"] Result:
[text name="variable_1" default="%"] 
 
Urine microalbumin to creatinine ration 
Date:[date name="variable_1" default="04/02/2021"] 
Result:[text name="variable_1" default="result"]

Estimated GFR: 
Date:[date name="variable_1" default="04/02/2021"] 
Result:[text name="variable_1" default="result"]   

[comment memo="ACE include lisinopril, accupril, quinapril; ARB include losartan, candesartan, valsartan, olmesartan"]
[radio name="Q4" value="Patient is currently on an ACE/ARB|Patient is not currently on an ACE/ARB"]

LDL: 
Date:[date name="variable_1" default="04/02/2021"] 
Result:[text name="variable_1" default="LDL"]  

[comment memo="High intensity statins are atorvastatin (Lipitor) 40 or 80mg or rosuvastatin (Crestor) 20 or 40mg"]
[radio name="Q5" value="Patient is currently on a high-intensity statin|Patient is currently on a low-intensity statin|Patient is not currently on statin therapy"]

-Prescribed medication regimen: 
[comment memo="Meal-time insulin, basal insulin, and sulfonylureas have higher risks of hypoglycemia than other medications"]
[checklist name="Q6" value="metformin|meal-time insulin|basal insulin|sitagliptin (Januvia)|GLP-1 agonist (Trulicity, Byetta, Victoza, Bydureon)|SGLT-2 inhibitor (Jardiance, Farxiga, Invokana)|sulfonylurea (glimepiride, glipizide, glyburide)|pioglitazone (Actos)"]

-Last eye exam: [date name="variable_1" default="date unknown"]

-Tobacco use: 
[radio name="Smoking" value="yes, not interested in quitting|yes, interested in quitting|no"]

-Immunization history: 
[checklist name="Vaccinations" value="Patient has received Pneumococcal (PCV-23) after age 65|Patient has received annual influenza vaccine"]

Recommendations:

Health Status: 
[comment memo="Healthy: Life expectancy >10y, age <75y\nComplex/Intermediate: 3+ chronic illnesses, 2+ IADL impairments, moderate cognitive impairment, age >75y\nVery Complex: SNF/LTC patient, end-stage COPD, dialysis patient, severe cognitive impairment, 2+ ADL impairments (most AL patients)"]
[select name="Q3" value="Healthy|Complex/Intermediate|Very Complex"]

[conditional field="Q3" condition="(Q3).is('Healthy')"]
A1C Goal: <7.5%
Check A1C every 3 months if above goal and every 6 months if at goal
Fasting blood sugar goal: 90-130
Bedtime blood sugar goal: 90-150
Blood pressure goal: <140/80
Recommend statin therapy
Monitor LFTs and electrolytes every 6-12 months
Monitor urine microalbumin/creatinine ratio annually OR treat chronic kidney disease with ACE/ARB
Annual eye exams[/conditional]

[conditional field="Q3" condition="(Q3).is('Complex/Intermediate')"]
A1C Goal: <8.0%
Check A1C every 3 months if above goal and every 6 months if at goal
Fasting blood sugar goal: 90-150
Bedtime blood sugar goal: 100-180
Blood pressure goal: <140/80
Recommend statin therapy
Monitor LFTs and electrolytes every 6-12 months
Monitor urine microalbumin/creatinine ratio annually OR treat chronic kidney disease with ACE/ARB
Annual eye exams[/conditional]

[conditional field="Q3" condition="(Q3).is('Very Complex')"]
A1C Goal: <8.5%
Check A1C every 3 months if above goal and every 6 months if at goal
Fasting blood sugar goal: 100-190
Bedtime blood sugar goal: 110-200
Blood pressure goal: <150/90
Monitor creatinine at least every 6 months
Treat chronic kidney disease (if present) with ACE/ARB[/conditional]

Patient is due for the following:
[comment memo="If patient is due for any of the following, send a message to appropriate CC to have it ordered per protocol"]
[checklist name="Labs Due" value="Hemoglobin A1C|Urine microalbumin/creatinine ratio|Lipid panel|Complete metabolic panel|Vitamin B12 (if on metformin)|Eye exam|Pneumococcal vaccine|Influenza vaccine"]

Consider the following:
[comment memo="The following are recommendations to the provider.  Providers should document if there is a reason any of these are not done for inclusion in future care plans"]
[checklist name="Considerations" value="Prescribe an ACE/ARB|Prescribe a high-intensity statin|Switch to medications with a lower risk of hypoglycemia|Stopping some medications to avoid polypharmacy and hypoglycemia"]

A1c:
-at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).
-quarterly in patients whose therapy has changed or who are not meeting glycemic goals
-for microvascular disease prevention and macrovascular risk reduction, the A1C goal for nonpregnant adults in general is less than 7%
-less stringent A1C goals (such as less than 8%) if 
-- a history of severe hypoglycemia
-- limited life expectancy
-- advanced microvascular or macrovascular complications
-- extensive comorbid conditions

Self-Management:
-appropriate glucose monitoring to meet specific goals (such as fasting blood sugar less than 130 mg/dL)
-medication adherence and self-adjustment as needed

Lifestyle:
-moderate weight loss (7% body weight) and regular physical activity (150 min/week) can reduce the risk of diabetes complications and improve glycemic control.
-the U.S. Department of Agriculture (USDA) recommendation for dietary fiber is 14 g fiber/1,000 kcal
-increase foods containing whole grains (one-half of grain intake).
-saturated fat intake should be reduced
-reduce intake of trans fat (lowers LDL cholesterol and increases HDL cholesterol)
-monitor carbohydrate, whether by carbohydrate counting, exchanges, or experience-based estimation
-perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate).
-in the absence of contraindications, perform resistance training three times per week.

5. Other counselling discussed:

«-Smoking: •» 
«-EtOH: •»
«-Exercise: advised 30 mins per day or 150 mins per week of moderate intensity aerobic exercise»
«-Diet: we reviewed all of the lifestyle options to achieve optimal glycemic control, including diet (ex. Mediterranean diet, portion control, fibre, etc), exercise (eventual goal of >30 minutes of moderate exercise most days of the week), and 
«-Weight loss: advised a target 5-10% of current body weight over 6 months»
«-Medications: - we also reviewed all of the medication options available including metformin, sulfonylureas, acarbose, DPP4 inhibitors, GLP analogues, SGLT2 inhibitors, and long-acting and rapid insulin
«-Sick day medications: Reviewed SADMANs medications to hold while unwell»
«-Driving: reviewed need to check sugar 1 hour prior to driving, "less than five, don't drive," and "less than four, don't drive for 1 hour"»
«-Hypoglycemia: reviewed need to carry glucose, how to treat a low (15g CHO q15 minutes until BG>4.0, take snack containing carbohydrate AND protein if not proximate to a meal)»