Diabetologist Template

Endocrinology Note

A professional Diabetologist template for healthcare professionals.

About this template

Effortlessly document patient encounters with this comprehensive "Endocrinology Note" template, specifically tailored for diabetologists and other endocrinology specialists. This essential tool streamlines the creation of detailed clinical notes, covering subjective patient concerns, objective findings, and a robust assessment and plan for endocrine conditions like diabetes mellitus. Ideal for capturing everything from a patient's reason for consultation and detailed history of presenting complaints to medication lists, lifestyle advice, and follow-up plans. Whether you're managing complex type 2 diabetes or other endocrine disorders, this template ensures all critical information is recorded accurately and efficiently. Heidi, your AI scribe, intelligently populates each section based on your conversation, ensuring a consistent and thorough record for every patient visit.

Preview template

Endocrinologist: Diabetologist Subjective: - The patient presents for consultation regarding poorly controlled type 2 diabetes mellitus, experiencing increased thirst, frequent urination, and fatigue over the past three months. - The patient reports a three-month history of polydipsia, polyuria, and persistent fatigue. Symptoms began gradually, with polyuria initially mild but worsening over recent weeks, now requiring waking multiple times at night. Polydipsia has increased in parallel. Fatigue is constant, impacting daily activities. The patient has been monitoring blood glucose at home, noting readings consistently above 15 mmol/L. She has not sought prior medical evaluation for these specific symptoms but has been managing her known type 2 diabetes with oral medications. - Past medical and surgical history: - Type 2 Diabetes Mellitus diagnosed 5 years ago. - Hypertension diagnosed 3 years ago. - Cholecystectomy 10 years ago. - No hospitalisations related to diabetes. - Current medications: - Metformin 1000mg twice daily - Ramipril 5mg once daily - Atorvastatin 20mg once daily - Social history: The patient is a 55-year-old female working as an accountant. She reports a sedentary lifestyle with minimal physical activity. Diet consists of convenience meals high in carbohydrates. She denies alcohol use or smoking. Stressors include demanding work and family responsibilities. No current family planning considerations. No significant cultural factors or environmental exposures affecting her condition. - Known allergies: - Penicillin (rash) Objective: - Vital signs: - Blood pressure: 145/92 mmHg - Heart rate: 88 bpm - Respiratory rate: 16 bpm - Temperature: 36.8°C - Weight: 98 kg - BMI: 34.5 kg/m² - Physical examination findings: - General: Overweight, no acute distress. - Head/Neck: No goitre or lymphadenopathy. - Cardiovascular: Regular rhythm, no murmurs. - Respiratory: Clear to auscultation bilaterally. - Abdomen: Soft, non-tender, no hepatosplenomegaly. - Extremities: No oedema, intact peripheral pulses, no neuropathic changes noted. - Investigation results: - HbA1c (current): 9.5% (previous 7.2% six months ago) - Fasting Plasma Glucose (current): 18.2 mmol/L - Creatinine: 90 µmol/L (eGFR 65 mL/min/1.73m²) - Urine Microalbumin/Creatinine Ratio: 45 mg/g (elevated) Assessment & Plan: Poorly Controlled Type 2 Diabetes Mellitus - Assessment: The patient presents with classic symptoms of hyperglycaemia and laboratory findings consistent with poorly controlled type 2 diabetes (HbA1c 9.5%, FPG 18.2 mmol/L). Current metformin therapy appears insufficient given the significant rise in HbA1c. There is also evidence of early diabetic nephropathy as indicated by the elevated urine microalbumin/creatinine ratio. The patient's lifestyle factors, including diet and physical inactivity, are contributing to her current suboptimal glycaemic control. - The clinician’s differential diagnoses with classification codes: - Type 1 Diabetes Mellitus, adult onset (LADA) - E10.9 (Less likely given 5-year history of T2DM, but should be considered if no improvement with intensified T2DM management) - Other specified diabetes mellitus - E13.9 (e.g., secondary to pancreatic disease, though no history provided) - Investigations planned: - C-peptide and GAD antibodies (to rule out LADA) - Lipid profile - Liver function tests - Thyroid function tests - Medical treatment plan: - Initiate empagliflozin 10mg once daily, titrating to 25mg after 4 weeks if tolerated. - Continue Metformin 1000mg twice daily. - Discuss initiation of insulin therapy if HbA1c remains >8% after 3 months on intensified oral regimen. - Targets: HbA1c <7.0%, BP <130/80 mmHg. - Monitoring: Blood glucose monitoring 4 times daily (before meals and at bedtime); weekly weight checks. - Risks: Hypoglycaemia (though low with empagliflozin), genitourinary infections, dehydration. - Lifestyle advice provided: - Referral to a registered dietitian for carbohydrate-controlled meal planning. - Recommendation for at least 150 minutes of moderate-intensity aerobic exercise per week. - Emphasis on portion control and hydration. - Follow-up plan: - Review in 4 weeks to assess medication tolerance and initial glycaemic response. - Subsequent review in 3 months with repeat HbA1c and full metabolic panel. - Referrals made: - Dietitian for nutritional counselling. - Ophthalmology for diabetic retinopathy screening. Additional Endocrine Issues or Conditions: - Hypertension - Assessment: The patient's blood pressure is elevated (145/92 mmHg) despite being on Ramipril 5mg daily. This contributes to her overall cardiovascular risk profile and potential for end-organ damage. - Investigations planned: - 24-hour ambulatory blood pressure monitoring. - Medical treatment plan: - Increase Ramipril to 10mg once daily. - Consider adding a calcium channel blocker if BP remains uncontrolled. - Targets: BP <130/80 mmHg. - Lifestyle advice provided: - Dietary salt restriction. - Regular physical activity. - Follow-up plan: - Recheck BP in 2 weeks. Additional Notes: - Patient education provided: Discussed the importance of medication adherence, self-monitoring of blood glucose, recognition and management of hypoglycaemia and hyperglycaemia symptoms. Emphasised the long-term complications of uncontrolled diabetes and hypertension. - Instructions for symptom or parameter monitoring: - Daily blood glucose checks (fasting and 2-hour post-prandial). - Weekly weight checks. - Monitor for symptoms of urinary tract infections or yeast infections with empagliflozin. - Daily blood pressure monitoring at home. - Patient or family concerns addressed: The patient expressed concern about the complexity of managing multiple medications and lifestyle changes. Reassurance was provided, and a stepwise approach was explained. Support systems and resources for diabetes education were discussed.

Subjective: - [Reason for consultation including endocrine concerns or symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences.) - [Detailed history of presenting complaints including onset, duration, progression, severity, pattern, associated symptoms, previous evaluations, treatments received, and patient response] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph form.) - [Past medical and surgical history including previous endocrine diagnoses, surgeries, hospitalisations, and complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - [Current medications including prescribed therapies and supplements with doses and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - [Social history including diet, physical activity, alcohol use, smoking status, occupation, stressors, family planning considerations, cultural factors, and environmental exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph form.) - [Known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Objective: - [Vital signs including measurements relevant to the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - [Physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as bullet points.) - [Investigation results including laboratory tests, imaging, or other diagnostic studies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Assessment & Plan: [Endocrine issue or condition] - [Assessment including the clinician’s diagnosis or working diagnosis and clinical reasoning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a paragraph. Do not invent or infer a diagnosis.) - [The clinician’s differential diagnoses with classification codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list. Do not invent or infer a diagnosis.) - [Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - [Medical treatment plan including prescribed therapies, dosing, targets, monitoring, and risks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as bullet points.) - [Lifestyle advice provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as bullet points.) - [Follow-up plan including timeframe and review arrangements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - [Referrals made] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Additional Endocrine Issues or Conditions: - [Assessment and plan for additional conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Repeat the same structure as above.) Additional Notes: - [Patient education provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences.) - [Instructions for symptom or parameter monitoring] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as bullet points.) - [Patient or family concerns addressed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph form.)

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