Diabetes Review Note

Specialty: Advanced Clinical Practitioner History: Presenting Complaint: Patient presented for a routine diabetes review, reporting general well-being but expressed mild concerns about occasional post-meal glucose spikes. History of Present Illness: Mrs. Jones, a 58-year-old female with type 2 diabetes for 10 years, reports adherence to her metformin and empagliflozin regimen. She checks her blood glucose twice daily, typically seeing fasting readings between 6.0-7.5 mmol/L and post-meal readings sometimes reaching 10-12 mmol/L, particularly after consuming certain carbohydrates. She denies symptoms of polyuria, polydipsia, or unexplained weight loss. She has noted a slight increase in fatigue in the afternoons but attributes this to her demanding work schedule. No recent hospital admissions or acute diabetic complications. Current Medications: Metformin 1000mg twice daily Empagliflozin 25mg once daily Simvastatin 20mg once daily Aspirin 75mg once daily Allergies: - Penicillin (rash, hives) - Sulphonamides (severe nausea, vomiting) Laboratory Results: Date: 1 November 2024 HbA1c: 6.9% (previously 7.2% three months ago) Fasting Glucose: 6.8 mmol/L Total Cholesterol: 4.5 mmol/L LDL-C: 2.1 mmol/L HDL-C: 1.3 mmol/L Triglycerides: 1.6 mmol/L U&Es: Creatinine 78 µmol/L (eGFR >60 mL/min/1.73m²), Urea 5.5 mmol/L ACR: <1 mg/mmol Relevant Past Medical History: - Hypertension (controlled with diet and exercise) - Dyslipidaemia - Appendectomy (2005) - Gout (occasional flares, managed with allopurinol as needed) Social History: Patient is married and lives with her husband. She is a retired teacher, now volunteering part-time. She denies smoking and reports occasional social alcohol consumption (1-2 units per week). She enjoys gardening and walking her dog regularly. Examination: Physical Examination: Vital Signs: BP 130/80 mmHg, HR 72 bpm (regular), RR 16 breaths/min, Temp 36.8°C. Weight: 82 kg, Height: 165 cm, BMI: 30.1 kg/m² (obese class I). General: Alert and oriented, no acute distress. Cardiovascular: S1S2 normal, no murmurs, rubs, or gallops. Peripheral pulses palpable and symmetrical. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no organomegaly. Extremities: No oedema, good capillary refill. Feet exam shows intact sensation with monofilament testing, no ulceration or deformities. Comments: Blood Glucose Monitoring: Patient records show good compliance. Fasting readings are generally within target, but post-meal readings are elevated, particularly after breakfast and dinner. Average readings suggest an overall improvement in control but room for optimisation of postprandial glucose. Diet and Exercise: Patient follows a generally healthy diet but admits to occasional indulgences in high-carbohydrate meals, especially on weekends. She walks for 30 minutes, 4-5 times a week, and gardens for 1-2 hours daily. Advised on further carbohydrate counting and portion control, particularly with refined sugars. Assessment: Overall well-controlled Type 2 Diabetes Mellitus with recent improvement in HbA1c. Persistent postprandial hyperglycaemia noted, requiring dietary adjustment and potential medication review. No new diabetes-related complications identified. Good adherence to current medication regimen. Patient Education: Discussed the importance of carbohydrate counting and reading food labels. Reviewed strategies for managing post-meal glucose spikes, including timing of medication with meals and increasing physical activity after eating. Emphasised foot care and regular eye checks. Plan: 1. Continue Metformin 1000mg BD and Empagliflozin 25mg OD. 2. Reinforce dietary advice, focusing on reducing refined carbohydrates and balanced meal planning. Refer to a dietician for further support. 3. Increase physical activity, aiming for 150 minutes of moderate-intensity exercise per week. 4. Encourage more frequent blood glucose monitoring for two weeks, particularly 2 hours post-meals, to identify patterns. 5. Recheck HbA1c in 3 months. 6. Annual diabetic foot screening and retinal screening to be scheduled. Follow-up: Schedule follow-up appointment in 3 months to review HbA1c, blood glucose diaries, and discuss progress. Patient to contact clinic if any concerns arise sooner.