DM Clinic

Sinai-Grace Internal Medicine Residency Ambulatory Clinic Documentation Guides

Diabetes mellitus

• HISTORY

  • Polyuria, polyphagia, polydipsia, weightloss?

  • Vision changes?

  • Numbness/tingling of feet?

  • Symptoms of Infections?

  • Average AM and PM blood sugar

  • Any hypoglycemic episodes?

  • Last HbA1c

  • Last fundus exam by Ophtho?

  • Last foot exam by Podiatry?

  • Any ED visits/hospitalizations/ICU admission/ for uncontrolled sugars or DKA?

  • Current maintenance therapy and prophylactic ASA

    • Symptoms when first diagnosed

    • H/O HTN, Dyslipidemia, MI, CVA, Smoking

    • FH of DM, MI, CVA

    • Last Pneumovax and flu shot

    • Diet and Exercise history

• PHYSICAL EXAM

  • CBG – hours post-prandial

  • Vitals – Temp, BP

  • General – BMI

  • Eyes – Fundus

  • Neck – JVD, carotid bruits

  • Heart – Rate, Rhythm, murmurs, gallops, S3, S4

  • Lungs – crackles

  • Pulses including femoral bruits

  • Foot- Skin breakdown, Monofilament test

  • Systems that suggest infection

• INVESTIGATIONS

  • • HbA1c – if at goal q6months, if not then q3months

    • Urine microalbumin – q6months

    • Fasting Lipid Profile – yearly if at goal. If not, q 6weeks.

    • EKG – baseline.

Items in BOLD should be addressed every visit.