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Sample Report

Dear Mr. John Doe:

Based on the detailed history that you had provided, our Endocrinologists have identified several areas in your diabetic care that you could modify or change to help improve blood sugar control. We strongly recommend discussing these areas of care with your Personal Care Physician to see if they are appropriate for you based on your physical examination and other lifestyle situations that may not be available for our endocrinologist. Please read our detailed disclaimer before using this information. We only provide information, and sometimes this information may not be appropriate, especially if you have not provided all the history needed to make an accurate care plan.

Considering that you are a 48-year-old diabetic with a family history of heart disease, we recommend starting low-dose enteric-coated Aspirin (for example, 81-mg daily). Based on the history provided, you do not indicate any intolerance or side effects to Aspirin. I would recommend discussing this with your Personal Care Physician to see if Aspirin therapy is appropriate for you. Aspirin is a blood thinner, which does help to reduce the risk for heart attack and stroke. But there is potential for serious bleeding problems in some individuals.

You did indicate that your last eye examination was two years ago. American Diabetes Association (ADA) recommends a dilated eye examination to screen for diabetic eye disease yearly. Note diabetic retinopathy can occur with absolutely no visual symptoms.

You have also not indicated any urine test for proteins. Your Personal Care Physician may have done this test, and you are negative for microalbuminuria. But if this screening test has not been done, we do strongly recommend getting a urine test for microalbumin/creatinine ratio. If this test is positive, it indicates that you have very early stages of diabetic kidney disease. ADA recommends using either an ACE inhibitor (Lisinopril) or an angiotensin receptor blocker (irbesartan). Discuss this with your Primary Care Physician and should consider the treatment if the urine test is positive, provided if there are no contraindications.

You mentioned that you were getting pain in the back of the calf when you walked a certain distance. This could indicate a decrease in the blood flow to your legs. Peripheral arterial disease is common in diabetics, and you should follow up with your Personal Care Physician to make sure that you have good pulses in the lower limbs. If the pulses are decreased, it is recommended that you get lower limb arterial Doppler. If abnormal, an arterial angiogram may be indicated. Please discuss these symptoms with your personal physician. A detailed history and physical exam may identify the cause for the above pain. Peripheral arterial disease is common in diabetics and more common in smokers. You did indicate that you smoked for several years in the past but currently do not smoke.

Based on the fact that you have peripheral neuropathy, you should read our section on foot care and follow the advice.

You mentioned hypoglycemia that is low blood sugars occurring at around noontime quite often also. In your diet history, you mentioned that you do not eat much of a breakfast. The reason for the low blood sugars at noontime may be secondary to the small breakfast. Also, your blood sugars at bedtime were elevated. This likely from excess carbohydrates at supper time. Redistributing the number of carbohydrates or calories from suppertime to breakfast may help. The low blood sugars at noontime are likely to abate, and the higher blood sugars at bedtime will improve once you have slightly re-distributed the carbohydrates from supper to breakfast. Discuss this with a registered dietician to plan your meals.

Considering your BMI of 34, you are certainly categorized as obese and would need to reduce your weight. Apart from a good diet and exercise, talk to your Personal Care Physician to see if the use of Byetta (Exenatide) or Victoza injection along with the Metformin that you are already taking is appropriate for you. This is likely to suppress your appetite and help with weight loss when it is likely to improve your blood sugar control. Your current A1c is 7.5%. ADA recommends trying to lower this to around 7%. The American Association of Clinical Endocrinologist (AACE) recommends tighter blood sugar control (A1c goal is 6.5%)

For the erectile dysfunction and decreased libido you mentioned, we would recommend that you have your serum-free testosterone checked. If this turns out to be low, further testing and follow-up with a local Endocrinologist would be recommended. If, however, the testosterone level is normal, you should discuss with your Personal Care Physician to see if agents such as Sildenafil, that is, Viagra, or Tadalafil, that is, Cialis are appropriate for you. These agents should not be used if you take any form of nitrates for the heart or certain blood pressure pills such as Alpha-blockers.

Blood pressure should be consistently under 130/80. Since your blood pressure is not well controlled based on your history, we recommend having blood pressure checked at weekly intervals. If they are consistently over 130/80, your doctor may need to increase the dose of Lisinopril from 5 to 10-mg daily, but this should be discussed with your Primary Care Physician who prescribes your medication. Blood pressure control in diabetics is of paramount importance, and multiple studies have shown that blood pressure control equally important to blood sugar control.

Based on the lipid panel you had provided, your LDL cholesterol is still above goal; the goal is less than 100-mg/dl. Your LDL cholesterol was 121. You have not indicated taking any cholesterol medication nor mentioned any intolerance or side effects to the statin group of drugs. The current recommendation is diabetics should have an LDL cholesterol of less than 100-mg/dl. A large study showed that taking an agent such as Simvastatin 40-mg daily in people with diabetes did reduce the risk of myocardial infarction and stroke very significantly compared to placebo. Knowing that cardiovascular disease is a widespread occurrence in people with diabetes, all people with diabetes are recommended to take a statin group provided; there are no side effects or contraindications. We recommend if you talk to your Primary Care Physician about starting a statin and monitoring for any side effects such as liver disease, which can be done on a simple blood test. Also monitoring for any side effects such as muscle pain, muscle soreness, generalized muscle weakness. If you do have any side effects, the medication should be discontinued. Please discuss this with your Personal Care Physician to see if starting a statin such as Simvastatin is appropriate for you.

You did mention occasional drinks of alcohol. As long as you do not drink more than one or two drinks on-and-off, this is perfectly fine. Sometimes alcohol can cause low blood sugars and high blood sugars, so frequent Glucameter checks should be done to monitor this. Red wine is known to improve HDL cholesterol and may have some beneficial effects on cardiovascular disease, so you could consider substituting your alcoholic drink for red wine. Alcohol is best consumed with or close to meals to reduce the risk of low blood sugars.

Please see a Registered Dietitian or Diabetic Educator for a diet plan. Based on the history provided, your meal timings are variable. We would recommend trying to keep the meal timings as consistent as possible. The number of carbohydrates consumed needs to be more consistent with each meal; hence we would recommend that you learn how to count carbohydrates by discussing this with a Registered Dietitian.

It would help if you exercised regularly, i.e., brisk walking 30 to 45-minutes at least every other day.

The goal is to reduce weight by at least half-a-pound every week with a consistent carbohydrate diet, an exercise program, and the use of appropriate medication.

Hopefully, you have found this personalized care plan useful. Our mission is to improve the diabetic care of one patient at a time. Hopefully, you will recommend other diabetic friends to our website to help improve their diabetic care. Please send us your comments on how we can improve this website. If your blood sugars worsen at any stage, our endocrinologist will be happy to review your diabetic care and draft a new personalized care plan.