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.