What should be included in the referral for comanagement of a patient with diabetic retinopathy, impaired renal function, and a benign uterine myoma scheduled for operation?

Comprehensive Referral for Comanagement: Diabetic Patient with Benign Uterine Myoma Scheduled for Surgery

This patient requires urgent multidisciplinary comanagement involving gynecology, nephrology, ophthalmology, endocrinology, and anesthesiology before proceeding with myomectomy or hysterectomy, with specific attention to optimizing diabetic control, assessing surgical risk related to impaired renal function, and ensuring diabetic retinopathy stability.

Critical Elements That MUST Be Included in the Referral

1. Nephrology Consultation (URGENT - Required Before Surgery)

Immediate nephrology referral is mandatory when elevated creatinine is present in a diabetic patient. 1

The referral must include:

• Current serum creatinine value and calculated eGFR using the CKD-EPI equation 1
• Urinary albumin-to-creatinine ratio (UACR) from spot urine collection (not 24-hour collection) 1
• CKD staging based on eGFR and albuminuria status 1
• Blood pressure readings from multiple visits 1
• Current medications, particularly any ACE inhibitors, ARBs, NSAIDs, or metformin 1
• Serum potassium, bicarbonate, hemoglobin, calcium, phosphorus, and parathyroid hormone levels 1
• HbA1c values over the past 6-12 months 1

Specific questions for nephrology:

• Is the patient's eGFR adequate for safe anesthesia and surgery? 1
• Does the patient require preoperative optimization of renal function? 1
• Are medication adjustments needed perioperatively? 1
• What is the risk of acute kidney injury with surgery and anesthesia? 1

2. Ophthalmology Follow-up (URGENT - Within Days)

The patient already has diagnosed diabetic retinopathy and requires immediate reassessment before surgery. 1, 2

The referral must specify:

• Current stage of diabetic retinopathy (mild/moderate/severe NPDR vs. PDR) 1, 3
• Presence or absence of macular edema 1, 2
• Most recent dilated fundoscopic examination date 1
• Current visual acuity in both eyes 1, 2
• Any new visual symptoms (blurred vision, floaters, vision loss) 2, 3

Specific questions for ophthalmology:

• Is the retinopathy stable enough to proceed with surgery? 1, 2
• Does the patient require laser photocoagulation or anti-VEGF therapy before elective surgery? 1, 2
• What is the risk of retinopathy progression with perioperative glycemic fluctuations? 1, 3

3. Endocrinology/Internal Medicine Consultation

The referral must include:

• Complete diabetes history: type, duration, current treatment regimen 1
• Recent HbA1c values (ideally <7% for surgery) 1, 4
• Frequency and severity of hypoglycemic episodes 1
• Current insulin or oral hypoglycemic regimen with doses 1, 4
• Perioperative glycemic management plan needed 1, 4
• Cardiovascular risk assessment including lipid panel, blood pressure control 1

Specific questions for endocrinology:

• What is the optimal perioperative glucose management strategy? 1, 4
• Should oral hypoglycemics be held preoperatively? 1
• What insulin regimen should be used perioperatively? 1

4. Anesthesiology Preoperative Assessment

The referral must include:

• Complete medical comorbidity list with emphasis on diabetic complications 5
• Current renal function (eGFR, creatinine) 1
• Cardiovascular status including blood pressure control and any history of coronary disease 1
• Autonomic neuropathy screening (orthostatic hypotension, gastroparesis) 1
• Current medication list with specific attention to nephrotoxic drugs 1

5. Gynecology Surgical Planning

The referral must clarify:

• Exact surgical procedure planned (myomectomy vs. hysterectomy, approach)
• Urgency of surgery vs. ability to delay for medical optimization 5
• Expected blood loss and transfusion risk given anemia from chronic kidney disease 1
• Duration of surgery and positioning requirements
• Postoperative pain management plan avoiding nephrotoxic NSAIDs 1

Critical Information LACKING from Current Presentation

Missing Laboratory Data:

• Calculated eGFR using CKD-EPI equation 1
• Spot urine albumin-to-creatinine ratio (UACR) 1
• Complete metabolic panel including potassium, bicarbonate, calcium, phosphorus 1
• Complete blood count (hemoglobin, hematocrit for anemia assessment) 1
• HbA1c within past 3 months 1, 4
• Lipid panel (total cholesterol, LDL, HDL, triglycerides) 1
• Coagulation studies (PT/INR, PTT) for surgical planning

Missing Clinical Information:

• Exact stage of diabetic retinopathy (mild/moderate/severe NPDR vs. PDR) 1, 3
• Presence or absence of diabetic macular edema 1, 2
• Blood pressure readings from multiple visits (not just single values) 1
• Current antihypertensive medications and doses 1
• Presence of other diabetic complications: neuropathy, cardiovascular disease 1
• Smoking status 1
• Body mass index 6
• Duration of diabetes 1, 3
• History of hypoglycemic episodes 1

Missing Imaging/Diagnostic Studies:

• Electrocardiogram for cardiovascular risk assessment 1
• Chest X-ray if indicated by pulmonary symptoms
• Recent fundus photography or OCT imaging documenting retinopathy severity 1, 3

SOAP Note for Comanagement Referral

SUBJECTIVE:

• Chief Complaint: 45-year-old woman with type 2 diabetes mellitus, diabetic retinopathy, and chronic kidney disease (elevated creatinine) presenting for preoperative evaluation for benign uterine myoma resection
• History of Present Illness: Months-long history of hypogastric and hip pain with increased vaginal bleeding. Ultrasound revealed uterine myoma, confirmed benign on biopsy. Symptoms persist despite conservative management. Now scheduled for surgical intervention.
• Diabetes History: [SPECIFY: Type 1 vs. Type 2, duration, current medications and doses, recent HbA1c values, frequency of glucose monitoring, history of hypoglycemia]
• Ophthalmologic History: Diagnosed with diabetic retinopathy by ophthalmology. [SPECIFY: Stage of retinopathy, presence/absence of macular edema, most recent dilated exam date, current visual acuity, any treatments received]
• Renal History: Elevated creatinine noted, referred to nephrology. [SPECIFY: Actual creatinine value, calculated eGFR, UACR if available, presence of edema, urine output]
• Cardiovascular History: [SPECIFY: Hypertension status, blood pressure readings, current antihypertensive medications, history of coronary disease, peripheral vascular disease]
• Gynecologic History: [SPECIFY: Menstrual history, parity, previous gynecologic surgeries, size and location of myoma, degree of bleeding/anemia]
• Medications: [COMPLETE LIST with doses]
• Allergies: [SPECIFY]
• Social History: [Smoking status, alcohol use, occupation, support system]

OBJECTIVE:

• Vital Signs: BP ___ mmHg (specify multiple readings), HR ___ bpm, Temp ___ °C, RR ___ /min, O2 sat ___% on room air, Weight ___ kg, BMI ___ kg/m²
• General: Alert, oriented, in no acute distress vs. appears uncomfortable
• HEENT: [Visual acuity OU, fundoscopic exam findings if available]
• Cardiovascular: Regular rate and rhythm, no murmurs/gallops/rubs, peripheral pulses 2+ bilaterally, no edema vs. [specify edema location and severity]
• Respiratory: Clear to auscultation bilaterally, no wheezes/rales/rhonchi
• Abdomen: Soft, [tender vs. non-tender] in hypogastric region, palpable pelvic mass [specify size], no rebound/guarding, normal bowel sounds
• Extremities: No cyanosis/clubbing, [presence/absence of edema], peripheral pulses intact, [monofilament testing results if available]
• Neurologic: Alert and oriented x3, cranial nerves II-XII intact, sensation intact vs. [specify neuropathy findings]

Laboratory Data:

• Creatinine: ___ mg/dL (SPECIFY ACTUAL VALUE)
• eGFR: ___ mL/min/1.73 m² (CALCULATE using CKD-EPI) 1
• UACR: ___ mg/g (OBTAIN IF NOT AVAILABLE) 1
• HbA1c: ___% (MUST BE <3 months old) 1, 4
• Hemoglobin: ___ g/dL 1
• Potassium: ___ mEq/L 1
• Bicarbonate: ___ mEq/L 1
• [Complete remaining labs as listed above]

Imaging:

• Pelvic ultrasound: [Size, location, characteristics of myoma; specify if single vs. multiple]
• [Other imaging as available]

ASSESSMENT:

1. Benign uterine myoma requiring surgical intervention for symptomatic relief (hypogastric pain, abnormal uterine bleeding)
2. Type 2 diabetes mellitus with microvascular complications:
   • Diabetic retinopathy [SPECIFY STAGE] 1, 3
   • Diabetic nephropathy, CKD Stage ___ (based on eGFR ___) 1
3. Chronic kidney disease with elevated creatinine (eGFR ___), requiring nephrology evaluation before surgery 1
4. Hypertension [controlled vs. uncontrolled on current regimen] 1
5. Anemia [if present, specify severity and likely etiology: chronic disease vs. blood loss vs. CKD-related] 1
6. High perioperative risk due to multiple comorbidities requiring multidisciplinary optimization 5

PLAN:

Immediate Actions (Before Surgery Can Proceed):

1. URGENT Nephrology Referral 1

   • Obtain spot UACR if not already done 1
   • Calculate and document CKD stage 1
   • Assess need for preoperative renal optimization 1
   • Determine perioperative medication adjustments 1
   • Evaluate risk of acute kidney injury with surgery 1
   • Consider initiating ACE inhibitor or ARB if not already on therapy and UACR >30 mg/g 1

2. URGENT Ophthalmology Follow-up 1, 2

   • Obtain dilated fundoscopic examination within 1 week 1, 3
   • Document exact stage of diabetic retinopathy 1, 3
   • Rule out macular edema requiring treatment before elective surgery 1, 2
   • Assess if laser photocoagulation or anti-VEGF therapy needed before surgery 1, 2
   • Obtain clearance for surgery from ophthalmology perspective 1, 2

3. Endocrinology/Internal Medicine Consultation 1, 4

   • Optimize glycemic control to HbA1c <7% if possible before elective surgery 1, 4
   • Develop perioperative insulin management protocol 1
   • Adjust oral hypoglycemic agents perioperatively (hold metformin if eGFR <30) 1, 4
   • Optimize blood pressure control to <140/90 mmHg (ideally <130/80 mmHg) 1
   • Initiate or optimize statin therapy for cardiovascular protection 1

4. Anesthesiology Preoperative Evaluation 5

   • Comprehensive assessment of surgical risk given renal dysfunction and diabetes 5
   • Plan for perioperative glucose monitoring and insulin administration 1
   • Avoid nephrotoxic agents during anesthesia 1
   • Plan for adequate hydration to prevent acute kidney injury 1

5. Gynecology Surgical Planning

   • Delay surgery until medical optimization complete (typically 4-12 weeks) 5
   • Plan for minimally invasive approach if feasible to reduce surgical stress
   • Avoid NSAIDs for postoperative pain management; use acetaminophen and opioids 1
   • Arrange for postoperative glucose monitoring protocol 1

Ongoing Management:

1. Glycemic Control 1, 4

   • Target HbA1c <7% to reduce risk of retinopathy and nephropathy progression 1, 4
   • Continue current diabetes regimen with adjustments per endocrinology 4
   • Increase frequency of glucose monitoring perioperatively 1

2. Blood Pressure Management 1

   • Target BP <140/90 mmHg (ideally <130/80 mmHg if tolerated) 1
   • Initiate ACE inhibitor or ARB if not already prescribed and UACR elevated 1
   • Monitor for hyperkalemia when starting renin-angiotensin system blockers 1

3. Renal Protection 1, 4

   • Avoid nephrotoxic medications (NSAIDs, contrast agents) 1
   • Ensure adequate hydration perioperatively 1
   • Monitor creatinine and electrolytes closely perioperatively 1
   • Consider SGLT2 inhibitor if eGFR 20-90 mL/min/1.73 m² 4

4. Retinopathy Monitoring 1, 3

   • Continue annual dilated eye examinations (or more frequently if retinopathy progressing) 1, 3
   • Avoid rapid glycemic changes that may worsen retinopathy 3
   • Ensure ophthalmology follow-up 3-6 months postoperatively 1, 3

5. Cardiovascular Risk Reduction 1

   • Initiate or optimize statin therapy 1
   • Consider aspirin for cardioprotection (not contraindicated by retinopathy) 1, 3
   • Smoking cessation counseling if applicable 1

Follow-up:

• Nephrology within 1-2 weeks 1
• Ophthalmology within 1 week 1, 2, 3
• Endocrinology within 2 weeks 1, 4
• Anesthesiology preoperative clinic 2-4 weeks before surgery 5
• Primary care/internal medicine for coordination of care within 1 week
• Gynecology for surgical planning once medical clearance obtained

Patient Education:

• Importance of glycemic control in preventing progression of retinopathy and nephropathy 1, 3
• Need for multiple specialist evaluations before surgery can safely proceed 5
• Perioperative glucose monitoring and insulin management 1
• Avoidance of nephrotoxic medications including NSAIDs 1
• Importance of blood pressure control 1
• Need for lifelong ophthalmology follow-up 1, 3
• Signs/symptoms requiring urgent evaluation (vision changes, severe hyperglycemia, decreased urine output) 1, 2

Critical Pitfalls to Avoid

Do not proceed with elective surgery until:

• Nephrology has assessed renal function and provided clearance 1
• Ophthalmology has documented stable retinopathy without macular edema requiring treatment 1, 2
• Glycemic control is optimized (HbA1c ideally <7-8%) 1, 4
• Blood pressure is controlled (<140/90 mmHg) 1

Avoid:

• NSAIDs perioperatively due to nephrotoxicity 1
• Metformin if eGFR <30 mL/min/1.73 m² 1, 4
• Rapid glycemic changes that may worsen retinopathy 3
• Dehydration or hypotension that may precipitate acute kidney injury 1
• Assuming absence of retinopathy means absence of nephropathy (especially in type 2 diabetes) 7

Remember: The presence of both diabetic retinopathy and proteinuria significantly accelerates the rate of kidney function decline, making this patient particularly high-risk 6, 8. Diabetic retinopathy is a strong prognostic factor for CKD progression 6, 8. Early referral and aggressive management of all diabetic complications is essential to improve surgical outcomes and long-term prognosis 1, 5.