Diabetes

Certainly, here's an even more detailed SOAPnote tag template for a patient with poorly controlled diabetes, including a thorough physical exam and additional pertinent negatives:

```markdown
**#Patient with Poorly Controlled Diabetes**

**Patient Information**
- **Name:** [text name="patient_name"]
- **Age:** [text name="patient_age"]
- **Gender:** [radio value="Male|Female|Other"]
- **Medical Record Number:** [text name="mrn"]

**Diabetes Control Status**
- **Select the patient's diabetes control status:**
  - [select value="Well Controlled|Moderately Controlled|Poorly Controlled"]

**Assessment and Plan**
- The patient, [text name="patient_name"], a [text name="patient_age"]-year-old [radio value="male|female"] with a medical record number [text name="mrn"], presents with poorly controlled diabetes.
- Key clinical factors include uncontrolled hyperglycemia (fasting blood glucose consistently >[text name="fasting_glucose"] mg/dL), persistent polyuria, polydipsia, and unexplained weight loss.
- Pertinent negatives:
  - No recent medication changes or noncompliance with prescribed medications.
  - Absence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).
  - No known allergies to diabetes medications.
- Physical Exam:
  - General: Alert and oriented, no signs of distress.
  - Cardiovascular: Regular rate and rhythm, no murmurs or gallops.
  - Pulmonary: Clear breath sounds, no wheezing or crackles.
  - Abdomen: Soft, non-tender, non-distended, no organomegaly.
  - Neurologic: No focal deficits, normal cranial nerves.
- The patient's diabetes control status is [var name="diabetes_control_status"].
- Assessment:
  - The patient's HbA1c is [text name="hba1c"]%, indicating poor control.
  - Urinalysis reveals glycosuria and ketonuria.
  - No evidence of diabetic retinopathy on fundoscopy.
  - Ankle-brachial index (ABI) is within normal limits, ruling out peripheral arterial disease.
- Evidence-based therapies include:
  - Initiation of insulin therapy with [text name="insulin_type"] at a starting dose of [text name="insulin_dosage"] units subcutaneously qhs, titrated to achieve target glucose levels.
  - Prescription of metformin [text name="metformin_dosage"] mg orally daily.
  - Implementation of a carbohydrate-controlled diet (carbohydrate intake <[text name="carb_intake"] g/day) and a regular exercise regimen (at least [text name="exercise_duration"] minutes/day).
- Plan:
  - Monitor blood glucose levels regularly (before meals, at bedtime, and occasionally postprandially).
  - Provide comprehensive diabetic education, including self-monitoring of blood glucose (SMBG) techniques.
  - Schedule a follow-up visit in [text name="follow_up_weeks"] weeks to assess glycemic control, adjust insulin dosing, and reinforce lifestyle modifications.
- Orders:
  - [textarea name="orders"]

**Provider Signature:** [text name="provider_signature"]

Please customize this template with patient-specific information and details as needed for a patient with poorly controlled diabetes. This template now includes a more detailed physical exam and additional pertinent negatives.