Diabetes

Certainly, here's an updated SOAPnote tag template for a patient with poorly controlled diabetes, including a brief history of present illness (HPI) in the assessment statement, a clinical impression, sample patient data, and example data:

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

**Patient Information**
- **Name:** [text name="patient_name" default="John Doe"]
- **Age:** [text name="patient_age" default="55"]
- **Gender:** [radio value="Male|Female|Other"]
- **Medical Record Number:** [text name="mrn" default="12345"]

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

**History of Present Illness (HPI)**
- 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.
- The patient reports a recent increase in thirst, frequent urination, and unintentional weight loss over the past [text name="duration_symptoms"] weeks.
- Despite adhering to the prescribed diabetes regimen, the patient continues to experience elevated fasting blood glucose levels consistently exceeding [text name="fasting_glucose_target"] mg/dL.
- The patient denies any recent medication changes, noncompliance with medications, or known allergies to diabetes medications.
- There is no history of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).

**Assessment and Plan**
- **Clinical Impression:**
  - This is a [radio value="new|established"] patient with poorly controlled diabetes.
  - HbA1c: [text name="hba1c" default="10.5"]%, 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.
- **Plan:**
  - Initiation of insulin therapy with [text name="insulin_type" default="glargine"] at a starting dose of [text name="insulin_dosage" default="20"] units subcutaneously qhs, titrated to achieve target glucose levels.
  - Prescription of metformin [text name="metformin_dosage" default="1000"] mg orally daily.
  - Implementation of a carbohydrate-controlled diet (carbohydrate intake <[text name="carb_intake" default="45"] g/day) and a regular exercise regimen (at least [text name="exercise_duration" default="30"] minutes/day).
  - 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" default="4"] weeks to assess glycemic control, adjust insulin dosing, and reinforce lifestyle modifications.
- **Orders:**
  - [textarea name="orders"]

**Provider Signature:** [text name="provider_signature" default="Dr. Jane Smith"]

Please customize this template with patient-specific information and details as needed. This template now includes a brief HPI, clinical impression, sample patient data, and example data.