Diabetes Mellitus Type 2

MOST RECENT VISIT
days ago
weeks ago
months ago

MANAGEMENT LAST VISIT
none
adding
stopping
changing the dose of
ordering

SYMPTOMS
polyuria
polydipsia
increased appetitive
fatigue
change in vision

ONSET
minute(s) ago
hours(s) ago
day(s) ago
week(s) ago
month(s) ago
year(s) ago


TIMING
constantly
frequently
intermittently
occasionally
rarely
during the day
during the night
nocturnally

SEVERITY
mild
moderate
severe

PROGRESSION
worsening
unchanged
improving
resolved

ASSOCIATED SYMPTOMS
extremity pain
extremity numbness
extremity paresthesia
lower extremity ulcers
abdominal discomfort
bladder dysfunction
erectile dysfunction
sexual dysfunction
impaired healing
recurrent candidiasis
unexplained weight loss
insomnia

HYPOGLYCEMIA INCIDENCE
times a day
times a week
times a month
most recently on

HYPOGLYCEMIA SYMPTOMS
sweating
shaking
palpitations
dizziness
confusion
light headedness
loss of consciousness
nausea

HYPOGLYCEMIA CHARACTERISTICS
are mild
are moderate in severity
are severe
occur with glucose < 60 mg/dl
occur with glucose < 40 mg/dl
occur with glucose <  mg/dl

HYPOGLYCEMIA MANAGEMENT
decreasing basal insulin
decreasing bolus insulin
decreasing oral agents
eating a bedtime snack
eating before testing
testing before eating
having oral glucose always available
using glucagon

CURRENT TREATMENT
none
basal insulin
bolus insulin
oral agents
metformin
glipizide
glyburide
pioglitazone (actos)
rosiglitazone (avandia)
acarbose (precose)
exenatide (byetta)
dyslipidemia medications
antihypertensives
daily aspirin
ACE inhibitor
angiotensin receptor blocker
dietary modification
exercise program
diabetic food care
home foot sensation testing
smoking cessation

COMPLIANCE . TOLERANCE . CONTROL
good compliance with treatment
fair compliance with treatment
poor compliance with treatment
good tolerance of treatment
fair tolerance of treatment
poor tolerance of treatment
good symptom control
fair symptom control
poor symptom control

INITIAL DIAGNOSIS
minute(s) ago
hours(s) ago
day(s) ago
week(s) ago
month(s) ago
year(s) ago

INITIAL PRESENTATION
typical diabetes symptoms
abnormal diabetes screening
infectious complications
cardiovascular complications
neurologic complications

GENERAL COURSE
worsening
Unchanged
Improving
Stable

RECENT COURSE
worsening
unchanging
improving
stable

DISEASE COMPLICATIONS
peripheral neuropathy
diabetic retinopathy
diabetic nephropathy
coronary artery disease
peripheral vascular disease
lower extremity ulceration
poor wound healing 
gastroparesis
diabetic ketoacidosis

CONTROL TRENDS
Hgb A1c is increasing
Hgb A1c is decreasing
Hgb A1c is unchanged
microalbumin is increasing
microalbumin is decreasing
microalbumin is unchanged
total cholesterol is increasing
total cholesterol is decreasing
total cholesterol is unchanged
LDL is increasing
LDL is decreasing
LDL is unchanged
HDL is increasing
HDL is decreasing
HDL is unchanged
Triglycerides are increasing
Triglycerides are decreasing 
Triglycerides are unchanged
Systolic blood pressure readings are increasing  
Systolic blood pressure readings are decreasing
Systolic blood pressure readings are unchanged
Diastolic blood pressure readings are increasing
Diastolic blood pressure readings are decreasing
Diastolic blood pressure readings are unchanged
Weight is increasing
Weight is decreasing
Weight is unchanged

SELF MANAGEMENT
exercise
dietary modification
aspirin use
smoking cessation
weight loss

HOME GLUCOSE FREQUENCY
once daily
twice daily
three times daily
four times daily
x times daily
x times weekly
x times monthly

HOME GLUCOSE RESULTS
a recent high glucose of . mg/dl
a recent low glucose of . mg/dl
an average glucose of . mg/dl
a usualy glucose range of . mg/dl

LAST HBA1C DATE
on .
days ago
weeks ago
months ago

LAST HBA1C RESULT
x %
<6.0 %
< 7.0 %
<8.0 %

LAST MICROALBUMIN DATE
on .
days ago
weeks ago
months ago

LAST MICROALBUMIN RESULT
normal
mcg/mg creatinine
<15 mcg/mg creatinine
>20 mcg/mg creatinine

LAST LIPID TEST DATE
on .
days ago
weeks ago
months ago

LAST LIPID TEST RESULT
total cholesterol . mg/dl
LDL . mg/dl
LDL <100 mg/dl
LDL <70 mg/dl
HDL . mg/dl
HDL <30 mg/dl
HDL > 35 mg/dl
TG . mg/dl
TG <150 mg/dl
TG >150 mg/dl
TG >500 mg/dl

HOME BP FREQUENCY
once daily
twice daily
three times daily
four times daily
x times daily
x times weekly
x times monthly

RECENT HOME BP RESULTS
at least 75% systolic pressures < 130 mm Hg
at least 75% diastolic pressures < 80 mm Hg
maximum AM systolic pressure of mm Hg
maximum AM diastolic pressure of mm Hg
minimum AM systolic pressure of mm Hg
minimum AM diastolic pressure of mm Hg
maximum PM systolic pressure of mm Hg
maximum PM diastolic pressure of mm Hg
minimum PM systolic pressure of mm Hg
minimum PM diastolic pressure of mm Hg

PERTINENT MEDICAL HISTORY
hypertension
dyslipidemia
hypertriglyceridemia
metabolic syndrome
gestational diabetes
polycystic ovarian syndrome
coronary artery disease
peripheral vascular disease
amputation
carotid occlusive disease
stroke
neurogenic bladder
recurrent skin infections
recurrent candidiasis
pancreatitis
cataract(s)
glaucoma
tobacco use
alcoholism

RISK FACTORS
obesity
inactivity
recent weight gain
prolonged corticosteroid use
frequent corticosteroid use
thiazide diuretic use
use of psychotropic medications

FAMILY HISTORY
Diabetes mellitus type 2
diabetes mellitus type 1
obesity
premature coronary artery disease

LIFESYTLE RECOMMENDATIONS
diabetic diet
dietitian consultation
weight reduction
aerobic exercise
resistance training
close monitoring of feet
smoking cessation
avoidance of alcohol

PRE EVALUATION SETTING
in this clinic
in urgent care
in the emergency room
during a hospitalization
by me
by a primary care provider
by a colleague

PRE EVALUATOION TIMING
days ago
weeks ago
months ago
years ago

PRESENTATION
polydipsia
polyuria
increased appetite
fatigue
change in vision
diarrhea
abdominal gas/bloating
bladder dysfunction
extremity pain
paresthesia
numbness

PAST EVALUATION
none
random glucose
fasting glucose
hemoglobin A1c
oral glucose tolerance test
fasting lipid profile
renal function testing
urine microalbumin
dilated eye examination
dietitian consultation
body mass index assessment
waist to hip ration measurement
ECG
echocardiogram
stress echocardiogram
nuclear cardiac imaging

PAST TREATMENT
none
basal insulin
bolus insulin
oral agents
metformin
glipizide
glyburide
pioglitazone
none
basal insulin
bolus insulin
oral agents
metformin
glipizide
glyburide
pioglitazone (actos)
rosiglitazone (avandia)
acarbose (precose)
exenatide (byetta)
dyslipidemia medications
antihypertensives
daily aspirin
ACE inhibitor
angiotensin receptor blocker
dietary modification
exercise program
diabetic food care
home foot sensation testing
smoking cessation
MOST RECENT VISIT
days ago
weeks ago
months ago

MANAGEMENT LAST VISIT
none
adding
stopping
changing the dose of
ordering

SYMPTOMS
polyuria
polydipsia
increased appetitive
fatigue
change in vision

ONSET
minute(s) ago
hours(s) ago
day(s) ago
week(s) ago
month(s) ago
year(s) ago


TIMING
constantly
frequently
intermittently
occasionally
rarely
during the day
during the night
nocturnally

SEVERITY
mild
moderate
severe

PROGRESSION
worsening
unchanged
improving
resolved

ASSOCIATED SYMPTOMS
extremity pain
extremity numbness
extremity paresthesia
lower extremity ulcers
abdominal discomfort
bladder dysfunction
erectile dysfunction
sexual dysfunction
impaired healing
recurrent candidiasis
unexplained weight loss
insomnia

HYPOGLYCEMIA INCIDENCE
times a day
times a week
times a month
most recently on

HYPOGLYCEMIA SYMPTOMS
sweating
shaking
palpitations
dizziness
confusion
light headedness
loss of consciousness
nausea

HYPOGLYCEMIA CHARACTERISTICS
are mild
are moderate in severity
are severe
occur with glucose < 60 mg/dl
occur with glucose < 40 mg/dl
occur with glucose < mg/dl

HYPOGLYCEMIA MANAGEMENT
decreasing basal insulin
decreasing bolus insulin
decreasing oral agents
eating a bedtime snack
eating before testing
testing before eating
having oral glucose always available
using glucagon

CURRENT TREATMENT
none
basal insulin
bolus insulin
oral agents
metformin
glipizide
glyburide
pioglitazone (actos)
rosiglitazone (avandia)
acarbose (precose)
exenatide (byetta)
dyslipidemia medications
antihypertensives
daily aspirin
ACE inhibitor
angiotensin receptor blocker
dietary modification
exercise program
diabetic food care
home foot sensation testing
smoking cessation

COMPLIANCE . TOLERANCE . CONTROL
good compliance with treatment
fair compliance with treatment
poor compliance with treatment
good tolerance of treatment
fair tolerance of treatment
poor tolerance of treatment
good symptom control
fair symptom control
poor symptom control

INITIAL DIAGNOSIS
minute(s) ago
hours(s) ago
day(s) ago
week(s) ago
month(s) ago
year(s) ago

INITIAL PRESENTATION
typical diabetes symptoms
abnormal diabetes screening
infectious complications
cardiovascular complications
neurologic complications

GENERAL COURSE
worsening
Unchanged
Improving
Stable

RECENT COURSE
worsening
unchanging
improving
stable

DISEASE COMPLICATIONS
peripheral neuropathy
diabetic retinopathy
diabetic nephropathy
coronary artery disease
peripheral vascular disease
lower extremity ulceration
poor wound healing
gastroparesis
diabetic ketoacidosis

CONTROL TRENDS
Hgb A1c is increasing
Hgb A1c is decreasing
Hgb A1c is unchanged
microalbumin is increasing
microalbumin is decreasing
microalbumin is unchanged
total cholesterol is increasing
total cholesterol is decreasing
total cholesterol is unchanged
LDL is increasing
LDL is decreasing
LDL is unchanged
HDL is increasing
HDL is decreasing
HDL is unchanged
Triglycerides are increasing
Triglycerides are decreasing
Triglycerides are unchanged
Systolic blood pressure readings are increasing
Systolic blood pressure readings are decreasing
Systolic blood pressure readings are unchanged
Diastolic blood pressure readings are increasing
Diastolic blood pressure readings are decreasing
Diastolic blood pressure readings are unchanged
Weight is increasing
Weight is decreasing
Weight is unchanged

SELF MANAGEMENT
exercise
dietary modification
aspirin use
smoking cessation
weight loss

HOME GLUCOSE FREQUENCY
once daily
twice daily
three times daily
four times daily
x times daily
x times weekly
x times monthly

HOME GLUCOSE RESULTS
a recent high glucose of . mg/dl
a recent low glucose of . mg/dl
an average glucose of . mg/dl
a usualy glucose range of . mg/dl

LAST HBA1C DATE
on .
days ago
weeks ago
months ago

LAST HBA1C RESULT
x %
<6.0 %
< 7.0 %
<8.0 %

LAST MICROALBUMIN DATE
on .
days ago
weeks ago
months ago

LAST MICROALBUMIN RESULT
normal
mcg/mg creatinine
<15 mcg/mg creatinine
>20 mcg/mg creatinine

LAST LIPID TEST DATE
on .
days ago
weeks ago
months ago

LAST LIPID TEST RESULT
total cholesterol . mg/dl
LDL . mg/dl
LDL <100 mg/dl
LDL <70 mg/dl
HDL . mg/dl
HDL <30 mg/dl
HDL > 35 mg/dl
TG . mg/dl
TG <150 mg/dl
TG >150 mg/dl
TG >500 mg/dl

HOME BP FREQUENCY
once daily
twice daily
three times daily
four times daily
x times daily
x times weekly
x times monthly

RECENT HOME BP RESULTS
at least 75% systolic pressures < 130 mm Hg
at least 75% diastolic pressures < 80 mm Hg
maximum AM systolic pressure of mm Hg
maximum AM diastolic pressure of mm Hg
minimum AM systolic pressure of mm Hg
minimum AM diastolic pressure of mm Hg
maximum PM systolic pressure of mm Hg
maximum PM diastolic pressure of mm Hg
minimum PM systolic pressure of mm Hg
minimum PM diastolic pressure of mm Hg

PERTINENT MEDICAL HISTORY
hypertension
dyslipidemia
hypertriglyceridemia
metabolic syndrome
gestational diabetes
polycystic ovarian syndrome
coronary artery disease
peripheral vascular disease
amputation
carotid occlusive disease
stroke
neurogenic bladder
recurrent skin infections
recurrent candidiasis
pancreatitis
cataract(s)
glaucoma
tobacco use
alcoholism

RISK FACTORS
obesity
inactivity
recent weight gain
prolonged corticosteroid use
frequent corticosteroid use
thiazide diuretic use
use of psychotropic medications

FAMILY HISTORY
Diabetes mellitus type 2
diabetes mellitus type 1
obesity
premature coronary artery disease

LIFESYTLE RECOMMENDATIONS
diabetic diet
dietitian consultation
weight reduction
aerobic exercise
resistance training
close monitoring of feet
smoking cessation
avoidance of alcohol

PRE EVALUATION SETTING
in this clinic
in urgent care
in the emergency room
during a hospitalization
by me
by a primary care provider
by a colleague

PRE EVALUATOION TIMING
days ago
weeks ago
months ago
years ago

PRESENTATION
polydipsia
polyuria
increased appetite
fatigue
change in vision
diarrhea
abdominal gas/bloating
bladder dysfunction
extremity pain
paresthesia
numbness

PAST EVALUATION
none
random glucose
fasting glucose
hemoglobin A1c
oral glucose tolerance test
fasting lipid profile
renal function testing
urine microalbumin
dilated eye examination
dietitian consultation
body mass index assessment
waist to hip ration measurement
ECG
echocardiogram
stress echocardiogram
nuclear cardiac imaging

PAST TREATMENT
none
basal insulin
bolus insulin
oral agents
metformin
glipizide
glyburide
pioglitazone
none
basal insulin
bolus insulin
oral agents
metformin
glipizide
glyburide
pioglitazone (actos)
rosiglitazone (avandia)
acarbose (precose)
exenatide (byetta)
dyslipidemia medications
antihypertensives
daily aspirin
ACE inhibitor
angiotensin receptor blocker
dietary modification
exercise program
diabetic food care
home foot sensation testing
smoking cessation

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