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
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