Diabetes UTD
Certainly, here are more sentences with interchangeable sections to vary the clinical picture and add more specificity to the SOAPnote template for a patient with poorly controlled diabetes: ```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 [select value="thirst and|appetite changes, frequent urination, and unintentional weight loss over the past|fatigue, polyuria, and unexplained weight loss for the last"] [text name="duration_symptoms"] weeks. - Despite adhering to the prescribed diabetes regimen, the patient continues to experience [select value="elevated fasting blood glucose levels consistently exceeding|fluctuating blood glucose levels, with fasting glucose reaching"] [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 [select value="diabetic ketoacidosis (DKA)|hyperosmolar hyperglycemic state (HHS)|severe hypoglycemic episodes."] **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 [select value="glycosuria and ketonuria.|evidence of microalbuminuria."] - [select value="Ophthalmic examination shows no|Fundoscopic examination reveals|Retinal examination demonstrates"] evidence of diabetic retinopathy. - [select value="Pulse is regular with no|Cardiovascular exam is unremarkable, without|There are no"] signs of peripheral arterial disease. - [select value="Additionally, the patient complains of|Furthermore, there are complaints of|In addition, the patient reports"] diabetic neuropathy with [select value="symptoms of numbness and tingling in the feet,|sensory deficits in both lower extremities,|loss of proprioception and balance issues."] - **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. - [select value="Considering the patient's comorbidities,|Given the patient's history,|Considering the patient's lifestyle,"] initiate [select value="statin therapy with|antiplatelet therapy using|angiotensin-converting enzyme (ACE) inhibitor therapy with"] [text name="additional_medication" default="atorvastatin"] [select value="20 mg|80 mg|40 mg"] [text name="additional_dosage"] once daily. - **Orders:** - [textarea name="orders"] **Provider Signature:** [text name="provider_signature" default="Dr. Jane Smith"] Feel free to mix and match these sentences to create different clinical scenarios and add specificity to the SOAPnote template.
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Sandbox Metrics: Structured Data Index 0.44, 34 form elements, 284 boilerplate words, 18 text boxes, 1 text areas, 3 radio buttons, 12 drop downs, 34 total clicks
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