Endocrine, Nutrition & Obesity
Loading Add to Favorites
0 ratings, 0 votes0 ratings, 0 votes (0 rating, 0 votes, rated)
You need to be a registered member to rate this.
Loading...
Share
Tweet
Cite
HPI:



-Recent glucose values:

-Prescribed medication regimen:

-Episodes of hypoglycemia:

-Taking medications as prescribed:

-Taking daily aspirin:

-Most recent labs: A1C- Albumin to Cr- Cr-

-Last eye exam: [date name="variable_1" default="11/02/2018"]

-Last foot exam: [date name="variable_1" default="11/02/2018"]

-Tobacco use:

-Immunization hx: Last pneumococcal- , Influenza- Y/N , Hep B- for unvaccinated adults 19-59

Pertinent ROS:

PE:

[checkbox name="variable_1" value="ORAL CAVITY:"] [checkbox name="variable_2" value="Moist oral mucosa w/no lesions, erythema or exudates. Normal dentition.|Moist oral mucosa w/no lesions, erythema or exudates. Poor dentition. |No sublingual jaundice.| OSA- Poor visualization of the posterior oropharynx due to excess tissue."]

[checkbox name="variable_3" value="NECK:"] [checkbox name="variable_4" value="Non-tender, no palpable cervical or supraclavicular lymphadenopathy."] [checkbox name="variable_12" value="No thyromegaly."]

CARDIAC: [checkbox name="variable_5" value="Audible S1 and S2. Regular Rate and Rhythm.|Audible S1 and S2. Tachycardia measured at XXX BPM. "] [checkbox name="variable_6" value="No murmurs, rubs, or gallops.| No JVD|Murmur- X/6 best heard at the X"]

PULMONARY: [checkbox name="variable_7" value="Clear to auscultation bilaterally. Non-labored respiration."]

[checkbox name="variable_8" value="ABDOMINAL:"] [checkbox name="variable_9" value="Soft, nontender, nondistended. No guarding or rebound. No masses palpated. | Soft, TTP in the XXX quadrant. No guarding or rebound. No masses palpated. | Costovertebral angle tenderness present on right flank| Costovertebral angle tenderness present on left flank| No costovertebral angle tenderness."]


Extremities- No LE edema

[checkbox name="variable_10" value="Diabetic Foot Exam:"]

-Hair is [select name="variable_1" value="present on bilateral lower extremities and feet.|sharply demarcated lack of hair beginning at the| sparse hair present on lower legs and feet."]
-Dorsalis Pedis pulse is [select name="variable_2" value="present|absent|weak"] bilaterally.
-Posterior tibial pulse is [select name="variable_3" value="present|absent|weak"] bilaterally.
-Skin is [select name="variable_4" value="warm|cold"] to touch.
- [select name="variable_5" value="NO wounds are present on bilateral feet or digits.| Wounds PRESENT:"] There is no dryness or cracking in between the toes bilaterally.
-Nails are [select name="variable_6" value="well-kempt, with good hygiene.|Unkempt."]
-Right monofilament: /5
-Left monofilament: /5


A/P
1. Diabetes, [select name="variable_7" value="appropriately controlled|poorly controlled"]
- Meeting/not meeting goal A1C of <7% recommended by ADA 2018 standards of care. 8% with less life expectancy or too many hypoglycemic episodes.
- ASCVD:
- Screening labs: A1C (3-6 months), BMP (albumin to creatinine ratio annually), Urine microalbumin
- Advised patient get pedicure to improve foot hygiene and decrease risk of developing wounds/ulcers.
- Preventative visits needed: podiatry (failed monofilament), dilated eye exam (annually), dental (annually). Patient overdue for XXX.
- Vaccines needed: Pneumococcus, Influenza, Hep B.
- Medication changes: Add/increase aspirin, statin, glycemic agent, insulin
- Side effects of meds?
- F/u in 6 months.

2. HTN
HTN is [select name="variable_8" value="appropriately controlled|poorly controlled."]
-Current 10 year ASCVD risk: [text name="variable_1" default=""]. Per USPSTF guidelines, [select name="variable_9" value="recommend high intensity statin therapy, 80 mg Lipitor once daily.|recommend moderate intensity statin therapy, 40 mg Lipitor once daily.|recommend low-intensity statin therapy.|no indication for statin therapy at this time"]
-Labs ordered: [text name="variable_2" default=""]
-Goal blood pressure is 140/90
-Medications ordered/refilled: [select name="variable_10" value="80 mg Lipitor once daily.| 40 mg Lipitor once daily.|None."]
-F/u in [text name="variable_3" default=""]
-Patient agrees with plan and has no further questions.

3. Obesity

Consistent with obesity due to excessive caloric intake. Patient BMI is currently [text name="variable_4" default=""] [select name="variable_10" value="increased|decreased|no change"] from last encounter. Patient with [checkbox name="variable_1" value="Class 1 (low risk obesity) BMI 30-34.9.|Class 2 Obesity (moderate risk) BMI 35-39.9. |Class 3 (high risk obesity) BMI 40 or greater. | First confirmed BMI over 30. "] [select name="variable_11" value="Patient is precontemplative. |Patient is contemplative| Patient is taking action | Not discussed at this visit. Recommend that patient is counseled regarding elevated BMI at next PCM visit."]

- Goal weight loss for next visit:
- Strategies/recommendations given to patient: [checkbox name="variable_11" value="Food diary: keep a written or digital meal diary that tracks all meals, snacks, and beverages|Bariatric Surgery: Patient meets NIH criteria for bariatric surgery. Age is between 18-64, BMI is greater than 40, and patient suffers from obesity related health problems.|Exercise: Per current guidelines, get at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity a week, or a combination of moderate and vigorous activity."]
-Patient [select name="variable_12" value="amenable|not amenable"] to recommendations. Will follow up at next visit.
-Consults placed: [checkbox name="variable_12" value="Nutrition|General Surgery for bariatric evaluation|Physical therapy"]
-Labs ordered: [checkbox name="variable_13" value="A1c to screen for diabetes|Lipid panel"]

4. Tobacco use
HPI:



-Recent glucose values:

-Prescribed medication regimen:

-Episodes of hypoglycemia:

-Taking medications as prescribed:

-Taking daily aspirin:

-Most recent labs: A1C- Albumin to Cr- Cr-

-Last eye exam:

-Last foot exam:

-Tobacco use:

-Immunization hx: Last pneumococcal- , Influenza- Y/N , Hep B- for unvaccinated adults 19-59

Pertinent ROS:

PE:





CARDIAC:

PULMONARY:




Extremities- No LE edema



-Hair is
-Dorsalis Pedis pulse is bilaterally.
-Posterior tibial pulse is bilaterally.
-Skin is to touch.
- There is no dryness or cracking in between the toes bilaterally.
-Nails are
-Right monofilament: /5
-Left monofilament: /5


A/P
1. Diabetes,
- Meeting/not meeting goal A1C of <7% recommended by ADA 2018 standards of care. 8% with less life expectancy or too many hypoglycemic episodes.
- ASCVD:
- Screening labs: A1C (3-6 months), BMP (albumin to creatinine ratio annually), Urine microalbumin
- Advised patient get pedicure to improve foot hygiene and decrease risk of developing wounds/ulcers.
- Preventative visits needed: podiatry (failed monofilament), dilated eye exam (annually), dental (annually). Patient overdue for XXX.
- Vaccines needed: Pneumococcus, Influenza, Hep B.
- Medication changes: Add/increase aspirin, statin, glycemic agent, insulin
- Side effects of meds?
- F/u in 6 months.

2. HTN
HTN is
-Current 10 year ASCVD risk: . Per USPSTF guidelines,
-Labs ordered:
-Goal blood pressure is 140/90
-Medications ordered/refilled:
-F/u in
-Patient agrees with plan and has no further questions.

3. Obesity

Consistent with obesity due to excessive caloric intake. Patient BMI is currently from last encounter. Patient with

- Goal weight loss for next visit:
- Strategies/recommendations given to patient:
-Patient to recommendations. Will follow up at next visit.
-Consults placed:
-Labs ordered:

4. Tobacco use
Result - Copy and paste this output: