IM DM Note
This patient has DM Type __ diagnosed in __. __ feels that things are going __. Main concerns today are __. Current treatment regimen is as noted in the meds list. Recent changes include __. Complications/Comorbidities: Hypertension: _ Nephropathy: _ Hyperlipidemia: _ CV Disease: _ Neuropathy: _ Retinopathy: _ CV: Denies chest pain, dyspnea, PND, DOE, edema, orthopnea GI: Denies nausea, vomiting, diarrhea, abdominal pain, constipation. GU: Denies dysuria, urgency, frequency, polyuria, hematuria Reproductive Men: Denies erectile dysfunction, painful intercourse Reproductive Women: Denies painful intercourse, vaginal discharge, pelvic pain, menstrual irregularities/missed periods Neuro: Denies numbness, tingling, pain in feet. Denies sores/ulcers. Denies focal weakness. PE Vitals including PAV and LWM General: Healthy, NAD. Mood/Cognition good. HEENT: Normocephalic, atraumatic. PERRL. EOMI. No peri-orbital edema, exophthalmus, lid lag, conjunctival injection or convergence noted. Dentition in good repair. No lymphadenopathy of the sublingual, submandible or cervical chains. Thyroid: Palpable, non-tender. No thyromegaly. No distinctly palpable nodules. Respiratory: No abnormal cough or dyspnea. Clear to auscultation in all fields. No clubbing or cyanosis. Cardiovascular: RRR without audible murmur, rubs, or thrills. . Radial pulses Dorsalis pedis pulses . No venous stasis or edema. Gastrointestinal: Abdomen soft, non-tender without HSM or palpable mass. Obese No CVAT. No striae. Musculoskeletal: Spine erect. No obvious deformities of the extremities. Neurological: No focal motor deficits Bicep Patellar Achilles DTR Sensate to the monofilament on the plantar surfaces of bilateral feet at Vibratory . Integumentary: Skin soft, dry. No lesions or rash noted. No acanthosis nigracans or Xanthomas. Feet are without callus or ulcer. . No terminal hair noted. 1. DM Reviewed pathophysiology of diabetes and complications associated with hyperglycemia such as retinopathy, cardiovascular disease, nephropathy, and neuropathy. Discussed goals for diet, exercise, and weight loss. Discussed tests/levels that would need to be monitored closely such as blood glucose, HbA1c, blood pressure, cholesterol, BMI, and microalbumin/creatinine ratio. Also discussed routine exams that would need to be done such as annual dilated eye examination, bi-annual dental examinations, and quarterly foot examinations. Discussed recommendations for Reviewed symptoms associated with hypo- and hyperglycemia. Discussed treatment of hypoglycemia by using the rule of 15. 2. High blood pressure: _ 3. Dyslipidemia: _ 5. __ (other) Additional labs __ Patient to follow-up in __ Visit Duration: _. >50% of this visit spent in education and counseling of the above conditions.
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