Assessment & Plan for T2DM in Inpatient Setting

Assessment & Plan for T2DM in Inpatient Setting

A:

Pt w/ long hx of T2DM
Recent A1c: 9.1% indicating poor glycemic ctrl
No DKA or severe hypo episodes
P:

Glycemic Control:

Incr Glargine to 30 U QHS
Cont Aspart 15 U TID AC
CBG q4h + SS insulin protocol
Diet & Edu:

ADA diet consult
DM edu re: lifestyle mod & med adher
Complication Screening:

Order annual diabetic eye exam
Foot exam + monofilament testing for neuropathy
Concomitant Issues:

Address CAD risk factors: cont statin & ASA
Tight BP ctrl w/ ACEi or ARB
Follow-Up:

Repeat A1c in 3 mths
F/U w/ endocrinology & PCP in 1 wk post-d/c
Assessment & Plan for T2DM in Inpatient Setting

A:

Pt w/ long hx of T2DM
Recent A1c: 9.1% indicating poor glycemic ctrl
No DKA or severe hypo episodes
P:

Glycemic Control:

Incr Glargine to 30 U QHS
Cont Aspart 15 U TID AC
CBG q4h + SS insulin protocol
Diet & Edu:

ADA diet consult
DM edu re: lifestyle mod & med adher
Complication Screening:

Order annual diabetic eye exam
Foot exam + monofilament testing for neuropathy
Concomitant Issues:

Address CAD risk factors: cont statin & ASA
Tight BP ctrl w/ ACEi or ARB
Follow-Up:

Repeat A1c in 3 mths
F/U w/ endocrinology & PCP in 1 wk post-d/c

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 104 boilerplate words
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: