SUBJECTIVE:
Routine Follow up/Chronic Condition
Chief Complain:
Symptoms analysis/HPI:
PMH:
Immunization:
Surgical History:
Family History:
Social Hx:
CONSTITUTIONAL:
Neurologic:
HEENT: Head:
Eyes:
. Ear:
Nose:
. Throat:
Respiratory:
Cardiovascular:
describe above
Gastrointestinal:
Genitourinary:
Musculoskeletal
Skin:
Objective data:
CONSTITUTIONAL: Vital Signs T: °F (Oral), HR: bpm, regular, RR: , BP: , SpO2: % on room air, Weight: , Height in BMI . Report pain 0/10.
General appearance:
NEUROLOGIC:
HEENT: Head:
. Eyes: PERRLA, sclera white, no discharge noted.
Ears:
Nose/Sinus:
Mouth:
Throat:
Neck:
Respiratory:
Cardiovascular
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary:
Assessment:
Differential diagnosis: is based in secondary causes of diabetes
• These basic laboratory tests are:
Pharmacologic treatment:
Non-Pharmacologic treatment:
Education Non-Pharmacologic treatment:
•
Office procedures:
Follow-ups/referrals:
in one week for evaluation follows up.
References: Less 5 years ago. APA format, 5
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