This medical document provides a routine follow up for a patient with chronic conditions. It includes the patient's medical history, family history, social history, vital signs, and physical exam findings. The assessment considers potential secondary causes of diabetes. The treatment plan involves pharmacologic therapies, non-pharmacologic lifestyle changes, patient education, and a follow up appointment in one week.

1. 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:

2. 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:

3. 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