General Practitioner-Vorlage
Diabetes HFP
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need help documenting diabetes care? This Diabetes HFP template is designed for GPs and other clinicians to efficiently record patient information related to diabetes management. This template helps you capture essential details like HbA1c results, medications, and patient goals. With Heidi, this template can be quickly populated from a patient's visit transcript, saving valuable time and ensuring comprehensive documentation. This template helps you create thorough and accurate medical records.
Vorlagenvorschau
face to face “F2F” seen with wife, Susan.
Type 2 diabetes, duration 10 years.
HbA1c 65 mmol/mol, previous result 72 mmol/mol. Medications: Metformin 1000mg twice daily, Gliclazide 80mg twice daily.
Non-HDL 3.5 mmol/L, QRisk 10%, taking Atorvastatin 20mg daily, compliant.
Urine ACR 2.0 mg/mmol, on Ramipril.
BP 130/80 mmHg.
Patient reports feeling well with their diabetes, no significant issues.
Self-recorded sugar levels: fasting levels between 6-8 mmol/L, post-meal levels between 8-10 mmol/L.
No hypos reported.
Insulin: Novorapid 6 units before meals, Lantus 20 units at bedtime.
CGM: Time in range 70%, time above range 25%, time below range 5%. Noted overnight lows.
Medication compliance: Excellent.
Patient goals: To maintain HbA1c below 58 mmol/mol.
Plan:
1. Continue current medications.
2. Review HbA1c in 3 months.
3. Reinforce healthy eating and exercise advice.
4. Next diabetes review due in 6 months.
History:
- Presented with a cough for 2 weeks.
- ICE: Patient is concerned about the cough and wants to rule out any serious cause.
- Presence or absence of red flag symptoms relevant to the presenting complaint: No red flag symptoms.
- Relevant risk factors: Smoker, 20 cigarettes per day.
- PMH: / PSH: - Type 2 diabetes, hypertension.
- DH: Drug history/medications: Metformin, Gliclazide, Atorvastatin, Ramipril. Allergies: NKDA.
- FH: Relevant family history: Father with heart disease.
- SH: Social history: Smoker, lives with wife.
Examination:
- Chaperone offered and present.
- Vital signs listed: BP 130/80 mmHg, HR 78 bpm, RR 16 breaths/min, Sats 98% on room air, Temp 37.0°C.
- Physical or mental state examination findings: Chest clear to auscultation.
- Investigations with results: Chest X-ray ordered.
Impression:
Cough. Assessment: Acute bronchitis.
- Differential diagnosis for Issue: Pneumonia.
Plan:
- Investigations planned for Issue: Chest X-ray.
- Treatment planned for Issue: Advised rest, fluids, and paracetamol for symptomatic relief.
- Relevant referrals for Issue: Advised to return if symptoms worsen or if any red flag symptoms develop.
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