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Medical Specialty:
General Medicine
Sample Name: Diabetes Mellitus - SOAP Note - 2
Description: Patient today with ongoing issues with diabetic control.
(Medical Transcription Sample Report)
SUBJECTIVE: I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change. What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. The staff reports to me that her appetite is good and that she is eating as well as ever. I talked to Anna today. She feels a little fatigued. Otherwise, she is doing well.
PHYSICAL EXAMINATION: Vitals as in the chart. The patient is a pleasant and cooperative. She is in no apparent distress.
ASSESSMENT AND PLAN: Diabetes, still with some problematic low blood glucoses, most notably in the morning. To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning. She will get 55 units in the morning. I am also decreasing once again her Humalog sliding scale insulin prior to meals. I will review the blood glucoses again next week.
See More Samples on General Medicine
Abdominal Pain - Consult
Accidental Celesta Ingestion - ER Visit
Acute Cystitis & Diabetes Type II
Admission History & Physical - Nausea
Air Under Diaphragm - Consult
Airway Compromise & Foreign Body - ER Visit
Anemia - Consult
Annual Health Maintenance Exam
Ant Bait Exposure - ER Visit
Antibiotic Management Consult
Antibiotic Therapy Consult
Asbestos Exposure - Hemoptysis
Atrial Fibrillation - SOAP
Blood In Toilet
Blood in Urine - ER Visit
Breast Calcifications - Preop Consult
Burn - Consult
Buttock Abscess
C. Diff Colitis Consult
Care Conference With Family
Cellulitis - Discharge Summary
Chest Pain & Respiratory Insufficiency
Chest Wall Lump - Consult
Chronic Abscesses - Discharge Summary
Chronic Medical Conditions - Followup
Congestion - 21-day-old
Congestion & Cough - 5-month-Old
Congestion & Fever - 2-month-old
Consult - Chest Pain
Consult - Chest Pain - 1
Consult - CHF & Lymphedema
Consult - Coronary Artery Disease
Consult - Hypertension
Consult - Sepsis
Consult - Stasis Ulcer
Consult - Syncope
Consult - Vomiting & Nausea
COPD & Pneumonia - SOAP
Cough & Abdominal Pain
Cut on Foot - ER Visit
Detox from Heroin
Diabetes Mellitus - SOAP Note - 1
Diabetes Mellitus - SOAP Note - 2
Discharge Summary - 1
Discharge Summary - 11
Discharge Summary - 12
Discharge Summary - 13
Discharge Summary - 14
Discharge Summary - 15
Discharge Summary - 16
Discharge Summary - 17
Discharge Summary - 18
Discharge Summary - 19
Discharge Summary - 2
Discharge Summary - 3
Discharge Summary - 4
Discharge Summary - 5
Discharge Summary - 6
Discharge Summary - 7
Discharge Summary - 8
Discharge Summary - 9
Discharge Summary - Migraine
Discharge Summary - Multiple Trauma
Disseminated Intravascular Coagulation
Dog Bite
Down's syndrome
Ecstasy Ingestion - ER Visit
Elbow Pain - Consult
ER Report - Chest Pain & Fever
ER Report - URI
Fall - ER Visit
Fall & Laceration
Feeling Dizzy - ER Visit
Female Exam & ROS
Female Physical Exam - 1
Female Physical Exam - 2
Female ROS
Fifth Disease - SOAP
Flank Pain - Consult
Flank Pain - Consult - 1
Followup on Asthma
Foreign Body - Fingernail
Foreign Body - Right Nose
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HIV Followup
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Hydrocarbon Aspiration - ER Visit
Hypergranulation - Consult
Hypersensitivity to Coumadin
Hypertension - Consult
Hypertension & Cardiomyopathy
Hyperthyroidism Following Pregnancy
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Infantile Spasms
Insect Sting
Itchy Rash - ER Visit
Jaw Pain - ER Visit
Lesions - Adrenal and Pancreatic
Low Back Pain from Exercise
Lymphoblastic Leukemia - Consult
Male Exam & ROS
Medical Management Consult Request
Melena - ICU Followup
Motor Vehicle Accident
MRI Brain - CO poisoning
Multiple Medical Problems - Discharge Summary
Nausea - ER Visit
Nausea & Vomiting - ER Visit
Normal Child Exam Template
Normal ENT Exam
Normal ENT Exam - 1
Normal Female Exam Template
Normal Female Exam Template - 1
Normal Female Exam Template - 2
Normal Female ROS Template
Normal Male Exam Template
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Normal Male Exam Template - 3
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Normal Newborn H&P Template
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Normal ROS Template
Normal ROS Template - 1
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Not Feeling Well - ER Visit
Obesity Hypoventilation Syndrome
Pain from Hernia - ER Consult
Patient with High Potassium
Perioperative Elevated Blood Pressure
Pneumoconiosis
Pneumonia - Discharge Summary
Possible Spider Bite
Post Thyroidectomy - Discharge Summary
Pressure decubitus
Pyelonephritis - Discharge Summary
Recurrent Abscesses - Consult
Refractory Hypertension - Followup
Renal Insufficiency - Consult
Request For Consultation
Revocation Admission
Right Hand Laceration
Sepsis - Consult
Shortness Of Breath - Progress Note
Sleep Apnea
Sleep Study Followup
Sleepiness - Consult
Snoring
SOAP - Substance Abuse
Thrombocytopenia - Consult
Thrombocytopenia - SOAP Note
Tongue Swelling
Toothache - ER Visit
Trouble breathing
Trouble Breathing - H&P
URI - SOAP
Viral Syndrome - ER Visit
Weight Loss Evaluation
Keywords: general medicine, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses,