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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