糖尿病病例分析(英文)
糖尿病(全英文版)DiabetesMellitus
Lab test
blood glucose is higher than 33.3 mmol/l, usually 33.3-66.6 mmol/l and serum osmolality > 350 mmol/l
Introduction
There are more and more people suffer from diabetes with the development of society, population aging and changes of life style.
Diabetes mellitus is a group of metabolic disorders characterized by chronic
Stage 5: clinical diabetes
Stage 6: beta cells of the clients who
have longtime diabetes are damaged
thoroughly, blood insulin level is very low
Type 2 diabetes
Type 1 diabetes
Stage 1: genetics emotivity Stage 2: start autoimmune Stage 3: immunology abnormality
Stage 4: progressive dysfunction of beta cells
gestational diabetes mellitus
糖尿病患者soap病历点评制度
糖尿病患者soap病历点评制度英文回答：Subjective:Chief Complaint: Diabetes management.History of Present Illness: The patient is a 55-year-old male with a 10-year history of type 2 diabetes mellitus. He is currently following up for routine management. He denies any acute symptoms or changes in his condition.Past Medical History: Diabetes mellitus type 2, hypertension.Medications: Metformin 500 mg twice daily, amlodipine5 mg daily.Social History: The patient is a married father of two. He works as a teacher. He is a non-smoker and drinksalcohol socially.Family History: The patient's father has a history of type 2 diabetes mellitus.Objective:Vital Signs: Blood pressure 130/80 mmHg, pulse 72 beats per minute, respirations 16 breaths per minute, temperature 98.6°F (37°C)。
Physical Exam: The patient is in no acute distress. He is obese with a body mass index (BMI) of 32. His skin is warm and dry. His head and neck are unremarkable. His chest is clear to auscultation bilaterally. His heart sounds are regular and S1 and S2 are present. His abdomen is soft and non-tender. His extremities are warm and well-perfused.Laboratory Data: A1C 7.2%, fasting blood glucose 120 mg/dL.Assessment:Type 2 diabetes mellitus.Hypertension.Plan:Continue metformin 500 mg twice daily.Continue amlodipine 5 mg daily.Follow up in 3 months for routine management.中文回答：主观症状：主诉，糖尿病管理。
糖尿病SOAP.docx
WORD格式全科医师 SOAP病历 (糖尿病）一般资料接诊日期 :2018 年月日姓名：——性别：年龄：岁S主观资料主诉主要症状描述、病情演变症状：多饮、多食、多尿、视力模糊、感染、手足麻木、下肢浮肿、体重明显下降病情演变：初次发病时间，血糖控制情况，眼、心、肾、血管、神经、足、皮肤、胃肠等慢性并发症情况，低血糖、糖尿病酮症、糖尿病乳酸酸中毒、糖尿病高渗昏迷等急性并发症情况治疗经过及结果服药或注射胰岛素情况，治疗结果，药物不良反应既往史血脂异常、痛风、甲亢、脑卒中、冠心病、慢性肾病、多囊卵巢综合征、睡眠呼吸暂停、支气管痉挛、肝炎、结核等病史？类固醇激素、抗精神病、抗抑郁药、他汀类药物使用家族史高血压、糖尿病、冠心病、脑卒中家族史，及发病年龄婚育、月经史巨大婴儿、妊娠糖尿病病史？生活方式吸烟、喝酒、饮食（特别是主食及烹调方式）、运动心理社会因素了解家庭、工作、个人心理和文化程度O客观检查查体血压：左手160/76mmHg，右手： 165/85mmHg脉搏： 68次/分呼吸：17次/分，体温：36.9℃身高： 160cm体重：55kg BMI:21腹围:80cm神清，语利，无“满月脸”及体毛增多，双肺呼吸音清晰，无干湿啰音，心率68 次 /分，心律齐，各瓣膜停诊区未闻及病理性杂音;腹软无压触痛、反跳痛，肝脾肋下未触及，双下肢无浮肿，双侧颈动脉未闻及血管杂音，无足背动脉搏动减弱。
实验室检查及辅助检查空腹、餐后血糖，糖化血红蛋白，血脂、尿酸、尿蛋白，肝肾功能、血脂、眼底、下肢动脉超声、糖尿病足筛查、甲功心理测验SAS焦虑量表HAMD抑郁量表A评价存在危险因素及健康问题危险因素：存在健康问题：血糖控制情况？并发症？并发症专业资料整理WORD格式眼、心、肾、血管、神经、足、皮肤、胃肠等慢性并发症情况，低血糖、糖尿病酮症、糖尿病高渗昏迷等急性并发症情况依从性1. 服药依从性：间断/规律/不服药；2.生活方式管理依从性家庭可利用资源由家属督促其进行慢病管理？P处置计划进一步诊查计划每月随访：体重、空腹餐后血糖、血压、尿常规每3 月随访：糖化血红蛋白、足部检查（足背动脉、神经病变相关检查）每 6 个月随访：尿蛋白 / 肌酐每年复查：身高、 BMI 、心电图、肝肾功能、血脂、眼底、下肢动脉超声、甲功治疗计划药物治疗 :1.注意监测血糖2.胰岛素注射技巧生活方式干预：1. 低盐、低脂饮食（少于 6 克盐， 25克油）；2.戒烟、限酒3.精神放松、保持愉快心情;4.饮食控制（总热量、各营养成分比例、简单配餐、水果、烹调方式）5.预防低血糖6.适当运动，每周5次，每次30min，选择适当运动方式如步行、体操等，心率控制在（220-年龄） *0.7次/分左右；根据摄入量调整运动量，餐后90min 运动为宜，注意预防低血糖。
高血压糖尿病门诊病历范文
高血压糖尿病门诊病历范文英文回答：Hypertension and Diabetes Mellitus Clinic Note Template.Chief Complaint: Hypertension and Diabetes Mellitus.History of Present Illness:The patient is a [age]-year-old [gender] with a history of hypertension and diabetes mellitus. The patient presents today with complaints of [symptoms]. The symptoms have been present for [duration]. The patient denies any other symptoms. The patient has been taking [medications] fortheir hypertension and diabetes, but their blood pressure and blood sugar have been uncontrolled.Past Medical History:Hypertension.Diabetes Mellitus.[Other past medical history]Social History:The patient is a smoker and drinks alcohol socially. The patient is employed as a [occupation]. The patient lives with [family members].Family History:The patient's father has hypertension. The patient's mother has diabetes mellitus.Physical Examination:Vital Signs:Blood pressure: [blood pressure]Heart rate: [heart rate]Respiratory rate: [respiratory rate]Temperature: [temperature]General:The patient is alert and oriented. The patient is in no acute distress.HEENT:The patient's head is normocephalic and atraumatic. The patient's eyes are normocephalic and atraumatic. Thepatient's ears are normocephalic and atraumatic. Thepatient's nose is normocephalic and atraumatic. Thepatient's mouth is normocephalic and atraumatic.Neck:The patient's neck is supple with no lymphadenopathy.Cardiovascular:The patient's heart is regular rate and rhythm. No murmurs, gallops, or rubs are appreciated.Pulmonary:The patient's lungs are clear to auscultation bilaterally.Abdomen:The patient's abdomen is soft, nontender, and nondistended. No masses or organomegaly are appreciated.Genitourinary:The patient's genitalia are normal.Musculoskeletal:The patient's range of motion is normal. No joint pain or swelling is appreciated.Neurological:The patient's cranial nerves are intact. The patient's motor and sensory examination is normal.Laboratory Data:Blood Tests:Hemoglobin A1c: [HbA1c]Creatinine: [creatinine]Electrolytes: [electrolytes]Lipid Panel: [lipid panel]Urine Tests:Albumin: [albumin]Creatinine: [creatinine]Glucose: [glucose]Assessment:1. Hypertension.2. Diabetes Mellitus.Plan:Medications:1. The patient will be started on [new medication] for their hypertension.2. The patient will be started on [new medication] for their diabetes mellitus.Lifestyle Modifications:1. The patient will be advised to lose weight.2. The patient will be advised to eat a healthy diet.3. The patient will be advised to exercise regularly.4. The patient will be advised to quit smoking.Follow-up:The patient will be followed up in [number] weeks.中文回答：高血压糖尿病门诊病历范文。
糖尿病体格检查病历书写范文
糖尿病体格检查病历书写范文英文回答：I remember one time when I had to write a medical record for a patient who came in for a physical examination for diabetes. The patient, a 55-year-old male, presented with symptoms such as frequent urination, increased thirst, and unexplained weight loss. Upon examination, his blood glucose levels were found to be elevated, indicating possible diabetes.I started the medical record by documenting thepatient's personal information, including his name, age, and contact details. I then proceeded to record the chief complaint, which was the patient's concern about his symptoms and the possibility of having diabetes.Next, I described the patient's medical history, including any pre-existing conditions, such as hypertension or family history of diabetes. I also noted any medicationsthe patient was currently taking. In this case, the patient had a family history of diabetes, which increased his risk for developing the condition.After that, I documented the physical examination findings. I mentioned the patient's vital signs, such as blood pressure, heart rate, and respiratory rate. I also noted any abnormalities or relevant findings, such as the presence of diabetic neuropathy or retinopathy.In addition, I included the results of the laboratory tests that were performed on the patient. These included a fasting blood glucose test, an HbA1c test, and a lipid profile. The results confirmed the diagnosis of diabetes, with elevated blood glucose levels and HbA1c levels above the normal range. The lipid profile also showed abnormalities, indicating the need for further managementof cardiovascular risk factors.Finally, I concluded the medical record by outliningthe treatment plan for the patient. This included lifestyle modifications, such as dietary changes and regular exercise,as well as medication management, which involved initiating oral hypoglycemic agents. I also made a note to schedule a follow-up appointment to monitor the patient's progress and adjust the treatment plan if necessary.中文回答：我记得有一次我需要为一位前来进行糖尿病体格检查的患者书写病历。
糖尿病酮症酸中毒的病历讨论范文
糖尿病酮症酸中毒的病历讨论范文英文回答：Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of ketones. Ketones are chemicals produced when the body breaks down fat for energy instead of using glucose. This can happen when there is not enough insulin in the body to help glucose enter the cells.DKA is commonly seen in patients with type 1 diabetes, but it can also occur in patients with type 2 diabetes. It is usually triggered by factors such as illness, infection, or missed insulin doses. The symptoms of DKA can include excessive thirst, frequent urination, fatigue, nausea, vomiting, and abdominal pain.If left untreated, DKA can lead to a life-threatening condition called diabetic coma. Treatment for DKA involves replacing fluids and electrolytes, correcting high bloodsugar levels, and administering insulin. In severe cases, hospitalization may be required.中文回答：糖尿病酮症酸中毒（DKA）是糖尿病的严重并发症，当身体产生高水平的酮体时就会发生。
糖尿病病例分析
糖尿病病例分析糖尿病(Diabetes)是一种常见的慢性代谢性疾病，其特点是高血糖(Hyperglycemia)和胰岛功能不全。
全球范围内，糖尿病患者数量呈快速增长趋势，成为一种严重的公共卫生问题。
本文将通过一个实际的糖尿病病例，来探讨糖尿病的病因、症状、诊断以及治疗方案。
病例描述：患者为一名男性，年龄45岁，体重超过BMI指数标准，有亲属糖尿病家族史。
患者最近感到频繁口渴，尤其在夜间。
他同时还出现了尿频、疲劳和体重下降等症状。
出于对症状的担忧，他前往医院寻求医疗帮助。
糖尿病病因：糖尿病的病因复杂，与遗传、环境和生活方式等多个因素有关。
在这个病例中，患者的家族病史表明可能存在遗传因素。
此外，患者体重超过了BMI指数标准，说明他可能存在肥胖的生活方式。
肥胖是糖尿病的一个主要危险因素，因为它可以导致胰岛素抵抗(Insulin Resistance)。
糖尿病症状：常见的糖尿病症状包括多饮(Polydipsia)、多尿(Polyuria)和多食(Polyphagia)。
患者在夜间频繁口渴可能与高血糖引起的尿频有关。
此外，疲劳和体重下降也是糖尿病常见的症状，这与细胞无法充分利用血糖导致能量不足有关。
糖尿病诊断：对于糖尿病的诊断，常用的方法是血糖检测。
患者在就诊时进行血液检查，结果显示其空腹血糖(Fasting Blood Glucose)水平高于正常范围。
此外，还可以进行糖化血红蛋白(HbA1c)测定，用于评估血糖控制的长期情况。
糖尿病治疗方案：糖尿病的治疗通常包括生活方式干预和药物治疗两个方面。
对于患者来说，重点应放在改善生活方式。
首先，通过控制饮食，避免高糖和高脂食物，正确使用低糖指数食物，控制每日卡路里摄入量。
其次，通过增加身体活动，帮助消耗多余的血糖和脂肪，并提高体内胰岛素的敏感性。
此外，戒烟和限制酒精摄入也是必要的。
药物治疗方面，胰岛素或口服降糖药物可以根据患者具体情况进行选择。
总结：通过这个糖尿病病例的分析，我们可以看到糖尿病是一个复杂的疾病，其病因涉及遗传、生活方式等多个方面。
2型糖尿病 住院病历模板
2型糖尿病住院病历模板## Admission Note for Type 2 Diabetes.Diagnosis: Type 2 Diabetes.Age: 65 years.Gender: Male.Chief Complaint: Polyuria, polydipsia, fatigue, weight loss.History of Present Illness:The patient is a 65-year-old male who presents to the clinic with a one-week history of increased thirst, increased urination, fatigue, and unintentional weight loss. He has been diagnosed with type 2 diabetes for the past 5 years and has been taking metformin 500 mg twice daily. He has not been following his diabetes management plan closelyand has been eating a diet high in sugar and carbohydrates. He denies any other symptoms such as blurred vision, pain, or numbness.Past Medical History:Type 2 Diabetes.Hypertension.Medications:Metformin 500 mg twice daily.Social History:The patient is retired and lives with his wife. He is a former smoker and has a 10-pack year history of smoking. He denies alcohol or illicit drug use.Family History:His father and brother both have type 2 diabetes.Physical Examination:Vital signs: Blood pressure: 140/90 mmHg, heart rate: 88 beats/min, respiratory rate: 18 breaths/min, temperature: 98.6°F.General: Obese male in no acute distress.HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Oropharynx is clear without erythema or exudate. Neck is supple without lymphadenopathy.Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. Pulses are palpable in all extremities.Respiratory: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.Gastrointestinal: Abdomen is soft, non-tender, andnon-distended. Bowel sounds are normoactive. No hepatosplenomegaly.Genitourinary: Genitalia are normal. No masses or tenderness.Musculoskeletal: No joint deformities or swelling. Range of motion is intact.Neurological: Mental status is intact. Cranial nerves are intact. Motor and sensory exams are normal.Laboratory Studies:Blood glucose: 300 mg/dL.Hemoglobin A1c: 8.5%。
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Shiyun Kim, PharmD, BCACP, BCPP, CDE
James Lee, PharmD, BCACP
University of Illinois at Chicago College of Pharmacy
Diabetes Cases – July 5, 2017
CASE 1
M.L. is a 48 y.o. Asian female who presents to the Internal Medicine Clinic clinical pharmacist for follow-up regarding hypertension (HTN). She was screened for diabetes at a recent health fair and was told to discuss her blood sugar reading with her health care provider. However, she does not remember the blood sugar reading. She tells you her sister was recently diagnosed with Type 2 diabetes.
PMH: HTN x 6 months, GDM (gestational DM) 7 years ago
PSH: Tubal ligation 7 years ago
FH: Mother: Type 2 DM
Father: HTN
Sister: Type 2 DM
M. Grandmother: Diabetes, unsure what type, was using insulin
SH: Smokes 1ppd x 15 years, occ EtOH, denies illicit substance use
Caffeine: Drinks 2 cups of coffee/ day, 1-2 regular Pepsi sodas/day
Diet: Does not always eat breakfast, usually eats fast food for lunch
NKDA (no known drug allergies)
Medications
HCTZ 25mg po daily
Vitals: Ht 5’5” Wt: 180 lbs (81.7kg) BMI 30 BP 144/82 P 82 R 20 Temp 98.6 F
1.What risk factors does ML have for DM?
2. A Fasting Blood Glucose (FBG) measurement was obtained from ML today: 140mg/dL.
What is ML’s diagnosis?
3.What specific lifestyle modification interventions would you suggest?
4.Which labs should you order?
5.What medication therapy for her blood glucose would you initiate? (state dose and
regimen)
6.How would you optimize her current anti-hypertensive regimen? (state
medication class and monitoring parameters)
7.What specific education should you provide for ML today?
8.When would you follow-up with ML?
CASE 2
ML returns for follow-up appointment. She is unsure if she is eating the best foods to control her BG. She is tolerating her new medications well. She is trying to eat breakfast, but has been mostly been eating a donut or potato chips on her way to work. She is increasing her physical activity to 10 minutes three days a week by walking after work. She has been eating 1 banana and chips for snacks.
She brought in her BG readings.
SMBG:
Fasting BG 160-180mg/dl
After meals 200-240mg/dl
1.What aspects of ML management of diabetes could be improved?
2.How would you adjust ML’s current medication therapy? (Give dose and regimen)
3.What are the clinical benefits of your recommendations?
4.When would you like to follow up with ML?。