Detailed Nurse Report
Detailed Nurse Report
I. Patient Information
Patient Name: [Patient's Name]
Date of Birth: [Date of Birth]
Address: [Patient's Address]
Phone Number: [Patient's Phone Number]
Emergency Contact: [Contact Name], [Contact Number]
II. Medical History
A. Current Conditions
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Diabetes: The patient is currently being treated with insulin therapy.
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Hypertension: Recent lab results indicate stable blood pressure levels.
B. Past Medical History
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Diabetes: History of diabetes mellitus type 2, managed with diet and medication.
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Appendectomy: Previous appendectomy performed in 2010.
III. Medication and Treatment Plan
A. Current Medications
|
Medication Name |
Dosage |
Frequency |
Start Date |
|---|---|---|---|
|
Insulin Glargine |
20 units |
Once daily |
01/01/2040 |
|
Metformin |
1000 mg |
Twice daily |
01/01/2040 |
B. Treatment Plan
-
Treatment Goal: Achieve stable blood glucose levels.
-
Plan Details: Follow up in 3 months for A1C check and medication adjustment if necessary.
IV. Assessment and Vital Signs
A. Vital Signs
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Blood Pressure: 130/80 mmHg
-
Pulse Rate: 72 bpm
-
Temperature: 98.6°F
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Respiratory Rate: 16 breaths per minute
B. Physical Assessment
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Cardiovascular: Regular rhythm, no murmurs.
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Respiratory: Clear lung fields bilaterally.
V. Recommendations and Follow-Up
A. Recommendations
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Adjust insulin dosage based on blood glucose readings.
-
Refer to a dietitian for personalized dietary counseling.
B. Follow-Up Plan
-
Schedule a follow-up appointment on July 15, 2050.
-
Provide patient education materials on diabetes management.
