Skip to content
ProductiveMedic
  • DDx
  • Templates
  • Pathways
  • Ramadan
  • Dermatology
  • ECG
  • Search Engine
  • Contact us

    • -----------

      ===============

      -----------


      Edit the text below <p>Please edit the text in the box to reflect your clinical history and examination. <br /><span style="color: yellow;"><b>NOTE: Use Shift + Enter to create a new line for correct line spacing.</b></span></p> <p>The templates (links on the right) can be used to help produce comprehensive documentation. The text will revert back to default on a page refresh.</p> Use the buttons to add/remove sections and Shift+Enter for new lines
      History [ ← HPC template ]
      -
      ‐ Non cardiac chest pain: non-exertional, non-constricting and not relieved by rest/GTN

      Associated symptoms [ ← Associated symptoms template ]
      -
      - cardiac risk factors: smoker, Diabetes, ^BP, ^lipids, PMHx, FHx

      Pertinent negatives [ ← Pertinent negatives template ]
      - No nausea or vomiting - No sweating - No palpitations - No syncope
      - No SOB - No orthopnea - No PND - No ankle swelling
      - No cough - No haemoptysis - No wheeze
      - No calf pain/swelling - No DVT risk factors
      - No dyspepsia or reflux - No abdominal pain - No neck / back pain
      - No fever - No night sweats - No fatigue - No weight loss
      - No shingles rash
      - No anxiety / low mood

      Further history [ ← Further history template ]
      - Past Medical History - No significant past medical history
      - Family History - No significant family history
      - Medication history and allergies as documented in clinical notes
      - Recreational drugs - Non-smoker - No alcohol - No recreational drugs

      Examination [ ← Examination template | Telemedicine template ]

      - Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused
      - HR = [ ] RR = [ ] Temp = [ ] BP = [ ] Sats = [ ]
      - No jaundice /anaemia /clubbing /cyanosis /oedema /lymphadenopathy
      - CVS: Normal pulse rhythm and character, JVP normal, HS I+II+0 no murmurs
      - Calves soft non-tender no DVT, no SOA
      - Chest: No respiratory distress, Good air entry, vesicular breath sounds, no crepitations /wheeze
      - Abdo: Soft non-tender - No masses / LKKSB, BS normal

      - Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused
      - HR = [ ] RR = [ ] Temp = [ ] BP = [ ] Sats = [ ]
      - No jaundice /anaemia /clubbing /cyanosis /oedema /lymphadenopathy
      - CVS: Normal pulse rhythm and character, JVP normal, HS I+II+0 no murmurs
      - Chest: No respiratory distress, Good air entry, vesicular breath sounds, no crepitations /wheeze
      - No / chest wall tenderness - reproduces pain exactly
      - No shingles rash
      - Abdo: Soft non-tender - No masses / LKKSB, BS normal
      - Calves soft non-tender no DVT, no SOA

      - *ECG:
      - *Wells score & near patient D-dimer: [ ← Wells score: DVT | PE ]

      Assessment [ ← Diagnostic Time-Out - consider what else could this be? ]
      - Impression:

      Management [ ← Management template ]
      - Explanation & Advice
      -

      Safety netting [ ← Safety netting template ]
      - Discussed and advised to observe for specific red flags - acute onset of severe pain, exercise-related pain, prolonged pain > 15 minutes, nausea/vomiting and sweating, dyspnoea, haemoptysis, syncope, weight loss, neurological symptoms
      - Understands to call or seek immediate medical review if any concerns

      Copy and paste text into the notesUse windows short cuts to select the text (Ctrl + A), copy (Ctrl + C), and paste (Ctrl + V) into the clinical notes. <br><span style="color: yellow;"><b>If your clinical system is pasting the links use Ctrl+Shift+V (or Ctrl+V then press Ctrl button again and use T to select text only).</b></span>

      Feedback or report an error on this page
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
    • GREENWOOD DIABETES CLINIC

      Your most recent results

      NOTE: Risk categories are for people living with Type 2 Diabetes without any complications.

    • HbA1c
      53
      HIGH RISK
    • HbA1c
      53
      MODERATE RISK
    • HbA1c
      53
      LOW RISK
    • ⬇

      High HbA1c Information Prescription

    • Blood Pressure
      135
      85
      HIGH RISK
    • Blood Pressure
      135
      85
      MODERATE RISK
    • Blood Pressure
      135
      85
      LOW RISK
    • * 150/90 if 80 years and older

      ⬇

      High Blood Pressure Information Prescription

    • Cholesterol
      4.5
      HIGH RISK
    • Cholesterol
      4.5
      MODERATE RISK
    • Cholesterol
      4.5
      LOW RISK
    • ⬇

      High Cholesterol Information Prescription

    • Please click the information prescription links above for general advice, Dr Rehman will give you specific individualised advice at your consultation.

    •  
    • Lifestyle advice is integral to the management of Diabetes and should be reinforced at every available opportunity

    • Blood pressure


    • Blood pressure

    • Diabetes and frailty: guidance on the management of older adults with type 2 diabetes

Save and Continue Later