Posted: December 8th, 2022
Model Note: CC: “Diabetes” HPI: Chelsea Warren is an 11-year-old Caucasian female hospitalized with new-onset type 1 diabetes. This is day 3 of her hospitalization. She is a good historian and able to answer questions appropriately. Her father is present in the room with her. She is due to be discharged home today. Chelsea Warren Type 1 Diabetes Shadow health SOAP Note. Chelsea was brought to the ED at 8:30pm 3 days ago by her father two days ago with dizziness, vomiting, and lethargy. She wasn’t feeling well during a horseback riding lesson and hadn’t been feeling well for the past few days. She was diagnosed with Diabetic Ketoacidosis and Diabetes Mellitus 1. She has admitted with a blood sugar above 500 mg/dL PMH: No previous hospitalizations. Nearsightedness diagnosed at age 8. Wears corrective lenses. Up to date on immunizations PSH: No previous surgeries Allergies: NKDA Medications: Started during hospitalization- 0.9% NaCl IV continuous 100ml/hr Insulin glargine – 5 units HS Insulin lispro – sliding scale AC BG 125-174 = 1 unit BG 175-224 = 2 units BG 225-274 = 3 units…Chelsea Warren Type 1 Diabetes Shadow health SOAP Note
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