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Built for endocrine clinic follow-ups where labs, device data, medication titration, and complication screening need a consistent longitudinal note.
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Endocrine Follow-Up Note Interval History - Target endocrine symptoms since last visit (polyuria/polydipsia, hypoglycemia, weight change, heat/cold intolerance, palpitations, bone pain, fractures, menstrual changes, fatigue). - Home monitoring: SMBG/CGM patterns, BP/weight if relevant, symptom logs. - Adherence, injection/technique issues, pump/CGM device problems, diet/activity changes, and hospitalizations. Current Regimen - Endocrine medications/devices with doses (insulin, non-insulin antihyperglycemics, levothyroxine, antiresorptives, steroids, etc.). - Recent dose changes and tolerability/adverse effects. Data Reviewed - Labs (A1c, glucose, BMP, lipids, TFTs, calcium/Vitamin D, cortisol, hormones as relevant). - CGM metrics (TIR, time below range, GMI), DEXA, imaging, or pathology if discussed. Complication / Risk Screening - Diabetes: hypoglycemia awareness, foot symptoms, retinopathy/nephropathy/neuropathy updates, CV risk. - Other endocrine: compressive thyroid symptoms, fracture risk, adrenal crisis precautions as applicable. Exam - Weight/BMI, BP, thyroid exam, foot exam if performed, injection sites, and other focused findings. Assessment - Endocrine diagnoses with control/status (e.g., T2D with suboptimal control; hypothyroidism adequately replaced). Plan - Medication/device adjustments with targets and monitoring plan. - Labs/imaging orders, referrals (diabetes education, ophthalmology, DEXA), lifestyle counseling, and follow-up interval.
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Interval History T2D follow-up. Home fasting glucoses 140–180; several afternoon readings >220 after larger meals. Two mild hypos (58–65) mid-morning after walks—treated with glucose tabs. Using CGM most days. Weight −4 lb with diet changes. Current Regimen Metformin 1000 mg BID, semaglutide 1 mg weekly, glargine 22 units qHS. Missed one semaglutide dose last month. Data Reviewed A1c 8.1% (was 8.6%). CGM: TIR 58%, time <70 mg/dL 3%, GMI 7.9%. BMP Cr 0.9, K normal. LDL 96 on statin. Exam BMI 31.2. BP 128/78. No foot ulcers; monofilament intact. Injection sites without lipohypertrophy. Assessment Type 2 diabetes with improving but suboptimal control; rare mild hypoglycemia with activity. Plan Increase glargine to 26 units qHS. Continue metformin/semaglutide. Carb awareness around walks; carry rapid glucose. Recheck A1c/CGM download in 3 months. Reinforce annual eye exam (scheduled). RTC sooner for recurrent hypos or ketones/illness.
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