Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document any symptoms suggestive of hyperglycemia, if present. These may include:
Increased thirst (polydipsia)
Frequent urination (polyuria)
Fatigue
Blurred vision
现病史 (xiàn bìng shǐ) History of Present Illness:
Date and time hyperglycemia was first identified.
Current glucose levels and trends.
Any recent changes in medications, diet, or activity level that may have contributed to hyperglycemia.
Presence of any symptoms suggestive of hyperglycemia (as mentioned above).
既往史 (jì wàng shǐ) Past Medical History:
Diabetes mellitus (type 1 or type 2):
Duration of diagnosis
Current medications and adherence
Other relevant medical conditions (e.g., chronic kidney disease, steroid use)
Prior hospitalizations for hyperglycemia or diabetic ketoacidosis (DKA)
家族史 (jiā zú shǐ) Family History:
Family history of diabetes mellitus (uncommon)
过敏史 (guò mìn shǐ) Allergies:
Allergies to medications used to treat hyperglycemia (e.g., insulin)
药物史 (yào wù shǐ) Medication History:
List of current medications, including:
Diabetes medications (insulin, oral hypoglycemics)
Other medications that may affect blood sugar (steroids, some diuretics)
Document any recent changes in medications or dosing.
实验室检查 (shí yàn shì jiǎn chá) Laboratory Tests:
Blood glucose levels (including point-of-care and fingerstick measurements)
Hemoglobin A1c (HbA1c): reflects average blood sugar control over the past 2-3 months (may not be available immediately)
Electrolytes (potassium, sodium) – to assess for electrolyte imbalances
Blood ketones (if suspected DKA)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not routinely used for hyperglycemia diagnosis.
诊断 (zhěn duàn) Diagnosis:
In-hospital hyperglycemia.
Specify the likely cause, if known (e.g., new diagnosis of diabetes, stress-induced hyperglycemia, medication side effect).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Goal: Achieve and maintain blood sugar levels within target range to prevent complications.
Dietary modifications (may involve consultation with a dietician)
Insulin therapy (sliding scale, basal-bolus regimen, or other as needed)
Adjustment of other medications that may affect blood sugar
Monitoring of blood glucose levels frequently (according to physician orders)
Education on diabetes management (if newly diagnosed)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hyperglycemia, underlying medical conditions, and response to treatment.
Early identification and treatment of hyperglycemia can prevent complications.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following the prescribed diet and medication regimen.
Self-monitoring of blood glucose levels (if applicable)
Recognizing signs and symptoms of hyperglycemia and hypoglycemia.
Importance of regular follow-up with a healthcare provider.
医师医嘱 (yī shī yī zhù) Physician Orders:
Document specific orders for:
Blood glucose monitoring frequency
Diet plan
Insulin administration (type, dosage, frequency)
Any other medications or interventions
护理记录 (hù lì jì lù) Nursing Notes:
Document:
Vital signs
Blood glucose levels and trends
Assessment for signs and symptoms of hyperglycemia
Patient education provided
Response to treatment
下一步计划 (xià yī bù jì huà) Next Steps:
Schedule for follow-up appointments with the diabetes care team.
Consideration for discharge planning and medication reconciliation (if applicable).