Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of Gestational Diabetes Mellitus (GDM), diagnosed at [weeks] weeks gestation via [1-step/2-step] testing. Reports [adherence/non-adherence] to medical nutrition therapy (MNT) and glucose monitoring. Current blood glucose logs show [stable/labile] glycemic control with [number] fasting values >95 mg/dL and [number] 1-hour postprandial values >140 mg/dL. Denies symptoms of hyperglycemia (polyuria, polydipsia, blurred vision) or hypoglycemia.
Clinical Examination Findings
General: Patient is alert and oriented, in no acute distress. Vitals: BP [value], HR [value]. HEENT: Normocephalic, atraumatic. Cardiovascular: RRR, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Gravid uterus, fundal height [value] cm, consistent with gestational age. Fetal heart tones (FHT) present at [value] bpm. Extremities: No peripheral edema noted. Skin: No acanthosis nigricans or signs of insulin resistance.
Treatment Protocol
Plan: 1. Continue MNT with strict carbohydrate counting (40-45% complex carbs). 2. Maintain glucose logs: fasting <95 mg/dL, 1-hr postprandial <140 mg/dL, 2-hr postprandial <120 mg/dL. 3. Initiate [Insulin/Metformin/Glyburide] at [dose] due to persistent hyperglycemia. 4. Weekly NST/BPP starting at [weeks] weeks. 5. Follow-up in [timeframe] for glycemic review.