History of Present Illness Template for Patients with High Blood Sugar
A comprehensive HPI for a patient with hyperglycemia should include specific details about onset, symptoms, glycemic patterns, and contributing factors to effectively guide management decisions and prevent complications.
Chief Complaint and Onset
- Date and circumstances of high blood sugar discovery (routine check, symptoms, emergency)
- Initial blood glucose reading and how it was measured (home meter, lab test, hospital)
- Duration of known or suspected hyperglycemia
- Previous diagnosis of diabetes (type, duration) or if this is a new finding 1
Current Symptoms
- Presence and severity of classic hyperglycemia symptoms:
- Polyuria (frequent urination)
- Polydipsia (excessive thirst)
- Polyphagia (increased hunger)
- Weight loss/gain
- Fatigue or weakness
- Blurred vision
- Nausea/vomiting
- Abdominal pain (especially important to assess for DKA) 2
- Neurological symptoms (confusion, altered mental status) - critical for assessing HHS 2
- Respiratory patterns (Kussmaul breathing in DKA) 2
Blood Glucose Patterns
- Recent blood glucose readings (range, timing, patterns)
- Most recent A1C value and date (if available)
- Frequency and severity of hyperglycemic episodes
- Any episodes of hypoglycemia (frequency, severity, awareness) 1
Current Diabetes Management (if previously diagnosed)
- Current medications (insulin type/dose/timing, oral agents)
- Adherence to medication regimen
- Blood glucose monitoring practices (frequency, method, record-keeping)
- Recent changes to treatment regimen 1
Precipitating and Contributing Factors
- Recent illness, infection, or trauma
- Medication changes or additions (steroids, antipsychotics)
- Dietary changes or indiscretions
- Changes in physical activity
- Emotional stress
- Missed medication doses 2
Risk Factors for Hyperglycemic Crisis
- Previous history of DKA or HHS
- Young age (for DKA)
- Presence of other diabetes complications
- Presence of other chronic health conditions
- Behavioral health conditions (depression, bipolar disorder, eating disorders)
- Alcohol or substance use
- Social determinants of health (access to care, financial barriers) 2
Self-Management Assessment
- Understanding of diabetes management
- Ability to monitor glucose and administer medications
- Dietary habits and understanding
- Physical activity patterns
- Problem-solving skills during illness or glucose fluctuations
- Access to diabetes supplies and medications 2, 1
Impact on Quality of Life
- Effect of hyperglycemia on daily activities
- Diabetes-related distress
- Financial concerns affecting diabetes management
- Support system 1
Preventive Care History
- Last eye examination
- Last foot examination
- Vaccination status
- Recent specialist visits 1
Red Flags Requiring Immediate Attention
- Blood glucose >250 mg/dL with ketones present
- Signs of dehydration
- Altered mental status
- Severe abdominal pain or vomiting
- Kussmaul breathing
- Inability to tolerate oral hydration 2
This template ensures comprehensive assessment of patients with hyperglycemia, focusing on factors that impact morbidity, mortality, and quality of life while facilitating appropriate management decisions.