Identifying elements
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Identifying Elements. JJ MR# 1234 Nov. 29, 2000 UAMS Endocrine Clinic Dr. Debra Simmons. Chief Complaint. CC: Routine follow up for type 1 diabetes. History.

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Identifying Elements

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Identifying elements

Identifying Elements

  • JJ

  • MR# 1234

  • Nov. 29, 2000

  • UAMS Endocrine Clinic

  • Dr. Debra Simmons


Chief complaint

Chief Complaint

  • CC: Routine follow up for type 1 diabetes


History

History

  • JJ is a 59 YO WF with type 1 diabetes for 22 years. She does not have any complaints or concerns today. She denies any significant changes since last visit.

  • She uses an insulin pump since 1995 and has no problems with the sites

  • She counts CHO and boluses 1 unit/15 gm CHO


Identifying elements

  • Her current basal rates of humalog

    • Midnight to 2 am 1.1 units/hr

    • 2 am to 8 am 0.6 units/hr

    • 8 am to 2 pm 0.7 units/hr

    • 2 pm to 6 pm 0.7 units/hr

    • 6 pm to midnight 1.1 units/hr


Identifying elements

  • SMBG records reviewed

    • Fasting 104-130

    • Lunch 113-140

    • Supper 92-140

    • Bedtime 130-149

  • Admits to occasional hypoglycemia 2-3 am, eats bedtime snack to prevent

  • HbA1c 8.4, prior 8.3


Identifying elements

  • Complications

    • mild background diabetic retinopathy first noted 5/00 better last appt 10/00

    • microalbuminuria 4/99 on zestril 2.5 mg

  • Hyperlipidemia

    • LDL 141, 145

    • started zocar 10 mg

    • LDL 96 on treatment

    • 11/00 TC 170 LDL 96 HDL 57, TG 87


Medications and allergies

Medications and Allergies

  • Humalog as above

  • zestril 2.5 mg/day

  • zocar 10 mg/d

  • Vit E, C, Calcium

  • No known allergies


Physical exam

Physical Exam

  • BP 103/61 P 80 WT 158.3

  • NAD

  • feet without lesions


Brief assessment plan

Brief Assessment/Plan

  • Type 1 diabetes for 22 years complicated by mild background retinopathy and microalbuminuria

    • HbA1c good

    • LDL cholesterol good on zocar

    • BP good

  • Doing well except need to add ASA

  • Routine fu in 3 months


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