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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

- 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

- 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

- 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

- 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

- Humalog as above
- zestril 2.5 mg/day
- zocar 10 mg/d
- Vit E, C, Calcium
- No known allergies

Physical Exam

- BP 103/61 P 80 WT 158.3
- NAD
- feet without lesions

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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