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Routine Follow-Up for a 59-Year-Old Woman with Type 1 Diabetes and Complications

This report outlines the routine follow-up visit of a 59-year-old white female (JJ) with type 1 diabetes for 22 years. The patient reports no new complaints and has been using an insulin pump without issues. Her diabetes management includes careful carbohydrate counting and a review of blood glucose levels. HbA1c is stable at 8.4, with prior levels showing improvement. Mild background retinopathy and microalbuminuria are noted, with good management of LDL cholesterol. The plan includes adding ASA and scheduling follow-up in three months.

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Routine Follow-Up for a 59-Year-Old Woman with Type 1 Diabetes and Complications

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  1. Identifying Elements • JJ • MR# 1234 • Nov. 29, 2000 • UAMS Endocrine Clinic • Dr. Debra Simmons

  2. Chief Complaint • CC: Routine follow up for type 1 diabetes

  3. 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

  4. 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

  5. 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

  6. 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

  7. Medications and Allergies • Humalog as above • zestril 2.5 mg/day • zocar 10 mg/d • Vit E, C, Calcium • No known allergies

  8. Physical Exam • BP 103/61 P 80 WT 158.3 • NAD • feet without lesions

  9. 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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