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Identifying Elements

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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  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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