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