DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: The patient states that she returns to the diabetes clinic for routine followup. She denies any interval problems, except with continued musculoskeletal joint pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who is followed in the diabetes clinic for type 2 diabetes that was diagnosed 15 years ago and has been insulin-requiring since the last year. Complications include retinopathy, nephropathy with chronic renal insufficiency and microalbuminuria and atherosclerotic cardiovascular disease. The patient was on Actos in the past and this was discontinued secondary to patient concerns about possible adverse effects two years ago.
She also has a history of hypertension, hyperlipidemia, and medically significant obesity. She does have a history of a nontoxic multinodular goiter and has undergone a total thyroidectomy 15 years ago. She does have postsurgical hypothyroidism. The patient was last seen in the diabetes clinic four months ago. She returns now for routine followup.
She is currently on the combination of glyburide at 10 mg b.i.d. and Levemir insulin at 16 units q.p.m. She is checking blood sugars with OneTouch Ultra meter in the mornings. Her average blood sugar is 150. Her range is 114-252. Her diabetes review of systems is outlined in the patient’s review of systems update.
MEDICATIONS: Amlodipine 7.5 mg daily, aspirin 81 mg daily, atenolol 100 mg b.i.d., atorvastatin 80 mg daily, Citracal, clopidogrel, Colcrys, desoximetasone ointment, ferrous sulfate, fish oil b.i.d., furosemide 20 mg daily, glyburide 10 mg b.i.d., isosorbide mononitrate ER 90 mg daily, ketoconazole shampoo, Levemir insulin 16 units q.p.m., Levoxyl 150 mcg daily, losartan 100 mg daily, naproxen, Nitrostat, omeprazole, and vitamin D.
ALLERGIES: Multiple medication allergies, listed in chart.
REVIEW OF SYSTEMS: A 15-point review of systems was done and is recorded in the patient’s clinic chart.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient’s height is 4 feet 8 inches, weight is 128 pounds, blood pressure is 110/60, and her heart rate is 64 and regular.
GENERAL: Well-developed, well-nourished female, in no acute distress.
SKIN: Scalp hair is normal. Minimal hirsutism is noted. No acanthosis nigricans. No vitiligo. The patient’s abdominal insulin injection sites appear normal without evidence of lipohypertrophy or lipoatrophy. There is some bruising at these sites.
HEENT: PERRL. Arcus corneae is present. No xanthelasmas. The fundi are very difficult to visualize. The oropharynx shows moist mucous membranes, and dentures are present.
NECK: No cervical or supraclavicular lymph nodes. A well-healed thyroidectomy scar is noted. We are unable to appreciate any palpable thyroid tissue. The carotids are 1+ without audible bruits.
LUNGS: Clear to auscultation.
HEART: There is a normal S1 and S2 without audible murmurs, rubs or gallops. The peripheral pulses are 1+.
ABDOMEN: Soft, obese, nontender, with normal bowel sounds.
BACK: No spinal or CVA tenderness. Minimal kyphoscoliosis is noted.
EXTREMITIES: There is 1+ lower extremity edema with puffiness around the bilateral ankles. The feet are benign with appropriate nail care; they are dry. There is some callus formation at pressure points. The nails are slightly thickened and long.
NEUROLOGICAL: Sensory examination reveals normal position, vibration, and 5.07 monofilament testing. The gait is normal.
PSYCHIATRIC: There is normal mood and affect.
LABORATORY DATA: The blood sugar in the clinic today was 98. Hemoglobin A1c today was 7.4%. The patient’s prior laboratory studies were done four months ago. This showed a creatinine of 1.62 with a GFR of 30. A prior LDL was 52. The urine microalbumin was 64 mcg per mg of creatinine last year. The TSH was 1.52 last year.
ASSESSMENT AND PLAN:
1. Diabetes mellitus type 2, insulin requiring, uncontrolled and complicated by retinopathy, nephropathy with chronic renal insufficiency and microalbuminuria and atherosclerotic cardiovascular disease. The patient’s hemoglobin A1c today was elevated at 7.4%. The goal is to keep this below 7%. This is higher than her prior values. She is currently checking blood sugars with OneTouch UltraMini meter once daily. Her numbers are outlined above. Overall, blood sugars are higher. We will again make a small increase in her Levemir to 17 units daily. She will continue the glyburide at 10 mg b.i.d. We do want to avoid low blood sugars given her age and cardiovascular disease. She has been instructed in the proper treatment of hypoglycemia and is able to repeat this. We have encouraged her to try to continue with a healthy diet and as much activity as she is able to do. She is quite limited by her musculoskeletal pain. She does understand the importance of tight blood sugar control in preventing progression of her existing complications or the onset of new complications. We will plan to see her back for routine followup in three months. She will call in the interim if she has any problems with hypoglycemia or worsening hyperglycemia.
2. Hypertension. Blood pressure is below goal today. The goal is to keep this below 130/80. She continues on the combination of atenolol, furosemide, isosorbide CR, and losartan. She does understand the importance of tight blood pressure control in preventing progression of her existing complications or the onset of new complications.
3. Hyperlipidemia. The patient’s last LDL is outlined above. The goal is to keep her LDL below 70 given her cardiovascular disease. She continues on Lipitor. She does take aspirin and Plavix. She also takes fish oil. She does understand the importance of tight lipid control in preventing further vascular disease.
4. Medically significant obesity. The patient is trying to eat healthier and to reduce portions for weight loss. She does note that this helps with regard to blood sugars, blood pressure, and lipid control. It also helps with regard to her musculoskeletal pain.
