Subjective:

Ms. H. is a 49 y/o woman here for f/u appt for management of Type 1 DM. Last clinic visit was 6 months ago at which time her A1C was 6.5 Pt. did not reach A1C goal on Metformin. Currently takes Mounjaro 5 mg. once weekly. Pt reports FSBS ranging between 70 and 100 daily. She denies polydipsia, polyphagia, and polyuria. Ms. H. reports she works a full-time job and often eats on the run but is trying to make more healthy food choices. History of hyperlipidemia, with last lab work showing LDL of 194. Other medications include Zoloft 50 mg qd, Folic Acid 2 mg qd, and Simvastatin 20 mg qd.

Objective:

Pleasant affect, alert and oriented x4, no complaints voiced, no acute distress noted. Vital Signs: BP 130/80, P 68, R 18, T 98.1. Repeat HgB A1C performed yesterday with result of 5.4, which is lower than the most recent A1C drawn six months ago. CBC within normal limits, CMP reflects the following: Glucose 78, creatinine 1 mg, potassium 4.5, all of which were elevated on previous lab results. Lipid panel this visit reflects LDL 125. All other labs remain WNL. Skin is warm, dry, and intact. No signs of compromised skin integrity. Diabetic foot assessment performed and was unremarkable.

Assessment:

This is a follow-up visit for continuing care of Type 1 Diabetes Mellitus. Pt. continues to have blood glucose levels per FSBS within normal limits and checks her levels twice daily. Hyperlipidemia and DM are well controlled with diet and medication as evidenced by lab work and patient report.

Plan:

Pt. Will continue meds as prescribed and daily FSBS. Repeat A1C and Lipid Panel in 6 months. Pt. to return to clinic with new onset of symptoms or concerns. Per pt.'s request, referral to nutritionist was given to assist with meal prep ideas within dietary restrictions for Diabetes and Hyperlipidemia.