6-month diabetes follow-up
María Altagracia Fernández
62female·DOB 1963-04-15·MRN MS-000142
🇩🇴 Dominican Republic·prefers Spanish·MassHealth
“Vengo a la cita de seguimiento de la diabetes.”Review the chart below, then begin the encounter. The patient will share some information on her own and hold back the rest; your job is to ask.
Begin consultation →HPI
Nurse intake
62F with T2DM × 8 years on metformin and glipizide presents for routine follow-up. Reports feeling "mostly OK" but endorses occasional morning shakiness that resolves with food. States she is adherent to her medications. Last A1c 3 months ago was 8.2%. No new symptoms reported at intake.
Past medical history
Problem list
- Type 2 diabetes mellitus (dx 2017)
- Hypertension
- Hyperlipidemia
- Overweight (BMI 29)
Rx
Active medications
- Metformin1000 mg · twice daily
- Glipizide5 mg · once daily in the morning
- Lisinopril10 mg · once daily
- Atorvastatin20 mg · once daily at bedtime
Labs
3 months ago
- HbA1c8.2%HRef <7.0% (goal)
- Fasting glucose165 mg/dLHRef 70–100
- LDL110 mg/dLHRef <100
- HDL42 mg/dLRef >50
- Triglycerides168 mg/dLHRef <150
- eGFR82 mL/min/1.73m²Ref >60
- UACR22 mg/gRef <30
- TSH2.1 mIU/LRef 0.4–4.5
| Test | Value | Reference |
|---|---|---|
| HbA1c | 8.2%H | <7.0% (goal) |
| Fasting glucose | 165 mg/dLH | 70–100 |
| LDL | 110 mg/dLH | <100 |
| HDL | 42 mg/dL | >50 |
| Triglycerides | 168 mg/dLH | <150 |
| eGFR | 82 mL/min/1.73m² | >60 |
| UACR | 22 mg/g | <30 |
| TSH | 2.1 mIU/L | 0.4–4.5 |
Social
History
Lives with adult daughter in Dorchester. Works as a home health aide, 12-hour shifts. Never smoker. No alcohol. Immigrated from Santo Domingo 22 years ago.
Family
History
Mother: T2DM, died age 68 from "complications." Father: hypertension, stroke. Two sisters with T2DM.
Screenings
Status
- Diabetic foot examLast done 14 months ago · Overdue
- Retinal screeningLast done 18 months ago · Overdue