You are on page 1of 4
You are a physician OR a nurse at a family medical practice. Ms Tabitha Taborlin is a 45-year- old patient at your practice. Office: ies ett Yipee IsAecl EES Ver onXSle tS OME LIEY Patient Details Name: Tabitha Taborlin (Ms) Marital status: Single Next of kin: Gregory Taborlin (69, father) Date seen: 08 April, 2018 Diagnosis: Type 1 diabetes mellitus Past medical history: | Essential hypertension Type 1 diabetes mellitus (non-compliant with insulin regimen) Multiple episodes of diabetic ketoacidosis (DKA) Scanned with Cam Social background: Schoolteacher, lives alone in apartment Does not exercise, BMI 18.2 (underweight - 48kg) Smokes moderately (2 cigs daily) Medical background: Long history of Type 1 diabetes (since 7 y.o.) and noncompliance with insulin regimen. On 45 units Lantus nightly and preprandial correctional scale Humalog with 12 unit nutritional baseline. 02/04/2018: admitted DKA (glucose 530 mmo/L) Appointment today: \V fluids and insulin administered. Discharge stable - HbAIc. Doing well since discharge. Still not using insulin. Has insulin available. Not following recommended diet. Discussed diabetes education, necessity of glucose testing, insulin administration, smoking cessation education. Discussed microvascular/macrovascular complications of diabetes. vvuaimicu wiur vam Plan: Discharge today - provide educational pamphlets and refills for Lantus and Humalog. Referral to endocrine specialist for stricter glycemic control and possible insulin pump. Follow-up in 1 month. Scanned with Cam Using the information given in the case notes, write a referral letter to Dr. Sharon Farquad, Endocrinologist at Endocrine Specialists and Associates, 115 Burke St. Omaha. Scanned with Cam

You might also like