You are a physician OR

.a nurse at a family medical practice. Ms Tabitha Taborlin is a 45-yearold patient at your practice
Office: First Family Primary Care, 3959 Abalone Lane, Omaha

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)Social background: Schoolteacher, lives alone in
apartment
Does not exercise, BMI
)underweight - 48kg( 18.2
Smokes moderately (2 cigs daily)
Medical background: Long history of Type 1 diabetes (since 7 y.o.) and
.noncompliance with insulin regimen
On
units 45
Lantus nightly and preprandial correctional scale Humalog with
.unit nutritional baseline 12
admitted DKA (glucose 530 mmo/L) :02/04/2018
.IV fluids and insulin administered. Discharge stable - HbA1c
.Appointment today: 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

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

Medical Writing Task 3

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