Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Routine follow-up visit for type 1 diabetes management
Evaluation of new symptoms (hyperglycemia, hypoglycemia, other)
Medication adjustment or pump management concerns
Sick day management guidance
II. History of Present Illness:
Duration of type 1 diabetes diagnosis
Current symptoms (frequency of urination, increased thirst, fatigue, blurry vision)
Blood sugar control (self-monitoring of blood glucose – SMBG results)
Recent illnesses or infections (can affect blood sugar control)
Insulin pump use (if applicable) – any issues with pump function or site changes
III. Past Medical History:
Diabetes complications (retinopathy, neuropathy, nephropathy) – if present
Other medical conditions
IV. Family History:
Diabetes in first-degree relatives
V. Social History:
Smoking, alcohol, or illicit drug use
Dietary habits and adherence
Exercise habits
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Weight assessment (looking for unintentional weight loss or gain)
Feet exam (assess for neuropathy)
VII. Laboratory Studies (consider as appropriate):
Hemoglobin A1c (HbA1c): Assesses long-term glycemic control (typically every 3-6 months).
Fasting blood glucose: Monitors current blood sugar levels (may be checked more frequently).
Urine ketones: May be checked if blood sugar levels are high.
Microalbuminuria testing: Early detection of diabetic nephropathy (may be done annually).
Lipid panel: Assesses cardiovascular risk (may be done annually).
Thyroid function tests (TSH): Abnormal thyroid function can affect blood sugar control.
VIII. Assessment:
Glycemic control based on SMBG results, HbA1c, and any other blood sugar checks.
Adherence to insulin regimen and carbohydrate counting (if applicable).
Risk of diabetes complications based on duration of diabetes, glycemic control, and physical exam findings.
IX. Plan:
Management plan may include:
Dietary modifications: Registered dietitian consultation for a personalized diabetic meal plan.
Exercise recommendations: Regular physical activity tailored to individual needs.
Medication adjustments: Insulin dose adjustments based on blood sugar monitoring may be needed.
Self-monitoring of blood glucose (SMBG): Review and adjust SMBG schedule as needed.
Insulin pump management education: For patients using pumps, address any concerns about pump settings or troubleshooting.
Sick day management plan: Provide specific instructions for managing blood sugar during illness.
Referral to a diabetes educator: For additional support with diabetes self-management.
Address any risk factors for complications:
Eye exams (annual dilated eye exam for diabetic retinopathy screening).
Foot care education and regular podiatry visits.
X. Prognosis:
Discuss the importance of ongoing diabetes management to maintain good glycemic control and reduce the risk of complications.
Early diagnosis and good management can help patients with type 1 diabetes live long and healthy lives.
XI. Notes:
Address the patient’s concerns and answer questions about diabetes management.
Provide emotional support and encouragement.
Offer resources and referrals for diabetes education and support groups.
XII. Resources:
Consider providing patient education materials on type 1 diabetes from reputable sources (e.g., American Diabetes Association (ADA), Juvenile Diabetes Research Foundation (JDRF)).