Clinical note section (GENHX): The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus.  Her last visit was approximately 4 months ago.  Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks.  She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial.  She is not reporting polyuria, polydipsia or polyphagia.  She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well.  She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity.  She is keeping up with all her other appointments and has recently had a good eye examination.  She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.

Dialogue:
Doctor: Hello, how are you doing? 
Patient: Hanging in there. Thank you. 
Doctor: So, you just celebrated your birthday. How was it? How is it feeling to be close to forties? 
Patient: I just turned thirty nine. I would say older the wiser. 
Doctor: That's true. Okay, so you are here for your follow up. Let's see, you have type one diabetes mellitus, right?
Patient: Yeah, that's right. Last time I was here almost four months ago. 
Doctor: How are you doing since last visit? 
Patient: I have been good. My sugar has been under the range. Unfortunately, my pump was having some issues for the last two weeks. 
Doctor: Oh no. What happened? 
Patient: I don't know. I tried to get it fixed but nothing worked out, so I had to buy a new one and then being old kind of hit me. You know, I was not able to set it up. I was stuck on the pump settings and was having a lot of difficulties. With all this going on, I was not able to control my sugar over past two weeks and there might have been like some ups and downs in my levels which I could not notice or register. 
Doctor: During this, did you notice anything like, did you lose your consciousness? Did you faint? 
Patient: Nope. 
Doctor: How about sweating, tired, or lightheadedness and or change in vision? Or any kind of confusion in mind? 
Patient: Nope, nothing like that. 
Doctor: That's good, so there hasn't been any hypoglycemic event. I mean, your sugar didn't drop down. 
Patient: Oh yeah, I didn't think so. 
Doctor: Okay, let's see how about hyperglycemia? Did you think your sugar levels went high? 
Patient: I think, there was some difficulties with both the fasting and after meals, but I'm not sure. 
Doctor: Are you urinating more than normal? 
Patient: Nope. 
Doctor: Are you eating more than normal or drinking more than normal? Are you feeling thirsty or not? 
Patient: Not that I noticed. 
Doctor: Are you exercising? 
Patient: Oh, I tried but didn't work out so not exercising at this point, but I follow a fixed diet. But you know, being a mother is in itself full of physical activities. I mean, I have twins and also a young baby who keep me busy. 
Doctor: Are you working? 
Patient: Yes, I'm working as a medical coder. It is a full time job and you just keep busy. Sometimes I don't even realize that I missed my meal, but I do keep some snacks with me I'm just eating while completing my work. It might not be the best case scenario, but I don't get any time for any kind of physical activities. 
Doctor: Are you visiting your physician regularly? 
Patient: Of course. I'm very regular. I keep a track of my annual visits. My annual examinations. I take my dental visits after every six months, and I recently had my eye examination done. All was good. 
Patient: This reminded me that we did a lab last time I came. How did it go? 
Doctor: Oh yes, thank you for reminding me. Let's see how your numbers are. Your cholesterol is still high. Your L D L recorded one hundred and forty four.