Chapter 11: The Endocrine System | Ralph Dixon's Chart Note


Patient Name: Dixon, Ralph
ID Number: 87457RD
Examination Date: August 4, 20xx

This is a diabetic, 20-year-old male patient who requests medical clearance to renew his driver's license.

The patient states that he checks his glucose levels twice daily, which run in the 100–200 range. Further questioning reveals intermittent glucose levels in the 275–300 range. He states that he had hyperglycemia-like symptoms of polydipsia and polyuria twice last month. He had hypoglycemic symptoms consisting of weakness and inability to concentrate once in the last month. Vital signs are normal. Eye exam is negative. Examination of the feet shows some slight callous formation on the heels bilaterally (pertaining to both sides) with some cracked skin. No evidence of fungal infection or ulceration. Examination of feet normal and symmetric.

Type 1 diabetes
with suboptimal control.

The importance of good glycemic control was discussed in detail with the patient. He is scheduled to see a diabetic nutritionist next week and was given information about local diabetic support groups. Return for a follow-up in one month or sooner if needed.

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