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What Is An Uncontrolled Diabetic?

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A 48-year-old Man With Uncontrolled Diabetes

A 48-year-old white man who has had diabetes mellitus for 6 years presents to the outpatient clinic because his blood sugar levels have been rising for the past week. Both his parents had diabetes, and at the time of his diagnosis he weighed 278 pounds, all of which supported a diagnosis of type 2 diabetes mellitus. His disease was initially managed with diet, exercise, and metformin (Glucophage). Four months later, with weight loss and exercise, his blood sugar levels were consistently under 100 mg/dL, and metformin was discontinued. He did well until 1 week ago, when he noted polyuria, polydipsia, and rising fingerstick glucose values, higher than 200 mg/dL. He has been eating well, with no nausea, vomiting, or symptoms of dehydration. He denies having any fever, chills, cough, nasal congestion, chest pain, abdominal pain, or dysuria. In addition to his type 2 diabetes, he has hypertension, for which he takes losartan (Cozaar); hyperlipidemia, for which he takes atorvastatin (Lipitor); and gout, for which he takes allopurinol (Zyloprim). His blood pressure is 148/70 mm Hg, pulse 100, and weight 273 pounds, and he is afebrile. On examination, his skin, head, eyes, ears, nose, thro Continue reading >>

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Popular Questions

  1. vanessa.falkoff

    Hi,
    Does anyone have a clinical definition of "Uncontrolled Diabetes" they
    could share? What would you do if the physician checked Uncontrolled DM
    type II on a query and the coder felt that the DM was not "uncontrolled"
    per the rest of the chart?
    Thanks in advance for any wisdom you are able to share
    Vanessa Falkoff, RN
    Clinical Documentation Coordinator
    University Medical Center of Southern Nevada
    office (702) 383-7322
    cell (702) 204-0054
    [email protected]

  2. Unknown

    I go by an article I read from ACDIS. I cannot remember the name but the parameters were:
    HgbA1C above 7 and multiple blood glucose greater than 250.
    Charlene

  3. ssalinas

    I would be really interested in other's response to the second question
    in email below -expanding the question to any diagnosis i.e. sepsis,
    respiratory failure, etc. listed by physician throughout a chart but
    lacking clinical indicators.
    What would you do if the physician checked Uncontrolled DM
    type II on a query and the coder felt that the DM was not "uncontrolled"
    per the rest of the chart?
    Sharon

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