Type 2 diabetes, uncontrolled on insulin

Clinical note

Type 2 diabetes, uncontrolled on insulin

CC: Diabetes follow-up, established patient.
HPI: 61 y/o with type 2 diabetes, uncontrolled, A1c 9.4 last month, on insulin glargine 30 units nightly plus metformin. Fasting glucose 190-240. No hypoglycemia. Denies neuropathic symptoms.
Exam: BMI 33, feet without lesions, sensation intact.
A/P: Diabetes with hyperglycemia. Increase insulin glargine to 36 units, titration instructions given, RTC 4 weeks, CDE referral. Long-term insulin use documented.
MDM: moderate.