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[IP] Give Them a Writen List of Your Medicines ER LETTER

Pumpers and Friends,

I have been using a letter like this from the time I start on a pump. First
one my doctor wrote up for me then later there was one in ADA mag. , I
worked them together to get this one. I clean it up abit ,  gave a sample of
things to add. I hope it helps :-) I update when needed, use it to show when
I going in hopsital or doctor office   save a lot of time with check in.

                            REMEMBER TO SMILE AND BE HAPPY


        NAME             uses and insulin pump to meet his needs for insulin
because of Type 1 Diabetes Mellitus. The insulin pump delivers insulin in a
way that more closely mimics release by the normally functioning pancreas
than does one or two injections a day.   NAME      's pump matches his
insulin needs as determined by history, blood glucose levels, food to be
eaten, and expected exercise. Normally,   NAME           checks his blood
glucose levels with a home glucose meter and adjusts insulin deliver to
maintain as near normal blood glucose levels as possible.
Insulin is given two ways via the insulin pump:
Basal Rate: a continuous insulin infusion, the amount of insulin the patient
requires to maintain a normal metabolic state when not eating.
Bolus: the insulin infused with food intake. NAME     has been taught to
adjust this depending on blood glucose levels, food to be eaten, and
expected exercise.
Leave pump in place. Continue basal rate, even if   NAME       is unable to
eat.  NAME    is infusing NovoLog Human Insulin Analog U100.
His set basal rates are as follows:
23:59 to 04:00  units per hour        12:00 to 13:00  units per hour
04:00 to 06:00  units per hour        13:00 to 18:00  units per hour
06:00 to 08:00  units per hour        18:00 to 19:00  units per hour   TOTAL
08:00 to 11:00  units per hour        19:00 to 20:00  units per hour
units per month to fill tubing
11:00 to 12:00  units per hour        20:00 to 24:00  units per hour
basal  bolus =/-9% =   Units

Allow     NAME      to test his own blood glucose levels with a glucose
meter and adjust bolus as he has been taught. Bolus will be adjusted as
1 unit insulin to     grams of carbohydrate High blood sugar bolus 1 unit
drops     mg/dl
<70 mg/dl Subtract 1 unit from bolus
70 to 100 mg/dl No Adjustment
Every     mg/dl above     mg/dl Add     unit
Every     mg/dl above     md/dl Add     units

If     NAME     need to bolus to counteract a high blood glucose condition,
NAME     will check his blood glucose levels every two hours until it
returns to normal plus 4 hours
If     NAME     is ketotic, it probably means that his pump is not
functioning properly or is blocked or been removed. Have     NAME     do a
site and pump check, if problem is found he will do a change as he has been
taught. Have     NAME     check his blood glucose every 2 hours and bolus as
As noted previously, continue the basal rates if     NAME     is unable to
eat. Blood glucose levels should be checked, by     NAME     if possible,
every 3 hours, and boluses adjusted as above.

*DO NOT DISCONTINUE PUMP without giving insulin by another means. Otherwise,
NAME     will have no insulin and will develop ketoacidosis. If pump is
discontinued,     NAME     will immediately need Regular Insulin.
*Blood glucose measurements used to determine bolus adjustments must be
current. It's much safer to make adjustments from     NAME's reading than to
wait for blood glucose results from the lab. NAME     has been trained to do
this, and routinely does 15 times a day, so it is second nature to him.
*The exceptions to this rule are if there is a doubt about     NAME's
ability to perform intelligently or if there is concern about the accuracy
of the glucose meter.
*If     NAME     has an infection or is under stress, blood glucose levels
may go up. Continuing the basal dose and covering high blood glucose levels
with boluses is a reasonably safe way of doing things.
NAME's Medical Problems:
Type 1 Diabetes Mellitus, treated by external pump delivering continuous
subcutaneous insulin infusion.
Gastrointestinal autonomic neuropathy, with severe Gastroparesis and bowel
Diabetic Peripheral Neuropathy.
Diabetic Retinopathy.
Diabetic Nephropathy
Frequent and severe hypoglycemia and the induction of seizure activity, this
being precipitated in large part by the erratic and unpredictable absorption
of foodstuffs induced by the gastrointestinal motility disorder.
Loss of Left Eye.
Name:                         ADDRESS
PUMP:Minimed sn#
Omaha, NE 68105-2315
Health Insurance Info:
Birthday                                birth place         mother name
Endocrinologist:                             Clinic:###-###-####
Endo:###-###-### Pager:###-###-##
PCP:  Clinic:
Dermatology:                                     Podiatry:

Tonsils & Adenoids (1968)
Nose DS at (1976)
Diabetes Mellitus Type 1 (5-20-77)
Severe Gastroparesis at (1980)
Started on Insulin Pump 10-7-1980
Hands: Carpal Tunnel in 1991 RIGHT - 1992 LEFT
Trigger Fingers:
Stopped working April 10, 1998 on Total Disability Social Security.
Pick-lines since 1987 for Erythromycin IV on/off since.
Port left side placed in 1998 for TPN
Major infections 5 times in 1998
J-tube placed 1998
Drugs & Meds:                         (SAMPLE OF THINGS) Drug    dose
NovoLog Insulin
Minimed 508 insulin pump S
Infusion Set (Silhouette or Quickset) 1 every 3 days SHIP
Batteries as needed SHIP
Cartridge 1 every 3 days SHIP
Skin Preparation: SHIP
Skin Prep as needed
I.V. Prep as needed SHIPN
Unsolve as needed SHIPN
Hibiclens Soap as needed SHI
Transparent Dressing as needed SHIN
Glucometer Elite Meter & Strips 14 AVE daily SAN
Glucagon ER Kit 1mg as needed SN
Acetaminophen 500mg as needed HUS
Enteric Coated Aspirin 325mg 1 daily HUS
Vitamin C 500I.U. 1 - 3 x daily HUS
Vitamin E 400I.U. 1 - 3 x daily HUS
Centrum Vitamin 1 daily HUS
Flonase 0.05% 1 - 2 x daily HUS
Allegra 180mg 1 daily HS
Pancrease Capsules as needed Ave 12 DISE
Metronidazole 500mg 1 - 3 x daily DIE
Doxycycline 100mg 1 - 2 x daily DIE
Lac_Hydrin 12% lotion 400gm 1 daily PAAN

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