Endocrinology Medical Transcription Transcribed Consultation Sample Reports


DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Evaluation and diabetes management.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man with a history of coronary artery disease, aortic stenosis and CABG, who was admitted with increasing shortness of breath and diagnosed with CHF. The patient has had diabetes for (X) years and was originally on oral medications, but for a number of years now, he has been on insulin. His current regimen is 70/30 insulin, 30 units twice a day. He uses insulin vial and sometimes does not take his medications.

The patient denies significant hypoglycemia and checks his blood sugar three times a day with most readings between 100 and 300. He sees an ophthalmologist for eye care and apparently has had laser therapy for retinopathy. Has renal insufficiency and elevated BUN and creatinine and currently undergoing evaluation by Dr. Doe. Has a history of peripheral neuropathy with amputation of his fifth right digit and skin grafting. He does not know what his most recent A1c is and consultation was requested for diabetes management.

CURRENT MEDICATIONS:  Amiodarone, aspirin 325 daily, Zithromax, Plavix, guaifenesin, codeine, Lexapro 10 mg daily, Combivent 2 puffs q.i.d. p.r.n., Advair 1 puff b.i.d., Lasix 80 mg b.i.d., insulin 70/30 b.i.d., metoprolol 50 mg b.i.d.

ALLERGIES:  NO KNOWN ALLERGIES.

PAST SURGICAL HISTORY:  CABG (X) years ago and amputation of his fifth right toe with skin grafting.

SOCIAL HISTORY:  The patient is a former smoker. Does not drink alcohol.

FAMILY HISTORY:  Negative for diabetes.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  He states he has gained a lot of weight recently perhaps due to fluid retention.  HEENT:  Follows with Ophthalmology.  CARDIOVASCULAR:  History of CABG and also aortic stenosis.  RESPIRATORY:  Some dyspnea.  GASTROINTESTINAL:  Denies constipation, diarrhea or liver disease.  GENITOURINARY:  No history of kidney stones or infection.  MUSCULOSKELETAL:  Denies fractures or joint pains.  Review of systems otherwise unremarkable.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a pleasant, cooperative man.
VITAL SIGNS:  Blood pressure 102/46, temperature 98.5, pulse 62 and regular, respirations 20.
HEENT:  Head is normocephalic. External ears unremarkable. Conjunctivae clear. Pupils equal and reactive to light. Dentition is poor but there are no intraoral lesions.
NECK:  Supple with no thyroid masses.
CHEST:  Symmetrical. Healed midline surgical scar.
LUNGS:  Clear to percussion, but diffuse bronchospasm bilaterally with prolonged expiration.
HEART:  Heart sounds distant, but appears in regular sinus rhythm, difficult to appreciate murmurs.
ABDOMEN:  Healed surgical scars. No masses or tenderness appreciated.
GENITAL/RECTAL:  Deferred.
EXTREMITIES:  No clubbing, cyanosis or edema. He has deformity in his right foot from amputation of his fifth toe and fifth metatarsal and skin grafting of this area. No edema at this time.
SKIN:  Clear without lesions.
LYMPHS:  There is no cervical or axillary lymphadenopathy.
NEUROLOGIC:  Cranial nerves II through XII are grossly intact. Proprioception and light touch normal.

LABORATORY DATA:  WBC 15,500, hemoglobin 10.8, hematocrit 31.4. Had absolute increase in neutrophils. Creatinine 2.4, BUN 50. CK 664, CK-MB 6.2, troponin I 0.64. Cholesterol 196, triglycerides 114, HDL 40, LDL 136. No chest x-ray is available, recent A1c or BNP.

ASSESSMENT: 
1.  Diabetes mellitus type 2. Fair control on 70/30 insulin, 30 units b.i.d. but no recent A1c test. Diabetic complications with peripheral retinopathy with laser therapy, renal insufficiency and peripheral neuropathy status post amputation of fifth right toe and skin grafting.
2.  Dyspnea. Possible pneumonia and/or congestive heart failure, but no chest x-ray or BNP available.
3.  Coronary artery disease, status post coronary artery bypass grafting.
4.  Hypertension.
5.  Dyslipidemia.

PLAN:
1.  We will continue 70/30 insulin 30 units b.i.d.
2.  Check hemoglobin A1c.
3.  We will adjust medications as appropriate.



DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Evaluation and diabetes management.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman with a history of diabetes since (XXXX), when she presented with an acute illness and was hospitalized and started on insulin. She has remained on insulin ever since and currently is on Lantus 40 units at night and NovoLog 7 units before meals. Her diabetes has been complicated by ESRD, on dialysis for (X) years, followed by Dr. Doe.

The patient has proliferative retinopathy, followed by Dr. Jane Doe, and has peripheral neuropathy with prior amputation of her left big toe and follows with Podiatry, with orthopedic shoes having been recently ordered for her. The patient was admitted on MM/DD/YYYY because of cellulitis involving her right leg. She was hospitalized previously in October, apparently for a similar condition and also had a blood clot at that time. She checks her blood sugars three to four times a day at home and has occasional hypoglycemic episode. Consultation was requested because of erratic blood sugars over the last couple of days. 

CURRENT MEDICATIONS:  
1. Cozaar 100 mg daily.
2.   Metoprolol 100 mg b.i.d.
3.   Protonix 40 mg daily for dyspepsia.
4.   Lantus 40 units at bedtime.
5.   Regular insulin high dose sliding scale before meals.
6.   Crestor 10 mg daily.
7.   Procrit Tuesday, Thursday, and Saturday.
8.   Morphine p.r.n. for pain.
9.   Tylox p.r.n. for pain.
10. Neurontin 300 mg t.i.d.
11. Zemplar.
12. Tramadol p.r.n.
13. Bactrim b.i.d.
14. Vancomycin Monday, Wednesday and Saturday.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient smokes a pack per day. She does not drink alcohol.

FAMILY HISTORY:  Negative for diabetes. 

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  Currently without fever or chills.  HEENT:  She has some visual impairment, follows with Dr. Doe for her proliferative retinopathy.  CARDIOVASCULAR:  She has a history of CHF and on medication for hypertension and dyslipidemia.  PULMONARY:  Denies cough or shortness of breath.  GASTROINTESTINAL:  No diarrhea, constipation or liver disease.  MUSCULOSKELETAL:  Denies fractures.  SKIN:  She has had recurrent episodes of cellulitis.  NEUROLOGIC:  She has peripheral neuropathy with loss of sensation below the knees. No seizures or blackout spells.  PSYCHIATRIC:  She is not on any medication.

PHYSICAL EXAMINATION:  
VITAL SIGNS:  Blood pressure 115/77, pulse 68, temperature 98.5.
HEENT:  Head was normocephalic. External ears were unremarkable. Lid and conjunctivae clear with mild pallor noted. Dentition is poor, but there are no intraoral lesions.
NECK:  Supple with no thyroid nodules. No carotid bruits.
CHEST:  Symmetrical.
BREASTS:  Not examined.
LUNGS:  Clear to P and A.
HEART:  Regular sinus rhythm, grade 2/6 SEM.
ABDOMEN:  Soft and nontender. No masses or organomegaly. 
GENITAL/RECTAL:  Exam deferred.
EXTREMITIES:  Some erythema in her right leg, although there is no warmth or tenderness. She has marked callus formation and possibly a hemorrhage and/or callus on her right heel. 
SKIN:  Multiple lesions consistent with diabetic dermopathy. 
LYMPHATIC:  No cervical or axillary lymphadenopathy.
NEUROLOGICAL:  Cranial nerves II through XII grossly intact. Deep tendon reflexes are 1 to 2+. Loss in light touch below the knees.
PSYCHIATRIC:  The patient is alert and oriented with good recall for recent and remote events.

LABORATORY DATA:  Laboratory studies are reviewed, including BUN ranging from 13 to 54 and creatinine ranging from 3.2 to 5.6. Hemoglobin 11.6, hematocrit 35.6. No recent A1c, although this was 8.2 on MM/DD/YYYY. Blood glucose levels reviewed with results ranging from 64 to 325.

ASSESSMENT:  
1.  Diabetes mellitus, probably type 1 based on her history.  Complications include end-stage renal disease, on dialysis for (X) years, proliferative retinopathy and peripheral neuropathy.
2.  Cellulitis of the right leg. 
3.  Dyslipidemia.
4.  Hypertension.
5.  Chronic smoking.


RECOMMENDATIONS:
1.  We will check hemoglobin A1c.
2.  We will adjust insulin to achieve better control.
3.  Diabetes education to review insulin injection technique, glucose monitoring and diabetic complications.
4.  I have discussed smoking cessation with her at length and every effort should be made to assist this patient woman with smoking cessation.

Thank you very much for this consultation.





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