DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Uncontrolled diabetes.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who came here to the emergency department initially with abdominal pain. He was admitted for abdominal pain workup as well as bad COPD. The patient says he has had diabetes for about 12 years. He takes insulin, he takes Actos, and he takes Glucophage in the house. He says at home his sugars run mostly close to 100. He does not have any problems with polyuria, polydipsia or nocturia. He does have problems with numbness and tingling in the legs. He does have problems with slow healing of wounds. He denies bruising. No problems with diarrhea. No constipation. No nausea. No vomiting. No problem with heartburn. No abdominal cramps. At this point, his abdominal pain is gone. He does have shortness of breath. He did have some cough. He felt fatigued and tired. He also felt chills when he came here. No other complaints for the patient upon review of systems.
PAST MEDICAL HISTORY: Positive for coronary artery disease, diabetes, diverticulitis, status post stent placement.
MEDICATIONS: Medications on the chart have been reviewed along with the dosage.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Positive for diabetes.
SOCIAL HISTORY: The patient used to be a past smoker but does not smoke anymore. There is no history of alcohol abuse.
PHYSICAL EXAMINATION: The patient is currently lying in bed and appears to be a little short of breath. Height is listed as 6 feet 2 inches. Weight is 268 pounds. He has 2+ peripheral edema. Positive pallor. No cyanosis. No raised JVD. No neck or axillary lymphadenopathy. No jaundice. JVD is raised to the lower third of the neck. Oropharynx is clear. Ears are normal. Eyes show conjunctivae are clear. Pupils are equal and reactive. Movement of the eyes is normal. Neck is supple and nontender. No masses are felt in the neck. Lungs revealed air movement in both lungs. There is prolonged respiration. No wheezing, no crackles are heard. Heart reveals normal first and second heart sound. No murmurs are heard. No carotid or abdominal bruits heard. Abdomen is soft and nontender. No masses are felt. It is distended from obesity. External genitals are male. Rectal per primary care. Joints show movement is normal; they are nontender to move. Feet show dorsalis pedis is at 2+. No ulcers. They are dry. Skin is dry. There is no rash. There are no bruises except at IV site. Neurological exam reveals he is awake, alert and oriented to time, place and person. Normal tone. Moves all his limbs. Cranials are normal. The sensory exam shows touch is impaired over the lower part of the legs.
LABORATORY DATA: The patient’s labs show sodium 140, potassium 4, chloride 106, bicarbonate 26, BUN 42, creatinine 1.7, glucose 146, theophylline 7.4. White cell count is 10, hemoglobin 10.2, platelets 184. His Accu-Cheks have been ranging 300 to 400, and right now, its reading is high on the Accu-Chek meter. Obviously, the Solu-Medrol that he is getting is increasing the sugars drastically.
ASSESSMENT:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease.
PLAN: For now, we will treat him with the NPH dose at bedtime and sliding scale breakfast, lunch and dinner. We will adjust the insulin as the steroids are weaned off. We will try to keep the sugars below 150, preferably close to 100. We will get a hemoglobin A1c in the morning.
