DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Management of uncontrolled type 2 diabetes mellitus.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old pleasant Hispanic male, nursing home resident, with no history of tobacco or ETOH use in the recent past, as per the chart, and history of type 2 diabetes mellitus, on Lantus, unknown dose, and regular insulin on a sliding scale basis at the nursing home. The patient has a history of cardiac arrest with history of anoxic encephalopathy, history of respiratory failure, status post tracheostomy, and history of CAD. The patient also has a history of multiple UTIs, history of sacral decubitus ulcer, history of atrial fibrillation, history of COPD, history of vancomycin-resistant enterococci, history of MRSA, history of C. diff positive, and history of ulcerative colitis. Endocrine consult was called for management of uncontrolled diabetes.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: None.
FAMILY HISTORY: Unknown.
REVIEW OF SYSTEMS: Unobtainable as the patient is on tracheostomy and on ventilator support.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly Hispanic male, awake, with opening and closing eyes, but not able to follow commands and in no cardiopulmonary distress.
VITAL SIGNS: Blood pressure is 132/52 mmHg, pulse rate of 72 per minute, temperature of 98.2 degrees Fahrenheit, and respiratory rate of 20 per minute.
NECK: Could not be evaluated as the patient has tracheostomy and is on ventilatory support.
CHEST: Decreased breath sounds bilateral.
ABDOMEN: Soft. Nontender. Bowel sounds positive.
EXTREMITIES: There is a pedal edema, 1+, on both the feet.
Rest of the physical examination could not be completely evaluated as the patient is completely bed-bound.
LABORATORY DATA: CBC: WBC 19.2, hemoglobin 10, hematocrit 30.6, and platelets 346,000. Basic metabolic panel shows sodium 132, potassium 4.2, chloride 92, CO2 of 32, glucose 110, BUN 32, creatinine 0.52, and calcium 8.2. Hemoglobin A1c is pending and glucometer readings yesterday were 300 and 375 and glucometer readings today are 204, 108, 146, and 164.
IMPRESSION AND PLAN: Uncontrolled type 2 diabetes mellitus, currently on Lantus and regular insulin regimen. We will change the Lantus regimen to 15 units in the morning and 52 units at night, and we will also change the regular insulin sliding scale to NovoLog subcutaneous q. 4 hours on a sliding scale basis. The patient is currently on Pulmocare continuous tube feedings at the rate of 65 mL per hour. We will also order hemoglobin A1c in the a.m. and will continue to monitor the patient’s diabetes while the patient is in the hospital. Also, ordered a hypoglycemic protocol for blood sugar less then 70.
Thank you once again for the consultation.
