Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Acute Cystitis & Diabetes Type II

Description: The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.
(Medical Transcription Sample Report)


HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.

PAST MEDICAL HISTORY: There is no significant past medical history noted today.

PHYSICAL EXAMINATION:
HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.
Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.
Resp: Patient denies asthma, lung infections and lung lesions.
GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.
GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.
Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.
Dermatology: Patient denies allergic reactions, rashes and skin lesions.

MEDS: Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.

SOCIAL HISTORY: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.

FAMILY HISTORY: No significant family history.

REVIEW OF SYSTEMS: Non-contributory.
Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.
Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.
Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.
Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.
Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.
Extremities: There is no clubbing, cyanosis, or edema.

ASSESSMENT: Diabetes type II uncontrolled. Acute cystitis.

PLAN: Endocrinology Consult, complete CBC.

RX: Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.

Keywords: consult - history and phy., bactrim, micronase, abdominal pain, endocrinology, cbc, diabetes type ii, acute cystitis, diabetes, abnormalities,