Sample Name: Consult - CHF & Lymphedema
Description: The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema. He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung. This consultation was made for better control of his blood sugars. On questioning, the patient says that he does not have diabetes. He says that he has never been told about diabetes except during his last admission at Jefferson Hospital. Apparently, he was started on glipizide at that time. His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem. He is not sure. He is not following any specific diet. He says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet. He has a long history of numbness of his toes. He denies any visual problems.
PAST MEDICAL HISTORY: As above that includes CA of the lung, COPD, bilateral cataracts. He has had chronic back pain. There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.
SOCIAL HISTORY: The patient has been a smoker since the age of 10. So, he was smoking 2-3 packs per day. Since being started on Chantix, he says he has cut it down to half a pack per day. He does not abuse alcohol.
1. Glipizide 5 mg p.o. daily.
5. Januvia 100 mg daily.
12. Albuterol sulfate.
13. Vitamin B tablet.
FAMILY HISTORY: Positive for diabetes mellitus in the maternal grandmother.
REVIEW OF SYSTEMS: As above. He says he has had numbness of toes for a long time. He denies any visual problems. His legs have been swelling up from time to time for a long time. He also has history of COPD and gets short of breath with minimal activity. He is also not able to walk due to his weight. He has had ulcers on his legs, which he gets discharge from. He has chronic back pain and takes OxyContin. He denies any constipation, diarrhea, abdominal pain, nausea or vomiting. There is no chest pain. He does get short of breath on walking.
The patient is a well-built, obese, white male in no acute distress.
Vital signs: Pulse rate of 89 per minute and regular. Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.
HEENT: Head is normocephalic and atraumatic. Eyes, PERRLA. EOMs intact. Fundi were not examined.
Heart: Shows normal sinus rhythm with S1 and S2.
Lungs: Show bilateral wheezes with decreased breath sounds at the bases.
Abdomen: Soft and obese. No masses. Bowel sounds are present.
Extremities: Show bilateral edema with changes of chronic venostasis. He does have some open weeping sores. Pulses could not be palpated due to leg swelling.
1. Diabetes mellitus, type 2, new onset. At this time, the patient is on Januvia as well as glipizide. His blood sugar right after eating his supper was 101. So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet. We will continue to follow his blood sugars closely and make adjustments as needed.
2. Neuropathy, peripheral, query etiology. We will check TSH and B12 levels.
5. Obesity, morbid.
6. Tobacco abuse. He was encouraged to cut his cigarettes down to 5 cigarettes a day. He says he feels like smoking after meals. So, we will let him have it after meals first thing in the morning and last thing at night.
7. Chronic venostasis.
8. Lymphedema. We would check his lipid profile also.
10. Backbone pain, status post back surgery.
11. Status post hernia repair.
12. Status post penile implant and removal.
13. Umbilical hernia repair.
Keywords: general medicine, diabetes mellitus, neuropathy, lymphedema, cellulitis, chronic venostasis, chf and lymphedema, umbilical hernia repair, short of breath, umbilical hernia, hernia repair, blood sugars, chf, chronic, blood, sugars,