Consult - History and Phy.
Sample Name: Gen Med Consult - 9
Description: Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is well-known to me. He comes in today for a comprehensive evaluation. Really, again he borders on health crises with high blood pressure, diabetes, and obesity. He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc. He knows better and has been through some diabetes training. In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004. Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days. He has had elevated blood pressure. His other concerns include allergic symptoms. He has had irritable bowel syndrome with some cramping. He has had some rectal bleeding in recent days. Also once he wakes up he has significant difficulty in getting back to sleep. He has had no rectal pain, just the bleeding associated with that.
MEDICATIONS/ALLERGIES: As above.
PAST MEDICAL/SURGICAL HISTORY: Reviewed and updated - see Health Summary Form for details.
FAMILY AND SOCIAL HISTORY: Reviewed and updated - see Health Summary Form for details.
REVIEW OF SYSTEMS: Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions: None.
VITAL SIGNS: As above.
GENERAL: The patient is alert, oriented, well-developed, obese male who is in no acute distress.
HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear.
NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit.
CHEST: No chest wall tenderness or breast enlargement.
HEART: Regular rate and rhythm without murmur, clicks, or rubs.
LUNGS: Clear to auscultation and percussion.
ABDOMEN: Significantly obese without any discernible organomegaly. GU: Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.
RECTAL: Smooth, nonenlarged prostate with just some irritation around the rectum itself. No hemorrhoids are noted.
NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits.
SKIN: Noted to be normal. No subcutaneous masses noted.
LYMPH SYSTEM: No lymphadenopathy noted.
BACK: He has pain in his back in general.
1. Diabetes and hypertension, both under less than appropriate control. In fact, we discussed increasing the Lantus. He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control. He knows what needs to be done with the absence of carbohydrates, and especially simple sugar. He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile. I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range. He has allergic rhinitis for which Zyrtec can be used.
2. He has irritable bowel syndrome. We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened. For the bleeding I would like to obtain a sigmoidoscopy. It is bright red blood.
3. For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene. I will look forward to seeing him back in a month. I will call him with the results of his lab. His medications were made out. We will use some Elocon cream for his seborrheic dermatitis of the face. Zyrtec and Flonase for his allergic rhinitis.
Keywords: consult - history and phy., blood pressure, diabetes, obesity, irritable bowel syndrome, comprehensive evaluation, allergic rhinitis, bowel syndrome, insomnia, allergic, irritable,