Clinical note · #35
Consultation
Patient: Linda Matthews
Age: 62
Place of Service: Office – Outpatient
Patient Status: New Patient
Insurance: Medicare (Traditional / Part B)
Referring Provider: Dr. R. Collins (Primary Care)
Reason for Consultation: Evaluation and management recommendations for poorly controlled type 2 diabetes mellitus.
Chief Complaint: Referred for persistently elevated blood glucose levels.
History of Present Illness (HPI):
The patient is a 62-year-old female referred by her primary care physician for consultation regarding poorly controlled type 2 diabetes mellitus. Despite adherence to oral hypoglycemic therapy, her glycemic control has progressively worsened.
She reports fasting blood glucose levels frequently above 200 mg/dL and postprandial readings exceeding 300 mg/dL over the past several months. Associated symptoms include polyuria, polydipsia, fatigue, and an unintentional weight loss of approximately eight pounds over three months.
She denies hypoglycemic episodes, chest pain, shortness of breath, visual changes, dizziness, syncope, recent emergency department visits, or hospitalizations.
Review of Systems (ROS):
- Endocrine: Polyuria, polydipsia
- Constitutional: Fatigue, weight loss
- Cardiovascular: Denies chest pain
- Respiratory: Denies dyspnea
- All other systems reviewed and negative
Past Medical History:
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia
Medications:
- Metformin 1000 mg twice daily
- Glipizide 10 mg daily
- Lisinopril
- Atorvastatin
Physical Examination:
- General: Alert, oriented, no acute distress
- Vital Signs: BP 138/84 mmHg, HR 78 bpm
- Cardiovascular: Regular rate and rhythm
- Respiratory: Clear to auscultation
Assessment:
- Type 2 diabetes mellitus – poorly controlled
Plan:
- Recommend discontinuation of sulfonylurea
- Initiate basal insulin therapy
- Continue metformin if renal function permits
- Consultation report to be sent to referring provider