Clinical note · #46
Consultation
Date of Service: 04/25/2026 Consulting Physician: Dr. John Smith Requesting Physician: Dr. Robert Wilson Facility: City General Hospital Payor: Medicaid Patient Name: Jane Doe DOB: 01/15/1950 MRN: 12345678
Reason for Consultation / Request
Consult requested by Dr. Robert Wilson for evaluation and management recommendations regarding uncontrolled hypertension and altered mental status.
History of Present Illness (HPI)
The patient is a 76-year-old female admitted to the hospital for confusion, weakness, and elevated blood pressure. The patient was noted to have systolic blood pressure readings above 190 mmHg despite current antihypertensive therapy. She is currently experiencing intermittent headache, dizziness, and generalized weakness. No chest pain or shortness of breath reported. Due to worsening symptoms and difficulty controlling blood pressure, internal medicine consultation was requested for further evaluation and treatment recommendations.
Past Medical History
Hypertension Type 2 Diabetes Mellitus Chronic Kidney Disease, Stage 3 Hyperlipidemia
Past Surgical History
Cholecystectomy Cataract surgery
Medications
Lisinopril 20 mg daily Metformin 500 mg BID Atorvastatin 20 mg daily Aspirin 81 mg daily
Allergies
No known drug allergies.
Family History
Positive for hypertension and diabetes.
Social History
Denies smoking, alcohol, or illicit drug use.
Review of Systems (ROS)
Constitutional: Weakness, fatigue. Neurological: Confusion, dizziness, headache. Cardiovascular: Denies chest pain, palpitations. Respiratory: Denies shortness of breath, cough. GI: Denies nausea, vomiting, abdominal pain. All other systems reviewed and negative.
Physical Examination
Vital Signs: BP: 198/102 mmHg HR: 92 bpm RR: 18/min Temp: 98.6°F SpO₂: 96% on room air
General: Awake but mildly confused; no acute distress. HEENT: Normocephalic, atraumatic. Neck: Supple, no JVD. Heart: Regular rate and rhythm; no murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, non-distended. Extremities: No edema. Neurological: Alert but oriented ×2; no focal deficits.
Diagnostic Data Reviewed CBC reviewed CMP reviewed CT head negative for acute bleed EKG: Normal sinus rhythm Creatinine: 1.8 mg/dL Glucose: 210 mg/dL
Assessment
Hypertensive urgency with poor control Altered mental status, likely secondary to hypertensive encephalopathy vs metabolic cause Type 2 diabetes mellitus with hyperglycemia Chronic kidney disease stage 3 Generalized weakness/deconditioning
Recommendations / Plan
Start IV antihypertensive therapy and monitor blood pressure closely. Continue current antihypertensive medications with adjustment as needed. Monitor neurological status and repeat imaging if symptoms worsen. Blood glucose monitoring with sliding scale insulin coverage. Monitor renal function and avoid nephrotoxic medications. Physical therapy evaluation for weakness and deconditioning. Will continue to follow during hospitalization and communicate recommendations to the attending physician.
Consultant Statement / Report Back
Thank you, Dr. Wilson, for allowing me to participate in the care of this patient. I have discussed my findings and recommendations with the attending physician and documented the consultation report in the medical record.
Signature
Dr. John Smith, MD Internal Medicine Consultant