Endocrinology Consultation1

ENDOCRINE CONSULTATION - 1

HISTORY: This 71-year-old woman did see me in the past last time in October 2001 with diabetes mellitus. She is presently on Glucophage 1000 mg twice a day, glyburide 5 mg twice a day, Novolin 35 units before breakfast and 20 units at bedtime, and Novolog 2-4 units before dinner. Her other diagnoses are hypertension, hypercholesterolemia, status post cancer of the breast, on tamoxifen 20 mg a day, Toprol XL 50 mg a day, hydrochlorothiazide 12.5 mg a day, Diovan 320 mg a day, Lipitor 20 mg a day, and Ecotrin 325 mg a day. She complains of tiredness. Fasting sugar yesterday was 120. Fasting sugar today is 130. Random glucose done in the office is 256.

PHYSICAL EXAMINATION: Weight is 207 pounds. Blood pressure is 140/80 mm Hg. Pulse is 92 per minute and regular. Lungs are clear to auscultation and percussion. Heart shows regular sinus rhythm. Abdomen is soft and benign. Feet show no calluses or ulcers.

LABORATORY DATA: Laboratory work showed hemoglobin A1c 8.1%, fasting sugar 200s SGOT 51, SGPT 44, TSH 1.10, calcium 9.5, sodium 140, potassium 4.5.

IMPRESSION:
1. Diabetes mellitus type II.
2. Hypertension.
3. Hypercholesterolemia.

PLAN:
1. Diet and exercise.
2. Add NovoLog 2-4 units before lunch.
3. Test sugars before meals and at bedtime.
4. Follow up with primary care physician in two months.
5. Follow up with me in two months.


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	ENDOCRINE CONSULTATION - 1 HISTORY: This 71-year-old woman did see me in the past last time in October 2001 with diabetes mellitus. She is presently on Glucophage 1000 mg twice a day, glyburide 5 mg twice a day, Novolin 35 units before breakfast and 20 units at bedtime, and Novolog 2-4 units before dinner. Her other diagnoses are hypertension, hypercholesterolemia, status post cancer of the breast, on tamoxifen 20 mg a day, Toprol XL 50 mg a day, hydrochlorothiazide 12.5 mg a day, Diovan 320 mg a day, Lipitor 20 mg a day, and Ecotrin 325 mg a day. She complains of tiredness. Fasting sugar yesterday was 120. Fasting sugar today is 130. Random glucose done in the office is 256. PHYSICAL EXAMINATION: Weight is 207 pounds. Blood pressure is 140/80 mm Hg. Pulse is 92 per minute and regular. Lungs are clear to auscultation and percussion. Heart shows regular sinus rhythm. Abdomen is soft and benign. Feet show no calluses or ulcers. LABORATORY DATA: Laboratory work showed hemoglobin A1c 8.1%, fasting sugar 200s SGOT 51, SGPT 44, TSH 1.10, calcium 9.5, sodium 140, potassium 4.5. IMPRESSION: 1. Diabetes mellitus type II. 2. Hypertension. 3. Hypercholesterolemia. PLAN: 1. Diet and exercise. 2. Add NovoLog 2-4 units before lunch. 3. Test sugars before meals and at bedtime. 4. Follow up with primary care physician in two months. 5. Follow up with me in two months.

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