Consultation note
Time in:
MR#:
Patient Name:
Date of Birth:

Dr. ___________ has asked for consultation on this patient regarding regarding _______________.

Thank you for inviting us to see this patient.

Chief complaint: ___ year old male/female presents today for evaluation and treatment of Diabetes.
Type:
Diagnosed:
Treated with:
Blood Glucose checks:
Blood Glucose average at home:
Hba1c:
For Diabetes is seen by:
Retinopathy:                                 Last Ophthalmologic exam:
Neuropathy:
Nephropathy:
Dyslipidemia:
Nocturia/Polyuria/Polydypsia:
Hypoglycemia/Symptoms:

My key findings of the ROS, Past Hx, Family Hx, and social Hx are:
ROS: Review of 12 systems was negative with exception of those things mentioned above in the HPI and weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Patient denies weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Past Medical History:

Past Surgical History:

Family History:

Social History:
Diet:
Exercise:
Smoking:
Recreational Drug use :
Education:
Occupation:
Lives with ____ where ____

Home Meds:

Allergies:

My key findings of this patient's Physical Exam are:
VITALS:
Pulse:
Blood Pressure:
Respirations:
Temperature:
Weight:
Height:
BMI:

GENERAL: sitting up/reclined in bed, awake, alert, and oriented
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa
EYES: EOMI, PERLA, no proptosis
NECK: supple, thyroid normal in size, thyroid small, thyroid low set, no thyromegaly or masses
RESPIRATORY: clear to ascultation bilaterally
CARDIOVASULAR: S1S2, no murmurs/rubs/gallops
GI: soft, non-tender, + bowel sounds
LYMPHATIC: no cervicoclavicular adenopathy appreciated
MUSCULOSKELETAL: moving all extremities
EXTREMITIES: no edema present
NEUROLOGIC: monofilament sensed in all areas of the foot, vibratory sensation intact, fine/crude touch intact, pulses palpable, DTRs 2+, CN grossly intact
DERMATOLOGY: no xanthomas appreciated, no skin ulcers, no calluses, no onchyomycosis/dermatophyosis, no striae,
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas

Labs:
Na
K
Cl
CO2
BUN
Creat
Gluc
Ca
Mg
Phos
WBC
Hgb
PCV
Plt
SGOT
SGPT
GGT
Alb
TBil
AlkP
CPK
CKMB
TropnT

Bone and Mineral
Intact PTH:
Ionized Calcium:
Ca:
Mg:
Phosphorus:
25-OH Vitamin D:
1,25-OH Vitamin D:

Thyroid:
TSH:
FT4:
TT4:
QT3:
Athyp:
AthyG:
Calcitonin:
Thyroglobulin:

Lipids:
Cholesterol:
LDL:
HDL:
TG:
Lipoprotein A:
hsCRP:
TSH:
Uric Acid:

Urine Drug Screen:
Amphetamines:
Barbiturates:
Benzodiazepines:
Cannabinoids:
Cocaine Metabolites:
Methadone:
Opiate:
Tricyclics:
Acetaminophen Metabolites:
Salicylates:
Ethchlorvynol:
Phenothiazines:
Propoxyphene:
Methanol:
Ethanol:

Adrenal Labs:
Urine Free Cortisol:
Cortisol Serum:
Aldosterone :
Renin:
ACTH: 17 OH Progesterone
Catecholamines:
Plasma Epinephrine:
Plasma Norepinephrine:
Plasma Dopamine:
Plasma Total Catecholamines:
Urine Epinephrine:
Urine Norepinephrine:
Urine Dopamine:
Urine Vanillyl Mandelic Acid:
Urine Total Catecholamines:
Urine Total Catecholamines per gram creatinine:
Urine Creatinine:

Pituitary Labs:
Growth Hormone:
Somatomedin-C:
Prolactin:
ADH:
Sodium:
Osmol:
Urine Specific Gravity:

Reproductive Endocrine:
LH:
FSH:
Free Testosterone:
Testosterone :
AFP:
B-HCG:
Estriol Unconjugates:

Glycemic Panel:
C-Peptide:
Insulin:
Pro-Insulin:
Beta Hydroxy-butyrate:

Misc:
5-HIAA:

Assessment:

Diagnostic Plans:
Hba1c
Urine Alb/Creat Ratio
Fasting Lipid Panel
Ophthalmology Referral
Chem 7
LFTs/CKs

Therapeutic Plans:
Sliding scale Regular insulin every six hours (0000, 0600, 1200, 1800)
Blood glucose = 0-60: 1/2 can non-diet soda or 4 oz of orange juice
Blood glucose = 61-109: give nothing
Blood glucose = 110-149: give ___ units
Blood glucose = 150-189: give ___ units
Blood glucose = 190-229: give ___ units
Blood glucose = 230-269: give ___ units
Blood glucose >=270:       give ___ units

Patient Education:
Return to Clinic:
We have discussed our diagnostic and treatment plans with the patients and family/friends that were present. All questions have been answered to the patient's satisfaction.

Thank you for inviting to see this consult!

Written by ___ _____________________ Time out_______