ENDOCRINOLOGY TEST FILES

ENDO_T1

INITIAL OFFICE EVALUATION

CHIEF COMPLAINT:  Elevated blood sugars uncontrolled by high-dose outpatient insulin.

HISTORY AND PHYSICAL FINDINGS:  The patient is an 80-year-old white male with history of type 2 diabetes intermittently requiring insulin, with recent flare-up of his chronic congestive heart failure and bronchitis, which resulted in an elevation of blood sugars.  He has been on Glucotrol 15 mg b.i.d., but blood sugars were going over 400 on his Glucometer at home for the last week and a half.  He was started on insulin and this dose increased to 90 units per day, given concomitantly with the Glucotrol.  He was also given some Zaroxolyn for the flair-up of congestive heart failure he had last week.  As a result, his blood sugars have not come down significantly, still running frequently off the scale on the Glucometer at home and running as high as 557  two days ago at a laboratory.  His sodium has dropped from the mid to high 120s down to low 120s, and BUN and creatinine have raisen secondary to Zaroxolyn as in the past.  He has been treated with ampicillin for his bronchitis.

The patient also has a history of permanent left nephrostomy tube for ureteropelvic junction dysfunction.

MEDICATIONS:  Allopurinol 100 mg b.i.d.; Lasix 160 mg a.m., 120 mg p.m.; Feldene 20 mg q.a.m.; Metamucil 2 tablespoons h.s.; Darvicet-N 100, one every 4 to 6 hours p.r.n. plain; Dalmane 15 mg h.s.; nitroglycerin 0.4 mg sublingually p.r.n. chest pain; Micro-K 10 mEq 1to 3 times per day; Cardizem 60 mg q.i.d.; Isordil 30 mg q.i.d.  He had 95 units of insulin a day prior to admission and, I believe, 80 units of combined NPH and regular insulin the day of admission.

PHYSICAL EXAMINATIO:

Vital signs include temperature 97.7, pulse 72, respirations 28, blood pressure 120/70.

Generalexamination reveals on obese white male.  HEENT reveals PERRL.  Normal fundi.  TMs normal.  Pharynx clear.  Neck without JVD.  Coronary examination reveals a regular rate and rhythm.  Lungs are clear.  A few coarse bibasilar rales.  Abdomen is obese without masses.  Back with left nephrostomy tube.  Genital examination indicates an uncircumcised male.  Testicular edema that was noted last week in the office prior to Zaroxolyn therapy is now resolved.  Extremeties show 1+ edema extending all the way to the thighs and presacral area.  Is wearing TED hose.  Right leg is worse than left per usual.

LABORATORY:  CBC reveals white blood count is 7000 with 66 polys, no bands, 23 lymphs, 8 monos, 3 eosinophiss.  Hematocrit 45.0.  Blood sugar on admission 445.  Electrolytes reveal sodium 115, potassium 3.2, chloride 72, CO2 32.  BUN 73, creatinine 2.6.

IMPRESSION

1.  Type 2 diabetes—flare-up secondary to congestive heart failure and bronchitis.

2.  Recent exacerbation of congestive heart probably secondary to hyperglycemia (artificial) and Zaroxolyn.

4.  Recent history of decreased auditory acuity—probably secondary to Lasix and Zaroxolyn, although Lasix dose has been chronically the same.

PLAN:  The patient will be given on a split-dose b.i.d. dosing regimen.

ENDO_T2

EMERGENCY ROOM REPORT

The 67- year-old female was evaluated by me in the emergency department at approximately 0630 hours for complaints of repeated episodes of vomiting, numbering at least 5 during the preceding 8 or so hours.  She stated that she is a known diabetic and has taken fingerstick readings of 423 and 241 at home.  She is on multiple medications, including regular insulin 10 units in the a.m., along with Ultralente 16 units at h.s., along with Trental, Pamelor, and niacin.  She is a known diabetic for 54 years.  She also admits to some chest pain, somewhat burning in nature, without radiation into her face, neck, or arms.  There is no history of diarrhea.  She has a previous history of coronary artery bypass surgery some 4 years earlier.

PHYSICAL ASSESSMENT:  Physical assessment reveals her temperature to be 98.2, pulse 60, respirations 20, and a blood pressure of 102/50.  Initially, her color was pale.  Her mucous membranes did appear dry.  Heart rate was regular without murmurs.  There was a well-healed cicatrix to the anterior medsternal region.  Lungs were clear to auscultation.  The abdomen was soft with generalized tenderness.  No unusual pulsating masses.  Lower extremities are free of any pretibial edema.

IMPRESSIONS

1.  Diabetes mellitus, out of control.

2.  Dehydration.

3.  Electrolyte imbalance.

PLAN:  While in the emergency department, multiple diagnostic studies were performed, including CBC, glucose, BUN, potassium, sodium, UA, Panel A, ABG, PT, PTT, electrocardiogram, CPK-MB via electrophoresis.  Her serum glucose was noted to be 511, serum sodium of 129, and a BUN of approximately 30.

During her ER stay she was given normal saline with some subjective improvement.  She was also given Compazine 10 mg for repeated vomiting.  Her condition at time of admission was slightly improved.

ENDO_T3

CONSULTATION

IDENTIFICATION AND HISTORY:  This patient is a 67-year-old Mexican-American female.  She was admitted to the hospital early this morning at approximately 0400 hours.  She was seen in the emergency room at approximately 3 a.m. because of diaphoresis and weakness, with subsequent diagnosis of hypoglycemia.  She was admitted to the hospital and placed on the progressive care unit.  She was admitted with a hemoglobin of 6.9 and a potassium of 6.2, with evidence of renal insufficiency.

It should be noted that she has been admitted to the hospital in the past because of chronic renal insufficiency and hyperkalemia. This resulted in a program which included DiaBeta 5 mg b.i.d., Inderal 20 mg 3 times a day.  Quinidex Extentabs 1 b.i.d., and ferrous sulfate.

IMPRESSION

1.  Diabetes mellitus, type2.

2.  Hypoglycemia secondary to oral hypoglycemic agents in the face of renal insufficiency, leading to hypoglycemia.

3.  Hyperkalemia, acute, secondary to her renal insufficiency and being on angiotensin converting enzyme inhibitors.

RECOMMENDATIONS

1.  Discontinue her Vasotec.

2.  Hydration with saline, since I think at least part of her renal failure is probably on the basis of perenal azotemia secondary to her furosemide therapy.

3.  Sodium bicarbonate for treatment of her metabolic acidosis.

4.  Kayexalate p.o. and Kayexalate enemas.

5.  Glucose infusion followed by regular insulin.