Endocrinology Case Study

DISCHARGE SUMMARY

ADMITTING DIAGNOSES

1. Diabetic ketoacidosis — mild to moderate in severity.

2. Type 1 diabetes mellitus.

3. Bronchitis and gastroenteritis.

4. Mild dehydration.

DISCHARGE DIAGNOSES

1. Diabetic ketoacidosis — resolved.

2. Type 1 diabetes mellitus.

3. Bronchitis and gastroenteritis.

4. Mild dehydration.

ADMITTING HISTORY AND PHYSICAL FINDINGS

The patient a 17-year-old white female with 8-year history of type 1 diabetes, now on 14 units of Ultralente insulin and
13 units of regular Humulin q.a.m.; 12 units of regular Humulin every noon; 14 units of Ultralente and 14 units of regular Humulin q.p.m., who insists she has been taking her insulin regularly but complains of 2- to 3-week history of cough with yellow phlegm for 2 days and emesis and abdominal pain for the day prior to admission.

LABORATORY

Arterial blood gases analysis shows pH 7.28, PCO2 29, PO2 85, bicarbonate 13, glucose 626.  Urinalysis unremarkable.

HOSPITAL COURSE

The patient was admitted to the medical floor and given IV insulin bolus of 10 units of regular and then placed on an insulin drip.  Blood sugar rapidly normalized, and her bicarbonate gradually rose to a level of 25.  She was given IV fluid hydration with normal saline and potassium chloride initially.  She received dietary counseling before discharge.  She seemed to understand the instruction adequately.  Her fasting blood sugar on the day of discharge on her usual insulin dose was 130.  This was on a 2000-calorie ADA diet (patient states she had been taking a 2800-calorie diet).

MEDICATIONS

Patient to continue the usual outpatient insulin dosage regimen.  Ampicillin 500 mg q.i.d. x10 days.

DISPOSITION

Discharged to home.  Patient was instructed to stop or minimize her smoking.  She will see her endocrinologist in 1 week and will be seen by me in 2 weeks as she has recently moved to this area.  She was instructed to call if blood sugars run less than 80 or greater than 300 — she will be checking these at home.

FOOTNOTE

Lines 13-17 (Page 1).  The physician indicates that the Discharge Diagnoses are the same as the Admitting Diagnoses, with the exception of diagnosis #1.  The Discharge Diagnoses should be transcribed in full.

Lines 21-22 (Page 1).  Humulin, Ultralente, and Lente insulin are trade names; regular insulin is generic.

Line 23 (Page 1).  Latin and English abbreviations are preferably not mixed, so q.noon was changed to every noon.

Line 29 (Page 1).  Lab was expanded in the heading.

Line 34, 37 (Page 1).  Alternative:  I.V.

Line 45 (Page 1).  Medications was taken as a different subheading prior to disposition to follow correct format.