Endocrinology Case Study

CHART NOTE

The patient is a 71-year-old female who was noted to have a slowly enlarging lesion in the right lobe of her thyroid.  Scans revealed this to be a cold nodule.  Thyroid function studies were within normal limits.  Fine-needle aspiration of this was thought to be a Hurthle cell adenoma.

The patient’s physical examination revealed a 2 x 1 x 1 mass in the right upper pole of the thyroid.  There were no lymph nodes palpable.  Patient was moderately obese but otherwise was unremarkable.

The patient did have an exploration of her right neck, and this was found to reveal a smooth mass in the right lobe of the thyroid, and a total right thyroid lobectomy was performed.  The left lobe was totally unremarkable and was not resected.

FINAL DIAGNOSIS

Follicular adenoma of the right lobe of the thyroid with Hurthle cell change.

FOOTNOTE

Line 13.  The dictator does not give the unit of measure.  The transcriptionist on the job would ask the physician for clarification.

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.

Endocrinology Case Study Report 5

DISCHARGE SUMMARY

This was one of several admissions for this nearly 3-year-old boy for bilateral inguinal hernia repairs.  Swelling in the left groin was noted several weeks prior to admission.  He has had pains in the groins on and off.  He was found to have bilateral inguinal hernia repairs.  The child is also followed because of congenital Addison disease.  He is on Cortef and Florinef Acetate.

Because of the Addison disease, he was treated with cortisone acetate IM, 50 mg on admission, and Solu-Cortef 50 mg IM 1 hour prior to surgery.  Solu-Cortef 50 mg was run during the surgery.  Four hours after completion of the surgery, he received 12.5 mg of Solu-Cortef IM.

LABORATORY DATA

Hemoglobin 12.1, WBC 5500, BUN 18, and electrolytes 140, 3.9, and 23.

DISCHARGE DIAGNOSES

1. Addison disease.

2. Bilateral inguinal hernias.

DISCHARGE MEDICATIONS

Discharge medication included only his usual medications for Addison disease.

FOOTNOTE

Lines 15-19.  Alternative:  I.M.

Line 17.  To avoid beginning the sentence with a numeral, the sentence was rephrased.

Line 22.  Alternative:  BUN 18.  Electrolytes:  Sodium 140, potassium 3.9, and CO2 23.

Endocrinology Case Study

CHART NOTE

A 34-year-old lady who comes to clinic today with longstanding history of hypothyroidism, for which she has taken Cytomel in the past.  Comes in today for a refill of medication and further evaluation.

Examination shows her to be in no acute distress.  Blood pressure 120/88.  HEENT normal.  Chest is clear.  Cardiac examination reveals regular rate and rhythm without murmur.

ASSESSMENT

A 34-year-old lady with longstanding hypothyroidism.  I would prefer to switch her to Synthroid 0.1 mg as I think the packaging is more uniform in this product.  Then test thyroid-stimulating hormone in 1 month.

FOOTNOTE

Line 7.  The article A was added to avoid beginning the sentence with a numeral.

Line 13.  The blood pressure value 120 by 88 is written 120/88.

Line 18.  A zero was inserted before the decimal point for clarity.

Lines 19, 20.  TSH is expanded in the assessment for clarity.

Endocrinology Case Study

CHART NOTE

One grain of thyroid did not work as well as 1-1/2 in terms of reducing facial and neck edema.  When she sleeps away from home, however, the edema does not occur.  It is almost certainly an allergy to some component of her house.  I suggested, since she is going to college, that she try to taper and discontinue the thyroid over a 3-month period.  Will return in 6 months if still on 1-1/2 grains, otherwise 1 year if on a lower dose of thyroid.  Pulse 75, blood pressure normal.  Heart and lungs okay.  Has a small mole which does not appear to be a problem.

CHART NOTE

ACTH injection given for adrenal function tests.