DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: Hyperglycemia.
HISTORY OF PRESENT ILLNESS: History of present illness was obtained from Dr. John Doe, the medical records, the patient, and the parents. This is a (XX)-year-old female, who presented with a history of rash following amoxicillin. Apparently, prior to that, she had been running fevers, sore throat, and the rash seemed to have increased and become systemic. The patient was then transferred to this hospital, to the intensive care unit, for the increasing systemic rash and consideration of mononucleosis. However, during the course of her stay, in the hospital, it was found that her blood sugars were elevated, requiring IV insulin. The patient was initiated on Solu-Medrol for three days, which exacerbated her hyperglycemia. Hemoglobin A1c was done, which showed that it is 8.7, and hence the possibility of new onset type 1 diabetes was entertained.
PAST MEDICAL HISTORY: Unremarkable.
SOCIAL HISTORY: The patient is in (XX) grade. She lives with her mother and stepfather and spent the weekends with the biological father.
FAMILY HISTORY: Negative for diabetes or autoimmune condition.
REVIEW OF SYSTEMS: Essentially as in HPI. The patient as well as the father recalled that there was increased thirst and increased urination in the last few weeks; however, there was no weight loss.
PHYSICAL EXAMINATION:
GENERAL: The patient looked alert and in no apparent distress. She did have generalized maculopapular rash.
VITAL SIGNS: Heart rate was 80, respirations 18, and blood pressure 92/42.
HEENT: Mucous membranes were moist. She had some swelling around the eyes. Pupils were equal and reactive to light.
NECK: Supple without any goiter.
LUNGS: Clear to auscultation without any rales.
HEART: Heart sounds were normal without any murmur.
ABDOMEN: Soft and nontender. No organomegaly appreciated.
EXTREMITIES: Full range of motion. The patient does have diffuse maculopapular rash.
LABORATORY DATA: Hemoglobin A1c of 8.7. Blood sugars have been ranging in the 200s to 300s requiring IV insulin at the rate of 4 units per hour. Solu-Medrol has just been discontinued.
ASSESSMENT: Most likely, this is new onset type 1 diabetes, which has been precipitated with the intercurrent viral syndrome, systemic rash, particularly with the history of increased thirst and urination. Average blood sugars of about 250 over the previous three months.
PLAN: To initiate her on subcutaneous insulin therapy, glucose monitoring, ketone testing, diabetes education, and nutrition consult. Continue to monitor. Follow her blood sugars and make insulin adjustments as necessary. We discussed the diagnosis with the parents. We also sent labs for GAD65 antibodies, islet cell antibodies, and insulin antibodies. If positive, we would confirm the diagnosis of type 1. If not, we will just have to wait and see how her blood sugars and insulin requirements progress over the next few months, to see if this is indeed type 1 diabetes.
Thank you very much for this consult.
