Reason Consultation Management Assignment Help: How to Answer This Question
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Original Question
Reason for Consultation: Management of uncontrolled diabetes and acute hypoglycemia Requested by: Hospitalist service History of Present Illness: This is a pleasant 50 y/o male known to our service in the past, was admitted with low blood sugar overnight. The consult was generated to assist in the management of his diabetes. Medical History: Positive for type 2 diabetes over the past few years complicated by hypertension, hyperlipidemia, obesity, coronary artery disease, peripheral vascular disease, neuropathy, GERD, and BPH. FAMILY HISTORY: Positive for hyperlipidemia and myocardial infarction. SOCIAL HISTORY: Does not smoke or drink. ALLERGIES: To heparin, penicillin and shellfish. MEDICATIONS: Lantus insulin 55 units at night, Humalog 12 units with every meal, Coreg, vitamin C, Advair, Zoloft, Prilosec, B12, Mag Delay, Flomax, vitamin D, and Lipitor, Cilostazol, Gabapentin REVIEW OF SYSTEMS: Showed hypoglycemia which happened in the early hours of the morning after going to sleep. The patient says he took his normal dose of 55 units of Lantus. Vitals: Temperature: 98.6°F Pulse: 66 Respirations: 20 Blood Pressure: 140/82 SpO2: 99% on room air Physical Examination: General-alert and awake. HEENT examination showed eye movements to be full. The pupils appeared equal. The mucous membranes were moist. Head was normocephalic, atraumatic. Examination of the neck was supple. Examination of the chest showed good air entry on both sides. Examination of the heart showed first and second heart sounds. Examination of the abdomen was soft with no organomegaly. Examination of the nervous system showed him to be alert and awake and appeared oriented for time, place and person. The cranial nerves were grossly intact. Motor and sensory systems were grossly intact. Gait was not tested. His sugar was 115, 94, 52 and 49. He was on a D5 IV drip. Looking at his hemoglobin A1c. Impression and Recommendation This is a patient with type 2 diabetes, who presents with uncontrolled blood sugar. At the present time, his hypoglycemia needs to be documented and otherwise, the patient denies taking the wrong insulin. He says he ate the usual food. Treated himself with glucose tablets. To this end, I am reducing the dose of Lantus as well as NovoLog to keep him safe, especially given these underlying comorbid conditions. In addition, the patient will be monitored, and insulin will be adjusted as needed. He can be discharged from the Endocrine standpoint. Type 2 DM with hypoglycemia, PVD and diabetic neuropathy. Hypertension Hyperlipidemia CAD BPH GERD Obesity what is the correct evalulation and management codes
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