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DEfRAG™ TechnologyConsultation_Note_Johnson_04182025.pdf
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Original Document
NEUROLOGY CONSULTATION
Date: 04/18/2025
PATIENT INFORMATION:
Name: Robert Johnson
DOB: 06/12/1972
MRN: 129845
REASON FOR CONSULTATION:
52-year-old male with history of Type 2 Diabetes referred for evaluation of increasing numbness and tingling in both feet for the past 6 months.
HISTORY OF PRESENT ILLNESS:
Patient reports gradual onset of numbness and tingling in both feet, beginning approximately 6 months ago. Symptoms began in the toes and have progressively extended to the mid-foot bilaterally. He describes the sensation as "pins and needles" that is worse at night and sometimes accompanied by burning pain. Patient has also noticed slight difficulty with balance when walking in the dark. Denies weakness, muscle cramps, or symptoms in the upper extremities. No bowel or bladder dysfunction.
PAST MEDICAL HISTORY:
1. Type 2 Diabetes Mellitus, diagnosed 8 years ago
2.
Hypertension
3. Hyperlipidemia
4. GERD
MEDICATIONS:
1. Metformin 1000mg BID
2. Glipizide 10mg daily
3. Lisinopril 20mg
daily
4. Atorvastatin 40mg daily
5. Omeprazole 20mg daily
ALLERGIES:
NKDA
SOCIAL HISTORY:
Patient works as an accountant. Denies tobacco use. Reports occasional alcohol use (1-2 drinks per week). Married with two adult children.
FAMILY HISTORY:
Father with Type 2 Diabetes and history of stroke. Mother with hypertension. No known family history of neurological disorders.
Entity Extraction
Demographics
8 entitiesRobert Johnson
06/12/1972
52 years
Male
Diagnoses
12 entitiesDiabetic Peripheral Neuropathy
ICD-10: E11.42
Type 2 Diabetes Mellitus
ICD-10: E11.9
Hypertension
ICD-10: I10
Hyperlipidemia
ICD-10: E78.5
Medications
15 entitiesMetformin 1000mg
Frequency: BID
Glipizide 10mg
Frequency: Daily
Lisinopril 20mg
Frequency: Daily
Atorvastatin 40mg
Frequency: Daily
Symptoms
18 entitiesNumbness and tingling in feet
Duration: 6 months
Pins and needles
Location: Bilateral feet
Burning pain
Frequency: Occasional
Difficulty with balance
Condition: When walking in the dark
Knowledge Graph
Key Relationships Detected
AI Clinical Insights
AI GeneratedClinical Summary
52-year-old male with 8-year history of Type 2 Diabetes presenting with progressive bilateral foot numbness, tingling, and occasional burning pain for 6 months, consistent with diabetic peripheral neuropathy. Patient reports slight difficulty with balance in the dark, suggesting early proprioceptive involvement.
Suggested Actions
- Order nerve conduction studies to confirm neuropathy diagnosis and assess severity
- Check A1C to assess glycemic control (last value: 9.2% on 01/12/2025)
- Consider starting Pregabalin 75mg BID for neuropathic pain
Similar Patient Cases
3 similar cases identified in your patient database:
Document Processing Queue
Document | Patient | Document Type | Status | Uploaded | Actions |
---|---|---|---|---|---|
Consultation_Note_Johnson_04182025.pdf | Robert Johnson | Neurology Consultation | Completed | 2 minutes ago | View |
Lab_Results_Williams_04182025.pdf | Sarah Williams | Laboratory Results | Processing | 5 minutes ago | View |
Discharge_Summary_Garcia_04182025.pdf | Maria Garcia | Discharge Summary | Queued | 12 minutes ago | View |
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