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Consultation_Note_Johnson_04182025.pdf

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Medical Entity Recognition
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Original Document

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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

78 Entities Detected
Confidence Threshold:

Demographics

8 entities
Name 98%

Robert Johnson

DOB 99%

06/12/1972

Age 95%

52 years

Gender 92%

Male

Diagnoses

12 entities
Primary Diagnosis 93%

Diabetic Peripheral Neuropathy

ICD-10: E11.42

Chronic Condition 97%

Type 2 Diabetes Mellitus

ICD-10: E11.9

Chronic Condition 95%

Hypertension

ICD-10: I10

Chronic Condition 94%

Hyperlipidemia

ICD-10: E78.5

Medications

15 entities
Medication 96%

Metformin 1000mg

Frequency: BID

Medication 95%

Glipizide 10mg

Frequency: Daily

Medication 94%

Lisinopril 20mg

Frequency: Daily

Medication 93%

Atorvastatin 40mg

Frequency: Daily

Symptoms

18 entities
Primary Symptom 91%

Numbness and tingling in feet

Duration: 6 months

Sensation 89%

Pins and needles

Location: Bilateral feet

Associated Symptom 87%

Burning pain

Frequency: Occasional

Functional Impact 85%

Difficulty with balance

Condition: When walking in the dark

Knowledge Graph

32 Relationships Added
Patient Diabetes Meds Symptoms Tests HTN Labs has takes shows needs

Key Relationships Detected

Causality 96%
Type 2 Diabetes Peripheral Neuropathy
Treatment 93%
Metformin + Glipizide Type 2 Diabetes
Manifestation 91%
Peripheral Neuropathy Numbness & Tingling
Comorbidity 89%
Type 2 Diabetes Hypertension

AI Clinical Insights

AI Generated

Clinical 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:

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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