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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.