Sample Patient Interview

Decent Essays
Dr.[Name] dictating on [Date], medical record #[Numbers].

[Name] is now 14-1/2 -years-old. He is seen in followup for insulin-dependent diabetes, which was diagnosed exactly 1 year ago, at the age of 13-1/2. He has been followed by me since January of 2007 and I have been in contact about twice a month with his mother [Name], who has faxed blood sugars and I have gone ahead and adjusted his insulin doses and I am very please with how well he is doing. This is an amazing teenage who really seems to take pride in taking care of himself, and is very compliant with his diabetes regimen.

He is approaching a big change in his life will be entering [Place] High School in the 9th grade, and he is apprehensive but also looking forward to this. His biggest focus has been that he would like to play football, and he wants to play for the [Name] team, and he will be attending tryouts shortly. He has been practicing with the team and doing workouts throughout the summer.

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In addition to football practice, he has been doing quite a bit of weight training.

He is not a big snacker and does not eat a large amount of food in-between his meals, but does have a hearty appetite.

He did have laboratory studies performed in May of 07. His cholesterol was 129, HDL 58, LDL 62, triglycerides 43, TSH 1.1, microalbumin 17.8 and celiac screen was negative.

He also had testing done to evaluate gynecomastia, and these levels were also excellent showing an estradiol of less than 1.4. An FSH of 3.8, and LH of 1.1. A β-hCG quantitative of less than 1. A total testosterone of 4.3, with a free testosterone of 12.33 pc/mL. A TSH of 1.1. He feels that the breast buds have started to decrease considerably in size.

He has definitely proceeded through puberty and it does appear to me that he soon be needing to shave. He is almost the exact height of his father. He has not had skin or joint problems and his review of systems is otherwise
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