Sample consultation — exactly what a clinician sees
Suspected new-onset type 2 diabetes
Sample patient — recorded consultation — 8:32 — Gulf Arabic · English
Red flags
- Unintentional weight loss of 3 kg over two weeks warrants prompt laboratory confirmation.
Clinical note
Subjective
38-year-old female presenting with approximately two weeks of fatigue, polydipsia and nocturia (3-4 episodes per night). Reports unintentional weight loss of approximately 3 kg. Strong family history of type 2 diabetes mellitus (mother, maternal uncle). No visual changes, no polyphagia reported.
Objective
Patient alert and well-appearing. Physical examination not performed during this encounter. Fasting laboratory workup ordered.
Assessment
Clinical presentation highly suspicious for new-onset type 2 diabetes mellitus: classic osmotic symptoms, unintentional weight loss and strong family history. Differential includes thyroid dysfunction.
Plan
1. Fasting plasma glucose and HbA1c ordered; patient instructed to fast from evening. 2. TSH added to rule out thyroid disorder. 3. Review appointment in two days to discuss results. 4. Brief dietary counselling given; advised to reduce sugary drinks pending results.
Suggested ICD-10 codes
Patient summary — Arabic
مرحباً، شكراً لزيارتك اليوم. الأعراض التي وصفتِها — التعب والعطش وكثرة التبول ليلاً — قد تكون مؤشراً على ارتفاع سكر الدم، خاصة مع وجود السكري في العائلة. طلبنا تحليل دم صائم وفحص السكر التراكمي، لذا يرجى عدم الأكل بعد العشاء في الليلة السابقة للتحليل. سنراجع النتائج معاً خلال يومين ونقرر الخطوات القادمة. في هذه الأثناء، حاولي تقليل المشروبات السكرية. نحن معك في كل خطوة.
Transcript
clinician
صباح الخير، تفضلي. شو اللي جايبك اليوم؟
Good morning, please come in. What brings you in today?
patient
دكتورة، صار لي أسبوعين تقريباً أحس بتعب وايد وعطش، وأقوم بالليل ثلاث أربع مرات أشرب ماي وأروح الحمام.
Doctor, for about two weeks I have been feeling very tired and thirsty, and I get up three or four times at night to drink water and use the bathroom.
clinician
في أحد بالعايلة عنده diabetes؟
Does anyone in your family have diabetes?
patient
إيه، أمي عندها السكري من عشر سنين، وخالي بعد.
Yes, my mother has had diabetes for ten years, and my uncle too.
clinician
طيب. وزنج تغير الفترة الأخيرة؟ نزلتي ولا زدتي؟
Alright. Has your weight changed recently? Have you lost or gained?
patient
نزلت شوي، يمكن ثلاث كيلو، بس ما سويت شي.
I lost a little, maybe three kilos, but I have not done anything differently.
clinician
بنسوي فحص دم اليوم — fasting glucose و HbA1c — وشوفي النتيجة بيومين إن شاء الله. لا تاكلين شي من الليل.
We will do a blood test today — fasting glucose and HbA1c — and you will see the result in two days. Do not eat anything from the evening onwards.
This entire page was generated from one audio recording — the note, the red flags, the codes and the Arabic summary. Your consultations could look like this next week.
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