Hillcrest Case 7 H&P

HISTORY AND physiologic EXAM retentiveanimous T. J. Moreno unhurried ID 110497DOB 02/15Age 44Sex M Room No. 502 Date of approach 10/09/2013 Admitting Physician Patrick Keathley, MD Endocrinology point Complaint Left ankle anguish. details OF PRESENT ILLNESS This is a 44 y head old Hispanic male person who I was kindly asked to admit by Dr. Max Hirsch. The patient is status brook arthrodesis of the go away ankle and has newly diagnosed diabetes and hypertension. olden MEDICAL HISTORY Pre-op rakehell glucose was say to be greater than 200. The patent asked for a medicine consult/admission for moreover evaluation.Currently he denies chest pain and huskiness of breath. No dysuria, or increased urinary frequency. Past history is significant for tryout loss in the right pinnule subsequent to an assault several geezerhood ago. PAST SURGICAL HISTORY sink back surgery and a left ankle surgery. SOCIAL HISTORY Patient admits to drinking beer on the weekends, some tobacco use, but no illicit drug use, is divorced with four children, is a long haul truck driver, lives with his fiancee. MEDICATIONS Patient is to put up a list, admits to taking no diabetes meds. PHSYICAL interrogative VITAL SIGNS afebrile, BLOOD PRESSURE one hundred fifty-five/98. HEART RATE 69.In general he is in no acute distress, bracing and oriented X4. HEENT Mucus membranes moist. No nervus facialis asymmetry. Left ear WNL, Right ear with profound hearing loss. LUNGS clear to auscultation and percussion section bilaterally. CV Normal. S1, S2 without murmurs or rubs. GI soft, non-tender, non-distended. No HSM. Positive Bowel sounds. GENITALIA deferred. EXTREMEITIES No edema. He has been admitted for left ankle surgery. neurological intact with the exception on cranial nerve on the right. LABS CBC inside normal range. Pre-op glucose 239. BUN and creatinine of 8 and 0. 5. Pre-op UA with 3+ glucose. (Continued)HISTORY AND PHYSICAL EXAM Patient T. J. Moreno Patient ID 110497DOB 02/15 Age 44Sex M Room No. 502 rascal 2 ASSESSMENT AND PLAN 1) shape post ankle arthrodesis tolerated procedure well, allow continue to manage. 2) Diabetes patient with elevated glucose and blood in urine. We will initiate slue scale for now. Likely needs Lantus. practical candidate for Metformin. 3) Hypertension We will start lisinopril. 4) Pain we will continue to monitor pain post-op and provide adequate pain control. _____________________________________________________________ Patrick Keathley, MD Endocrinology PH/xx D 10/09/ T 10/10