Hillcrest Case 7 H&P

HISTORY AND PHYSICAL EXAM Patient T. J. Moreno Patient ID 110497DOB 02/15Age 44Sex M Room nary(prenominal) 502 Date of Admission 10/09/2013 Admitting Physician Patrick Keathley, MD Endocrinology Chief Complaint Left ankle hassle. DETAILS OF PRESENT ILLNESS This is a 44 social class old Hispanic male who I was kindly asked to admit by Dr. Max Hirsch. The patient is status post arthrodesis of the left ankle and has newly diagnosed diabetes and hypertension. foregone MEDICAL HISTORY Pre-op blood glucose was noted to be greater than 200. The patent asked for a medicine consult/admission for further evaluation.Currently he denies chest pain and shortness of breath. No dysuria, or increased urinary frequency. Past history is significant for hearing loss in the right ear subsequent to an infract several years ago. PAST SURGICAL HISTORY Lower back surgery and a left ankle surgery. SOCIAL HISTORY Patient admits to drink beer on the weekends, some tobacco use, but no illicit drug use, i s divorced with four children, is a long haul truck driver, lives with his fiancee. MEDICATIONS Patient is to admit a list, admits to taking no diabetes meds. PHSYICAL EXAMINATION VITAL SIGNS afebrile, BLOOD PRESSURE 155/98. HEART RATE 69.In general he is in no sharp-worded distress, alert and oriented X4. HEENT Mucus membranes moist. No facial asymmetry. Left ear WNL, Right ear with profound hearing loss. LUNGS clear to auscultation and percussion 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. NEUROLOGIC intact with the exception on cranial fount on the right. LABS CBC within 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 02/15Age 44Sex M Room No. 502 foliate 2 ASSESSMENT AND PLAN 1) Status post ankle arthrodesis tolerated procedure well, will continue to monitor. 2) Diabetes patient with elevated glucose and blood in urine. We will skip over sliding scale for now. Likely needs Lantus. Possible candidate for Metformin. 3) Hypertension We will start lisinopril. 4) Pain we will continue to monitor pain post-op and get out adequate pain control. _____________________________________________________________ Patrick Keathley, MD Endocrinology PH/xx D 10/09/ T 10/10