Hillcrest Case 7 H&P

HISTORY AND PHYSICAL EXAM Patient: T. J. Moreno Patient ID: 110497DOB: 02/15Age: 44Sex: M Room No. : 502 Date of Admission: 10/09/2013 Admitting Physician: Patrick Keathley, MD Endocrinology Chief Complaint: Left ankle pain. DETAILS OF PRESENT ILLNESS: This is a 44 year 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. PAST 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 assault several years ago. PAST SURGICAL HISTORY: Lower 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 f our children, is a long haul truck driver, lives with his fiancee. MEDICATIONS: Patient is to provide 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 acute 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 nerve 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 Page: 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 start 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 provide adequate pain control. _____________________________________________________________ Patrick Keathley, MD Endocrinology PH/xx D: 10/09/ T: 10/10