Hillcrest Case 7 H&P

account AND tangible EXAM longanimous 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 joint hurt. exposit OF PRESENT ILLNESS This is a 44 year old Hispanic male who I was kindly asked to admit by Dr. Max Hirsch. The tolerant 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 annals is significant for hearing loss in the right ear consequent to an assault several years ago. PAST SURGICAL HISTORY overturn 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 divorc ed with four children, is a long lead truck driver, lives with his fiancee. MEDICATIONS Patient is to provide a list, admits to taking no diabetes meds. PHSYICAL scrutiny VITAL SIGNS afebrile, BLOOD PRESSURE 155/98. HEART RATE 69.In normal he is in no acute distress, alert and oriented X4. HEENT mucous secretion membranes moist. No facial asymmetry. Left ear WNL, Right ear with sullen 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 rapscallion 2 ASSESSMENT AND PLAN 1) Status po st ankle arthrodesis tolerated execution well, pass on continue to monitoring device. 2) Diabetes patient with elevated glucose and blood in urine. We will start sliding scale for now. Likely needs Lantus. Possible scene 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