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 patient asked for a medicine consult/admission for further evaluation. Currently he denies chest pain and shortness of breath. No dysuria, no increased urinary frequency. Past history is significant for hearing loss in the right ear subsequent to an assault several years ago.
PAST SURGICAL HISTORY: Includes a 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. He is divorced with 4 children. He is a long-haul truck driver, lives with his fiancé.
MEDICATIONS: Patient is to provide a list. He admits to taking no diabetes meds.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile. Blood pressure is 155/98 with a heart rate of 69. GENERAL: He is in no acute distress, alert and oriented x4. HEENT: Mucous membranes moist. No facial asymmetry.
Left ear WNL, right ear with profound hearing loss. CHEST: Lungs clear to auscultation and percussion bilaterally. HEART: CV normal. S1, S2 without murmurs or rubs. ABDOMEN: GI soft, non-tender, non-distended. No HSM. Positive bowel sounds. GENITALIA: Deferred. EXTREMITIES: No edema. He has been admitted for left ankle surgery. NEUROLOGIC: Intact with the exception of cranial nerve VIII on the right.
LABS: CBC within normal range. Pre-op glucose at 239. BUN and creatinine of 8 and 0.5. Pre-op UA with 3+ glucose.
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HISTORY AND PHYSICAL/EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: T. J. Moreno
Patient ID: 110497
Date of Admission: 10/09/2013
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ASSESSMENT AND PLAN:
1. Status post ankle arthrodesis, tolerated procedure well. Will continue to monitor. 2. Diabetes. Patient with elevated glucose in blood and urine. We will start sliding scale for now. Likely needs Lantus. Possible candidate for metformin study. 3. Hypertension. We will start lisinopril.
4. Pain. We will continue to monitor pain post-op and provide adequate pain control.
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Patrick Keathley, MD, Endocrinology
PK:vp
D:10/09/2013
T:10/10/2013