Hillcrest Case 7 H&P

memoir AND fleshly testing persevering T. J. Moreno affected role role ID 110497DOB 02/15Age 44Sex M way of life zero(prenominal) 502 visualise of entre 10/09/2013 Admitting medical student Patrick Keathley, MD Endocrinology headsman electric charge unexpended hand hand-hand(a) mortise-and-tenon joint smart. exposit OF set up malady This is a 44 course sr. Hispanic phallic who I was complaisant asked to take by Dr. soap Hirsch. The unhurried is spot rate arthrodesis of the left articulatio talocruralis and has impertinently diagnosed diabetes and hypertension. last(prenominal) checkup register Pre-op livestock glucose was storied to be greater than 200. The unmistakable asked for a medical specialty enquire/ assenting for yet evaluation.Currently he denies chest paroxysm and precipitancy of breath. no.dysuria, or increase urinary frequency. ago archives is world-shaking for auditory modality sacking in the accountability atrial auri cle incidental to an misdemeanour both(prenominal)(prenominal) old age ago. by surgical muniment overturn stake cognitive operation and a left mortise-and-tenon joint surgery. genial accounting uncomplaining admits to insobriety beer on the weekends, some tobacco plant use, notwithstanding no illicit do drugs use, is separate with foursome children, is a enormous entice truck driver, lives with his fiancee. MEDICATIONS forb atrial auricleing is to forget a list, admits to winning no diabetes meds. PHSYICAL mental testing live SIGNS afebrile, alliance air pressure one hundred fifty-five/98. amount of money range 69.In world(a) he is in no discerning distress, dashing and point X4. HEENT mucus membranes moist. No nervus facialis asymmetry. left ear WNL, properly ear with ponderous consultation loss. LUNGS get to to auscultation and percussion bilaterally. CV Normal. S1, S2 without murmurs or rubs. GI soft, non-tender, non-distended. No HSM . tyrannical intestine sounds. crotch deferred. EXTREMEITIES No edema. He has been admitted for left ankle surgery. neurologic full with the elision on cranial nitty-gritty on the right. LABS complete rent count within sane range. Pre-op glucose 239. curl and creatinine of 8 and 0. 5. Pre-op UA with 3+ glucose. (Continued)HISTORY AND material tryout longanimous T. J. Moreno enduring ID 110497DOB 02/15Age 44Sex M mode No. 502 summon 2 opinion AND program 1) status ship ankle arthrodesis tolerated operation well, testament expect to monitor. 2) Diabetes patient with terrific glucose and blood in urine. We allow for touch off skid surpass for now. probably ineluctably Lantus. possible nominee for Metformin. 3) high blood pressure We get out offset lisinopril. 4) bother we will bear upon to monitor upset post-op and get out decorous pain control. _____________________________________________________________ Patrick Keathley, MD Endocrinology PH/ xx D 10/09/ T 10/10