Case 8 H&P Gerald Edwards
Student Name:____________Chamila Brown__________________________ Case No.______8_____ Student Number:__________21098154_______________________________
HILLCREST MEDICAL CENTER
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Gerald Edwards
Hospital No.: 11058
Room No.: 481
Date of Admission: 07/15/2010
Admitting Physician: Catherine Baker, MD
Admitting Diagnosis: Complications of known diabetes mellitus.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old black individual a patient of Dr. Shelton, who has had diabetes for at least six months, but he thinks it has been longer than that. He says his last known blood sugar was in the 300’s. He presents in the ER today with a foot ulcer since January of this year. He stated that it started with blisters where he had soaked his feet too long in hot water. He has had no eye examination for two years. There has been no surveillance of chronic complications of diabetes.
PAST MEDICAL HISTORY: Allergies: No known allergies. He has had measles, mumps, and chicken pox. Denies scarlet, rheumatic, or typhoid fever. No epilepsy, cancer, tuberculosis, tuberculosis contact, STDs, AIDS, or whooping cough. In 2000 he was admitted to the hospital for an anxiety attack, at that time he weighed 382 pounds. He had a T&A at five years of age. He had all of his teeth removed ten years ago. He had a skin graph to his right foot ulcer in March of this year.
CURRENT MEDICATIONS: 1. Trental 400 mg p.o. t.i.d. with meals 2. Cipro unknown dosage
(Continued)
Student Name:_____________Chamila Brown_________________________ Case No.:______8_____
Student Number:___________21098154_____________________________
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Gerald Edwards
Hospital No.: 11058
Page 2
FAMILY HISTORY: Mother died at age 73 from cancer of the left breast. Father died at age of 56 from alcoholism. He has two brothers 42 and 45 both alive and well. He had two
HILLCREST MEDICAL CENTER
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Gerald Edwards
Hospital No.: 11058
Room No.: 481
Date of Admission: 07/15/2010
Admitting Physician: Catherine Baker, MD
Admitting Diagnosis: Complications of known diabetes mellitus.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old black individual a patient of Dr. Shelton, who has had diabetes for at least six months, but he thinks it has been longer than that. He says his last known blood sugar was in the 300’s. He presents in the ER today with a foot ulcer since January of this year. He stated that it started with blisters where he had soaked his feet too long in hot water. He has had no eye examination for two years. There has been no surveillance of chronic complications of diabetes.
PAST MEDICAL HISTORY: Allergies: No known allergies. He has had measles, mumps, and chicken pox. Denies scarlet, rheumatic, or typhoid fever. No epilepsy, cancer, tuberculosis, tuberculosis contact, STDs, AIDS, or whooping cough. In 2000 he was admitted to the hospital for an anxiety attack, at that time he weighed 382 pounds. He had a T&A at five years of age. He had all of his teeth removed ten years ago. He had a skin graph to his right foot ulcer in March of this year.
CURRENT MEDICATIONS: 1. Trental 400 mg p.o. t.i.d. with meals 2. Cipro unknown dosage
(Continued)
Student Name:_____________Chamila Brown_________________________ Case No.:______8_____
Student Number:___________21098154_____________________________
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Gerald Edwards
Hospital No.: 11058
Page 2
FAMILY HISTORY: Mother died at age 73 from cancer of the left breast. Father died at age of 56 from alcoholism. He has two brothers 42 and 45 both alive and well. He had two