Patient Demographic Information and History
Initials: DT Age: 54 Sex: M
Date of admission: 9/18/2006 Date of Surgery, if applicable: 9/25/2006
Date assigned to Patient: 9/28/2006
1. Primary medical diagnosis: Diabetes Mellitus Type II
2. Reason for admission—Briefly describe signs, symptoms, and events that led to this hospitalization.
Presented to ED with SOB, vomiting, chest pressure, anorexia, and an infected, slow-healing foot wound. Blood glucose was 579 mg/dL and BUN was 21. Was admitted with exacerbation of unmanaged diabetes mellitus, diabetic ketoacidosis, and gastritis r/t excess aspirin intake.
3. Significant Secondary Medical Diagnoses and Past Medical History (include past hospitalizations/surgeries)
Medical hx: Essential HTN, hyperlipidemia, hypercholesterolemia, GERD, DVT, & neuralgia. Surgical debridement of foot wound on 9/25.
Name Dose Frequency Purpose for taking
Insulin glargine 40 units qhs blood glucose management
Novolin-R sliding scale ac & hs blood glucose management
Avandia 4 mg bid blood glucose management
Ampicillin 3g q6h tx of foot infection
Ceftriaxone 1 g q24h tx of foot infection
Aspirin 81 mg qd prevention of MI
Lipitor 10 mg qhs lower blood cholesterol
Lovenox 40 mg q24h prevent thromboses
Neurontin 300 mg q12h relieve neuralgia
Metoprolol 25 mg qd manage HTN
Valsartan 80 mg qd manage HTN
Pantoprazole 40 mg q24h prevent acid reflux
Tramadol 50 mg qd relieve pain r/t foot wound
Dilaudid 3 mg q4h prn relieve pain r/t foot wound
(Deglin et al., 2005)
5. Prescribed diet: 1800 calorie diabetic diet
Educational Readiness Assessment
1. What is the patient’s current understanding of the health problem and/or medical diagnosis?
He understands the basic pathophysiology of the diabetic disease process. Until this hospitalization, he was unaware of some of the potential complications associated with diabetes