Mr. Hamilton Case Summary
SUBJECTIVE
Mr. Hamilton was readmitted to MCCRC on 03/02 and seen on 03/05/2018. Mr. Hamilton had been here after a motor vehicle accident, leaving here with fractured ribs, pneumonitis, fractured sternal, and a complicated right acetabular hip fracture. He recuperated and was able to return home on analgesics. He was on amiodarone, Lasix, metformin, and glimepiride for his diabetes. He did not check his blood sugar, although I had advised him to do so. He has been thinking his diabetes is a static disease for which he was placed on medication, 15 years ago and that was the end of it. He has now had a total hip replacement and was up during the night, confused and fell hitting his head, probably not hurting his hip, and was seen by the orthopedist today who reassures us that the x-ray looks okay and there is no damage. He also bumped his left knee. Mr. Hamilton says he has been eating okay and now this afternoon his blood sugar is up to 300. He denies cough, congestion, chest pain, or urinary issues. I was told the scar looked good today.
Review of systems reveals that he has had atrial fib in the past. He has not presently anticoagulated. He is sent to us on aspirin 325 twice daily as an anticoagulant.
OBJECTIVE …show more content…
Mental status is good. Pupils are equal and react to light. EAC are clear. TM are normal. Extraocular muscles are intact. Tongue protrudes in the midline. I hear no carotid bruits. The neck is supple. Lung fields show a few scattered rhonchi, but no worrisome wheezes. No consolidations noted. His heart rhythm is regular. No ectopy is noted. The PMI is displaced slightly laterally. Abdomen is soft, nontender. No organomegaly is noted. Liver span is about 8 cm. Spleen cannot be felt. There is no suprapubic tenderness. Peripheral pulses are present. There is no calf tenderness. No ankle edema, and I am told that the orthopedist examined the scar and it looked
Mr. Hamilton was readmitted to MCCRC on 03/02 and seen on 03/05/2018. Mr. Hamilton had been here after a motor vehicle accident, leaving here with fractured ribs, pneumonitis, fractured sternal, and a complicated right acetabular hip fracture. He recuperated and was able to return home on analgesics. He was on amiodarone, Lasix, metformin, and glimepiride for his diabetes. He did not check his blood sugar, although I had advised him to do so. He has been thinking his diabetes is a static disease for which he was placed on medication, 15 years ago and that was the end of it. He has now had a total hip replacement and was up during the night, confused and fell hitting his head, probably not hurting his hip, and was seen by the orthopedist today who reassures us that the x-ray looks okay and there is no damage. He also bumped his left knee. Mr. Hamilton says he has been eating okay and now this afternoon his blood sugar is up to 300. He denies cough, congestion, chest pain, or urinary issues. I was told the scar looked good today.
Review of systems reveals that he has had atrial fib in the past. He has not presently anticoagulated. He is sent to us on aspirin 325 twice daily as an anticoagulant.
OBJECTIVE …show more content…
Mental status is good. Pupils are equal and react to light. EAC are clear. TM are normal. Extraocular muscles are intact. Tongue protrudes in the midline. I hear no carotid bruits. The neck is supple. Lung fields show a few scattered rhonchi, but no worrisome wheezes. No consolidations noted. His heart rhythm is regular. No ectopy is noted. The PMI is displaced slightly laterally. Abdomen is soft, nontender. No organomegaly is noted. Liver span is about 8 cm. Spleen cannot be felt. There is no suprapubic tenderness. Peripheral pulses are present. There is no calf tenderness. No ankle edema, and I am told that the orthopedist examined the scar and it looked