HISTORY & PHYSICAL EXAMINATION REPORT
Patient Name: T. J. Moreno
Patient ID: 110497
DOB: 02/15/- - - -
Room No.: 502
Date of Admission: 05/10/- - - -
Admitting Physician: Patrick Keathley, MD, Endocrinology
Chief Complaint: Left ankle pain.
DETAILS OF PRESENT ILLNESS: This is a 44-year-old Hispanic male, when 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: Per-op blood glucose is noted to be greater than 200. The patient asked for a medical consult/admission for further evaluation. Currently he denies chest pain and shortness of breath. No dysuria, no increased urine infrequency. 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 the left ankle surgery.
SOCIAL HISTORY: Patient admits to drinking beer on the weekends, some tobacco use, but no illicit drug use. Divorced with 4 children, 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 155/98, heart rate 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. LUNGS: Clear to oscultation and percussion bilaterally, CV normal, S-1 S-2 without murmurs or rubs. GI: Soft, non-tender, non-distended no HSM. Positive bowel sounds. GENITALIA: deferred. EXTREMETIES: No edema. Has been admitted for left ankle surgery. UROLOGIC: Intact with the exception of cranial nerve ink on the right. LABS: CVC within normal range. Pre-op glucose 239, BUN 8, creatinine 0.5.
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