Case 8 HP Gerald Edwards Essay - 611 Words

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†¦show more content†¦He has three children a 19-year-old son, a 24-year-old son, and a 27-year-old daughter all alive and well. He has a first cousin with diabetes other than that there is no family history of diabetes. SOCIAL HISTORY: He smokes two packs of cigarettes per day. He drinks a rare beer. He is divorced and lives alone. He is Protestant, has a 10th grade education, and works at Taylor Auto Body Repair. REVIEW OF SYSTEMS: Essentially negative with the exception of numb feet and a headache. PHYSICAL EXAMINATION: HEENT: Tympanic membranes and external auditory canals are within normal limits. Throat is clear with no gingival lesions. He is ______________. No obvious proliferate retinopoathy. NECK: No carotid bruit. No thyroid enlargement. LUNGS: Clear to auscultation. HEART: No S3, S4 or murmurs. ABDOMEN: Soft with no organomegaly. Normal bowel sounds. FEET: Good dorsalis and posterior tibial pulses bilaterally. Left foot has no abrasions, lesions, sores or ulcers. Right foot shows obvious deformity from previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has an obvious foot ulcer located over the instep of his right foot, full thickness. There is tracking to the broken foot, to which the ulcer area is connected and there is a question of osteomyelitis in this area. PLAN: Admit the patient for IV antibiotics,Show MoreRelatedEbooks Solution Manuals and Test Banks for Text Books19223 Words   |  77 PagesHealth by Rebecca J. Donatelle, Emeritus,Patricia Ketcham 12 Instructor’s Manual Access to Health by Rebecca J. Donatelle, Emeritus,Patricia Ketcham 12 Test Bank Accounting and Auditing Research Tools and Strategies by Weirich, Pearson, Churyk 7 Cases Solutions Accounting and Auditing Research Tools and Strategies by Weirich, Pearson, Churyk 7 Solution Manual Accounting by Carl S. Warren, James M. Reeve 24 Instructor’s Manual Accounting by Carl S. Warren, James M. 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