SECTION I: Introduction/Assessment Data
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.
4. Medications:
Name Dose Frequency Purpose for taking
Insulin......
Join Now or Login to view the rest of this paper.
Approximate Word Count: 1314
Approximate Pages: 6 (260 words per double-spaced page) |