Resident Admission Note

CC: "I was in an accident and brokemy leg"

HPI:

47 y/o WM with no significant PMHx that was BIBA, s/p MVA with resulting left femoral fracture and is POD 1 for ORIF is found to have elevated glucose during observation and stabilization in the 300+ range on Q6HR FSG checks. His labs are negative for ketosis. He has not shown any signs or symptoms of hyperosmolar coma post operatively. HgbA1C is 13% and pt is unaware of a family history of diabetes. He denies blurry vision, nocturia and urinary frequency. He denies numbness or tingling or swelling in his extremities. His hospital stay has been uncomplicated.

PMHx: See Above

PSurgHx: See Above

FHx: Allergies: NKDA

Meds: Colace PRN, St. John's Wort

Social Hx: IT technician that is married with 2 teen children from prior marriage. Denies smoking, drug use. Dinks 3-5 alcohol beverages per week. Sedentary lifestyle and drinks colas regularly.

FMHx: See Above

ROS:

General: 10 lb weight gain in the past 6 mos

GI: + for constipation and heartburn

MS: See Above

Psychosocial: See Above

Physical Exam;

HEENT: PERRLA

Neck: supple, no lymphadenopathy

Lungs: CTA bilaterally

CV: RRR, S1S2 without murmurs

Abd: NTND, normoactive BS

Ext: Left leg in dressing. Dorsalis pedis pulse is 1+ bilaterally. 1+ pitting edema distal to dressing on left lower extremity.

Neuro: AAOX3, CN 2 through 12 intact, reflexes intact

Labs: See HPI

Problem List:

1. s/p ORIF, POD 1, for left femoral fracture
2. Uncontrolled Type 2 DM without complications

Summary:

47 y/o WM with no significant PMHx that was BIBA, s/p MVA with resulting left femoral fracture and is POD 1 for ORIF and newly dx'd Type 2 DM with hyperglycemia.

Problem 1: s/p ORIF, POD 1, for left femoral fracture

Plan: Consult Ortho Surgery, Consult PT, DVT PPX, Tramadol APAP 37.5/325 mg tablets PO Q6HR PRN for 5 days.

Problem 2: Uncontrolled Type 2 DM without complications

Plan: Sliding Scale Insulin, FSG checks every 2 hours postprandial, AM fasting and at bedtime, CMP and UA every day, Consult Nutrition, Consult Endocrinology

Admit to Med Surg Unit

Dx: 1. s/p ORIF of left femur, 2. Uncontrolled Type 2 DM without complications

VS Q6HR

Activities: ad lib with assistance if needed. Use crutches with ambulation. Leg dressing change after assisted shower.

Allergies: NKDA

Diet: 2000 kcal consistent CHO diet

Ins: IVF, NS at 50 mL per hour

Outs: toilet or urinal without output measure

Daily Weight

Labs drawn by Phlebotomy Tech, FSG checks by RN or CAN

Sanjay Adjay, MD

Dr. Adjay 303-253-5678