video of the patient i recommend to watch this please

https://www.youtube.com/watch?v=aULRXQaHFbA

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

step to complete for this assignment i recommend to follow:

Assessment

PMHx:

Anthropometrics:

HT:

Biochemical data/clinical data:

Diet Rx:

Social Hx:

Meds:

Diet History:

diet order:

LABS:

EST. NUTRITION NEEDS:

EST . FLUID NEEDS:

Estimated Energy Intake:

Diagnosis:

Intervention:

DIET PRESCRIPTION:

Goal:

I-EDUCATION:

Recommend

Goal:

Monitoring/E