Report Example: Diabetes Mellitus Evaluation Prior to Surgery

CHIEF COMPLAINT: Diabetes mellitus evaluation prior to surgery.

PRESENTING ILLNESS: The patient is a twenty-seven-year-old white male referred by Dr. zatts for evaluation before surgery because of his diabetes mellitus. The patient apparently was involved in a car accident last month and broke some of his nasal bones and septum, and this is to be repaired tomorrow. The patient has a history of diabetes that has been fairly controlled, and evaluation was undertaken for this reason. His nose is slightly painful, and he does have some headaches since his accident.

PAST MEDICAL HISTORY:

Surgeries: There is no history of surgeries.

Hospitalizations: The patient was found to have diabetes mellitus at age eight and has had multiple hospitalizations since that time. He had one episode when he had a hyperglycemic coma because his glucose was too high. The patient has never been hospitalized because of hypoglycemia. His last admission was approximately four years ago to University City hospital for dental work. The patient has had irregular follow up and is aware of some of the things he should do about his diabetes, but he has not conformed to them nor has he checked his urine. He is not following a diabetic diet, he frequently skips meals, he drinks excessively, and when he drinks or skips meals, he sometimes will vary the amount of his regular insulin he has. No family history of diabetes mellitus.

Medication: No additional medicine taken.

Allergies: No known drug or food allergies.

FAMILY HISTORY: No family history of diabetes mellitus. The father died at age forty-four years from cancer, and he also had a heart problem. The mother died at age Sixty-one years from breast cancer, and she also had an ulcer. The patient has two sisters, and they are alive and well and one brother who is also active, and well his wife is twenty-eight alive and well. The patient has one child who is alive and well.

SOCIAL HISTORY: The patient was born in Alberta and has lived in Toronto for the last six years. He is a high school graduate and was married in 2005. He is a new car salesman.

Habits: He smokes one pack a day drinks up to a six pack a day does not use drugs.

REVIEW OF SYSTEMS: The patient has had some decreased vision lately which seems to fluctuate as his diabetes fluctuates otherwise unremarkable physical examination.

PHYSICAL EXAMINATION:

General: I found a twenty-seven-year-old appearing his stated age in no acute distress.

Vitals: Blood pressure was120/80, pulse was 80 beats per minute, and regular respiration rate was 16 breaths per minute.

Heent: Ears temporal membranes are occluded.

Eyes: Conjunctivae are pink sclera are non-icteric, extraocular movements are full, pupils are equal and reactive to light, fundi show flat disks no hemorrhages or exudates. The vessels are normal with no evidence of diabetic retinopathy.

Oropharynx: Benign neck supple carotid upstroke is normal no carotid bruits thyroid is in the midline back no spinal or costovertebral angle tenderness.

Chest: Lungs clear to percussion and auscultation, no jugular venous distensions, s1 and s2 are normal no murmur or gallop.

Per abdomen: No abdominal tenderness no hepatosplenomegaly bowel sounds are normal.

Genitourinary system: Normal male no testicular masses or tenderness rectal no masses or tenderness prostate is normal.

Extremities: No finger clubbing, no cyanosis or edema, and distal pulses are intact.

Central nervous system: Within normal limits.

IMPRESSION AND PLAN: The patient is to be admitted tomorrow for repair of his facial fracture. He will need to have his diabetes closely controlled while in the hospital.