Asthma: no hospitalizations for exacerbation.
DM II
PSHx:
Denies
SHx:
Former tobacco user: ceased smoking 2 years ago. Had smoked 1ppd x 5 years
ETOH: socially
Illicit drugs: denies
FHx:
Significant for paternal DM, otherwise unremarkable
Medications:
Metformin: 500mg BID po - did not take the last few days
Albuterol MDI: 2 puffs every 6 hours prn - last use just PTA
Singulair: 10mg po daily
Trinessa: 1 tab po daily - last taken this am
Allergies:
PCN: hives
LNMP: 2 weeks ago.
G0p0
ROS:
General: denies any weight changes, fatigue or fever; + body aches
Skin: denies any rashes; + wound to left foot
HEENT: denies headache, head injury, dizziness, lightheadedness;
Denies any vision changes
Denies any hearing changes, tinnitus, vertigo, earache
Denies any nasal congestion, discharge, nose bleeds or sinus tenderness
Denies any sore throat, difficulty swallowing
Neck: denies any swollen glands, pain
Breasts: denies any pain, discharge
Respiratory: denies any dyspnea; positive cough and wheezing
CV: denies any chest pain, edema
GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools
PV: denies claudication, swelling to LE
GU: denies frequency, urgency, burning;
Denies vaginal discharge, itching, sores
Denies penile discharge, itching or sores
MS: positive pain to left foot
Psych: denies nervousness, depression
Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE
Heme: denies any easy bruising
Physical Exam:
Vital signs: 100.5 (tympanic), 162/88, 118, 22, O2 sat 95% on RA
Height: 5’5” Weight: 250 lbs.
Blood glucose: 230 (Fasting; states has not eaten yet today)
patient awake, alert, oriented x 4 in NAD
Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drng; + surrounding erythema extending up 7 cm proximally
HEENT: head nontraumatic, normocephalic
Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted
Ears: bilateral TM with good cone of light and intact
Nose: mucosa pink, septum midline; no sinus tenderness appreciated
Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate
Neck: supple; trachea midline; no LAD
Resp: regular and unlabored; lungs with end expiratory wheezing throughout
CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated
Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion
Genitalia: deferred
Rectal: deferred
Extremities: warm and without edema; calves supple, non-tender
PV: no LE edema
MS: + swelling to left foot; + tenderness of 2-4th left metatarsals; + left pedal pulse; CMS intact; Cap refill < 2 sec.
Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact