FM- H&P

Identifying Data:

Full Name: RJ

Address: St. Alban, NY

Date of Birth: xx/xx/1990

Date & Time: 2/10/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: “I’m always thirsty.” x 3 months.

History of Present Illness:

31 y/o male with no previous medical history presents for annual physical exam, c/o increased thirst and urination for 3 months. He reports drinking 2 liters of water daily and still feels thirsty. Patient has been taking Metamucil for the past 2 months to help alleviate symptoms. Patient states he was trying to lose weight by eating healthier. Patient reports 47 lb weight loss over the past 2 months (240lb – 193lb). Denies dysuria, hematuria, abdominal pain, decreased appetite, weakness, fatigue, dizziness, palpitation, and chest pain.

Past Medical History:

None

Past Surgical History:

Denies past surgical history

Medication:

Metamucil: 1 scoop in 8oz of water, once daily

Allergies:

NKDA

Family History:

Mother: alive, diabetes mellitus, hypertension, anemia

Father: alive, hypertension

Brother: alive, ADHD

Denied family history of substance abuse

Social History:

Habits: Denies tobacco and illicit drug use. Drinks 2 bottles of beer per week.

Travel: No recent travel

Marital History: Single

Sexual History: Sexually active with girlfriend. Denies history of STD

Occupation: Works at post office

Home: Living with girlfriend

Diet: Reports that he consumes a balanced diet, has been eating more lean meat and vegetables, and less carb in the past 2 months

Exercise: Reports that he doesn’t exercise regularly

Review of System:

GeneralAdmitted to recent weight loss. Denied decreased appetite, fatigue, fever, and night sweats

SkinAdmitted to dryness of skin. Denied moles, change of skin texture, sweating, itchiness.

Head – Denied headache, light-headedness, recent head trauma.

Eyes –Denied visual changes.

Ears – Denied tinnitus, deafness, pain, discharge, or use of hearing aids.

Nose – Denied discharge, obstruction, epistaxis, loss of smell, itchiness.

Mouth/throat – Denied sore throat, bleeding gum, mouth ulcers, voice change.

Pulmonary system –Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain, palpitations, syncope or known heart murmur.

Gastrointestinal system – Denied dysphagia, abdominal pain, constipation, diarrhea, and hemorrhoids.

Genitourinary systemAdmitted to urinary frequency. Denied urinary urgency, oliguria and incontinence.

Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.

Musculoskeletal system – Denied joint pain, back pain and muscle pain.

Endocrine system Admitted to polydipsia. Denied polyphagia, heat intolerance, goiter, or excessive sweating.

Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 98.1 F, oral

BP: 129/93, sitting

Pulse: 96, regular

RR: 16/min, unlabored

O2 saturation: 98% room air

Ht: 69 in

Wt: 193 lb

BMI: 28.5

On general inspection, patient is not in acute distress, appears his stated age, well developed and well groomed. AAO x 3. Lungs clear to auscultation bilaterally, heart has regular rate and rhythm. Overall no abdominal findings on his physical exam.

Finger stick was done, and showed glucose of 473.

General – AAO X3. Not in acute distress. Appears his stated age. Well developed and well groomed.

Skin –Warm and dry, good turgor. No lesions, no rashes, no jaundice.

Hair – Average quantity and distribution

Nails – No clubbing, capillary refill <2 seconds on fingers and toes.

Head – Normocephalic, atraumatic, non-tender to palpation throughout

Ears – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex.

Eyes – Symmetrical OU. EOMs intact with no nystagmus. No conjunctival injection, pallor, or scleral icterus.

Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.

Neck – Trachea midline. No palpable masses, no thyromegaly. No cervical adenopathy noted.

Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout

Lungs– Clear to auscultation bilaterally, no wheezes/rhonchi/rales.

Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs. No splitting of S2 or friction rubs appreciated.

Abdomen –Non-distended. Bowel sounds normoactive in all four quadrants. Non-tender to palpation throughout, no guarding or rebound noted. No CVA tenderness.

Musculoskeletal – Full passive and active range of motion in shoulders, elbows, wrist, hips, knees, and ankles. No soft tissue swelling, erythema, deformities in bilateral upper and lower extremities. Non-tender to palpation. No crepitus noted throughout.

Neurologic – Sensation intact to touch in bilateral upper and lower extremities. Strength 5/5 in bilateral upper/lower extremities.

Peripheral Vascular – Extremities are symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities.

Labs:

Finger stick blood glucose: 473 mg/dl

DDx:

  • Type I Diabetes
  • Type II Diabetes

Assessment:

31 y/o male with no past medical history here for annual physical, c/o increased thirst and urination for 3 months, and 47 lb weight loss over the past 2 months. Finger stick showed blood glucose of 473mg/dl. Patient’s symptoms and finger stick result consistent with diabetes.

Problem list:

  1. Newly diagnosed diabetes
  2. Encounter for annual physical

Plan:

Newly diagnosed diabetes

  • Labs: CMP, Hbg A1C, C-peptide
  • Patient is asymptomatic, give 10 units of regular insulin in office
  • Repeat finger stick in 45 mins, discharge home if remains asymptomatic
  • Start insulin glargine, 20 units, SC, daily at bedtime until next follow up
  • Start insulin glulisine, 5 units, SC, twice a day with meal until next follow up
  • Educate patient on insulin administration and glucometer use and documentation
  • Educate patient on s/s of hypoglycemia and action to eat candy or sweet drink immediately
  • Referral to Endocrinologist for evaluation of newly diagnosed diabetes
  • Referral to nutritionist for evaluation and education on proper nutrition
  • Follow up in 2 weeks for lab report

Encounter for annual physical

  • Labs: CBC w/diff, lipid profile, TSH/FT4 reflex, urinalysis, Hep C ab, HIV Ag/Ab screen by CMIA, syphilis

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