I need help with a history and physical examination report .
present complaint patient is a (twenty-seven/27) year old white male referred by dr zatts for evaluation before surgery because of his diabetes mellitus patient apparently was involved in a car accident last month and broke some of his nasal bones and septum 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 he does have some headaches since his accident
- past medical history
- surgeries none
- hospitalizations patient was found to have diabetes mellitus at age (8/eight) and has had multiple hospitalizations since that time he had (1/one) episode when he had a hyperglycemic coma because his glucose was too high he has never been hospitalized because his glucose was too low his last admission was approximately ( four/4 years) ago to university city hospital for dental work the patient has had irregular followup and is aware of some of the things 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 mealshe 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
- medical none additional
- medications none
- allergies no known allergies
- family history father died at age (44/forty-four) from cancer also had a heart problem mother died at age (sixty- one/61) from breast cancer also had an ulcer he has (2/two) sisters alive and well and (one/1) brother alive and well his wife is (twenty-eight/28) alive and well and he has (1/one) child alive and well
- social history the patient was born in alberta and has lived in toronto for the last (six/6) years he is a high school graduate was married in 2005 he is a new car salesman
- habits he smokes (one/1) pack a day drinks up to a (6/six) pack a day does not use drugs
- review of systems he has had some decreased vision lately which seems to fluctuate as his diabetes fluctuates otherwise unremarkable
- physical examination
- general on physical examination i found a (twenty-seven/27) year old appearing his stated age in no acute distress blood presssure (one hndred twenty over eighty/120/80) pulse (eighty/80)and regular respirations (16/sixteen)
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