Objective Data:
VITAL SIGNS and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add more
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Main Diagnosis: Diabetes mellitus type 2 explain why
Obesity, HTN\