History and Physical Examination Progress Notes ADMITMD: DIAMOND, ELIZABETH HISTORY…

History and Physical Examination Progress Notes ADMITMD: DIAMOND, ELIZABETH HISTORY AND PHYSICAL EXAMINATION CHIEF COMPLAINT: Weakness. HISTORY OF PRESENT ILLNESS: Patient is a known type 2 diabetic who is living at home. Apparently he developed cough and increasing weakness about 48 hours prior to admission. It is uncertain whether he had any fever at home, but because of the increasing weakness, he was unable to get out of bed. He was brought to the emergency room and found to be in significant respiratory distress and fairly unresponsive. He was in a very poor historian because he really did not answer many questions at all. He was found to be in atrial fibrillation with a normal blood glucose level. He was given Digoxin IV in the emergency room as well as put on a diltiazem drip which improved his rate somewhat, however, his blood pressure came down to around only 100 systolic. He was somewhat improved, however, and was admitted to the coronary unit. PAST MEDICAL HISTORY: Type 2 diabetes mellitus, peptic ulcer disease, degenerative arthritis. Previous surgeries: 1998 right lung lobectomy, 1983 TURP, 1994 cholecystectomy. Other hospitalizations for hepatitis secondary to sulfa reaction. Allergies to sulfa. CURRENT MEDICATIONS: Glucophage 500 mg two with breakfast, one with lunch, two with supper, Glipizide 10 mg po tid. SOCIAL HISTORY: Does not smoke or drink alcohol. Caffeine occasionally. FAMILY HISTORY: He had a sister, brother and cousin with diabetes. He also had a brother with multiple myeloma. He has one brother with CHF: No family history of atherosclerotic heart disease. Search