1/29/2016, 1300, Vital signs: BP 138/88, T100.6, P99, RR20. UTI caused rash, no other allergies. 54 years old male patient admitted to Medical Unit. No family in attendance. Came from homeless shelter. PT has infection and swelling of left foot off and since he broke foot approximately 4 year ago in a motorcycle accident. Fractures of metatarsals and left malleolus. Diabetes Mellitus type 2. Alcohol abuse developed after this accident. Smoked 2 packs per day since age 18.
Motorcycle accident 4 years ago resulting in foot fracture and subsequent infection, alcoholism and type 2 diabetes. Cellulitis with osteomyelitis of left foot, type 2 diabetes, al
Neuro-Alert and oriented to person, place, time and situation. Pt denies problems with headaches, dizziness, tremors, or numbness. Pt is in no visible distress. Pupils 2 mm diameter, bilaterally equal and reactive light. Ear without swelling, large amount of cerumen in ear canal. Nares clear, no redness, drainage or swelling.
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S1 and S2 auscultated. No murmurs, rubs or clicks. No history of heart disease. No c/o of any chest pain.
GI-Last bowel movement on Tuesday of formed brown stool. Bowel sound x 4. No anal fissure or hemorrhoids. Reports normal bowel