Patient Encounter 2 Part 2 Diabetic Foot Infection Medical History Physical Examination and Diagnostic Tests

PMH: Type 1 diabetes mellitus ^ 37 years, hypertension, dyslipidemia, peripheral neuropathy, and GERD

FH: Father died of an MI at age 77; mother died at age 56 of esophageal cancer. Two siblings alive with no significant PMH.

SH: Divorced, with two teenage children who live with their mother. Works in the computer tech industry. Smoked 1 PPD for 20 years, quit at age 39. Denies alcohol use.

Meds: Lantus 55 units at bedtime, Humalog Sliding Scale with meals, lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, Lipitor 40 mg at bedtime, gabapentin 600 mg three times daily, Prilosec OTC 20 mg daily, and aspirin 81 mg daily

Allergies: Sulfa (rash)

ROS: (+) left foot findings per HPI; (-) headache, chest pain, shortness of breath, cough, nausea, vomiting, diarrhea, and weight loss

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