Admission Info Adir Azibo 02/02/1968

Admission History

Admit DateDischarge DateLocationReason for Visit
YesterdayunknownTRU Simulation HospitalFever NYD

Health History

Source of InformationPatient
Reason for VisitReadmitted last night for fever NYD. Other presenting symptoms are T37.9 C, general malaise, slight SOBOE, poor fluid and food intake last 3 days. Plan course of IV antibiotics for 3 days then oral antibiotics for 7 days.
Health HistoryHigh blood pressure
Obstructive sleep apnea (uses BiPAP at night)
GERD (gastro esophogral reflux disease = heartburn)
Diabetes type 2 – diagnosed 20 years ago – managed with metformin, diet, and exercise. 
BPH (benign prostatic hypertrophy – 5 months)
Height170cmWeight104kgs
Allergies
Penicillin
Reaction type:unknownSeverity:unknown
Language SpokenEnglishReading/WritingEnglish
Family History
Previous Illnesses
ARO ScreeningMRSA:CPO:Close contact with someone positive:
Isolation PrecautionsType:
Surgical HistoryDay of Injury (8 days ago): Adir slipped and fell on an icy day, tearing ligaments in his ankle and fracturing his tibia.  Surgery the next day for Open Reduction and Repair of left tibia. He has a half-slab cast and tensor on his left lower leg.
Post-Op: surgery uneventful, discharged six days ago. Follow up with surgeon in one month. Given ERAS instructions and information on pin site care. Discharge meds: acetaminophen prn and tramadol prn.
WoundsHalf-slab cast and tensor on his left lower leg with exposed pins
Aggressive Behavior ScreeningHistory of Violence:noPhysically violent:noVerbally Aggressive:noAGG FORM
Dietary Historyfluid and food intake last 3 days.Diet Type:diabeticConsistency:
Substance UseType: cigarettes 4-5/dayLast Used:yesterday, trying to quit
Substance UseType:Last Used:
HousingLives in house with spouse, SusanBarriers:Community Support:
Current MedicationsDrugDoseRouteFreqComments
Metformin500mgpoBID
Telmisartan/HCT 80mg/12.5mgpoOD
Pantoprazole40mgpoOD
Ibuprofen600mgpoPRNfor pain

Patient Demographics

Last Name:First Name:Middle Name:Age:DOB:Gender:Marital Status:Ethnicity:Religion:
AziboAdir5602/02/1968Mmarried
Address:StreetApt. #CityProvincePostal CodeMRP
112233 6th StreetKamloopsBC
Home Phone:Cell Phone:
Guarantor/Legal Guardian of Minor (If different from patient)
Last Name:First Name:Middle Name:Age:DOB:Sex:Relation:
Address:StreetApt. #CityProvince:Postal Code
Home PhoneCell Phone
Employer Information
Name
AddressStreetSuite #CityProvince:Postal Code
Primary Insurance Information
Name of Insurance Company:MedicarePhone:
Policy #
Group name:
Group Number:
Insured:Last:First:MI:
Sex:Relation:DOB:
Emergency Contact
Name:SusanRelationship:wife
Address:same as patientCity:
Phone:Province:Postal:

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