Physician Reports Adir Azibo DOB 02/02/1968
MRP
| Date | Time | Focus | Report File | MRP | ||||||
| Yesterday | 2330 | Admission Report | Martial Status: married x 32 years. Occupation: manager of accounting firm, works from home most days Social History: lives with spouse. One grown child (Susan) who lives out of town. Active social life. Was more physically active prior to the pandemic. Weight gain x 20 pounds (10kg) last year due to sedentary life and eating habits. States he smokes 4-5 cigarettes/day, trying to quit. Medical History: Health Issues: High blood pressure Obstructive sleep apnea (uses BiPAP at night) GERD (gastro esophageal reflux disease = heartburn) Diabetes type 2 – diagnosed 20 years ago – managed with metformin, diet, and exercise. BPH (benign prostatic hypertrophy – 5 months) His medications at home are: • Metformin 500mg po BID • Telmisartan/HCT 80mg/12.5mg po OD • Pantoprazole 40mg po OD • Ibuprofen 600mg po PRN for pain Day 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. Day of re-admission: Readmitted 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. | |||||||
