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Diabetic Write-Up

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Diabetic write-up

Encounter Date/Time: 11/09/2014; 1700
Patient Initial: AA
Age: 72 years old
Chief Complaint: “Ulcer on my right foot”
History of Present Illness:
O- 1 week prior to visit
L- Right foot
D- 1 week
C- Painless ulcer
A- Constrictive footwear
R- Therapeutic footwear and rest
T – Wound care, rest

Past Health History:
Adult Medical/Physical * Type 2 diabetes * Hx of foot ulcers * Hyperlipidemia * HTN * BPH
Surgeries
* None
Problems at Birth: Patient reports that she was a full term healthy baby; 7lbs 8oz. Denies any problems at birth.
Childhood Illnesses: The patient reports having had chicken pox.
Immunizations: Patient claims to be up to date on all immunizations. Last flu shot (Fall of 2014) He denies any international travel or related immunizations.

Family Health History:
None
Social History/Health Maintenance Activities:
A.A. is married and lives with his wife. Retired engineer. Inactive lifestyle. Has a daughter that lives in Kansas. * Tobacco * Quit smoking 10 years ago. 2 pk/day x 50 years * Alcohol * Patient reports no alcohol use. * Diet * Patient reports a “regular diet”, “orders take-out often and drinks 4-6 diet cokes each day. * Exercise * Patient reports no regular exercise. * Colon * Patient denies any colon problems. He reports having a “normal” BM once daily or every other day. * Dental * Patient reports annual dental appointments. No complaints. * Skin * A.A. reports no regular dermatology appointments. He reports wearing sunscreen with prolonged sun exposure. * Eyes * Patient claims to have “good” vision. He does not report wearing glasses/contacts. Reports having last eye appointment last year. * Safety * Patient reports wearing seatbelt when in an automobile and

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