Question

please help me fill out Database based on Case Study

w the case stady for patient Concept Map Case Study Mr. Al Soto is a 67 year old Hispanic male admitted with the medical diagnosis of hyperglycemia secondary to uncontrolled non-insulin type diabetes mellitus (DM). Mr. Soto has been diagnosed with DM for two years and has been controlled with diet, exercise, and oral hypoglycemic medications. Mr. Soto admits to forgetting to take his medications despite a home care nurse coming to his home to prepour his medications on a weekly basis. His medications are Glucotrol XL 5 mg PO daily. Metformin 500 mg TID PO with food, and Lisinopril 2.5 mg PO daily. Additionally, Mr. Soto receives home health aide (HHA) support and physical therapy (PT). Mr. Soto has a past medical history of Hypertension (HTN)and he had multiple hospital admissions - (Last month's hospitalization was secondary to S/P Fall), Mr. Soto has NKDA or No Food Allergies. Mr. Soto lives with his son in a two-story house. His son is a busy attorney who travels constantly. Mr. Soto is a retired postman and he has been a widower for 3 years. You are the Nurse assigned to Mr. Soto. It is the beginning of your shift at 7am and you perform a head to toe assessment. These are your findings: T= 99.80F, P=98, R=22, BP= 106/78, Pain= 5-6/10, HT5'8", Wt-235 lbs., FBS200 mg/dl WBC 12,000 mm3, Hgbe 18 gm/dl, Hct=52 vol/dl, Na-138, K 4.6, Cl-102, BUN-24, Cr-0.9, HbA1C-7.5, EKG NSR, CXR-No infiltrates, dry mucous membranes and poor skin turgor, Skin No tenting of the skin, Lungs- Bibasilar crackles, Heart-S1 and 52, No murmurs, Abdomen Hypoactive bowel sounds in all four quadrants, Extremities. Toenails are dry, thick, and brittle; Diminished pedal pulses bilaterally, Left shin skin ulcer (8cm X 1.7cm X 0.5cm) with serous drainage. Mr. Soto complains of: Urinary frequency 4-5 times/day and wakes up 1-2 times/night, Pins and needle sensation of both legs during ambulation, left shin pain secondary fall and hitting a table, passing a small, hard stool, lack of appetite; eats 25-50% of breakfast and lunch; picks 25% of dinner, eats 100% of snacks and fruits and always requests for a piece of cake Current orders: Activity- Bedrest with left lower extremity elevated, Diet- 1800 Cal ADA, an evening snack and sugar-free fluids ad lib, Vital signs & 1/0 every shift, Daily weight, Finger Stick q ac and hs with regular insulin on a sliding scale, Normal saline wet to dry dressing every shift to left shin, IV fluid-0.45% NS at 50ml/hr Medications: Lisinopril 2.5 mg daily po (Hold for SBP<100), Glucotrol XL 5 mg daily po, Metformin 500 mg TID po with meals

Answer 1

* Reason for hospitalization - Hyperglycemia and left shin skin ulcer with serous drainage

* Living will - no

* Power of Attorney- no

*DNR - no

Hematocrit	Normal 37-47vol/dl	patient value 52
Blood glucose	65-115mg/dl	200
Chloride	95-108mEq/L	102
Blood Urea Nitrogen	8-26mg/dl	24
Others
Creatinine	0.8-2mg/dl	0.9
HbA1C	<5	7.5

X ray	No filtration
EKG	Normal Sinus rhythm