Clinical note · #57
Hospital & observation
Patient Name: Michael Brown
MRN: 19876543
Date of Admission: 09/08/2024
Date of Discharge: 09/17/2024
Attending Physician: Dr. Lisa Carter
Primary Diagnosis: Diabetic ketoacidosis (DKA)
Secondary Diagnosis: Type 1 Diabetes Mellitus
Hospital Course:
Michael Brown was admitted in diabetic ketoacidosis. He required IV insulin therapy and careful electrolyte management in the ICU. After stabilization, he was transitioned to subcutaneous insulin. Extensive education was provided on insulin administration and glucose monitoring.
Final Physical Exam:
- Vitals: BP 125/78, HR 80, Glucose controlled
- Endocrine: No signs of ketoacidosis
Discharge Medications:
- Insulin glargine 20 units at bedtime
- Insulin lispro before meals
Discharge Instructions:
- Check blood glucose before meals and at bedtime
- Administer insulin as prescribed
- Attend diabetes education sessions
Follow-Up:
- Endocrinology follow-up in 7 days
- Appointment for diabetes education
Discharge Condition:
Stable with blood sugar control.
Discharge Time: 60 minutes
Disposition: Discharged home.