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Discharge Summary
Patient Name: Ramon Gutierrez
Medical Record: 14821-27
Admitted: 04/27/2019
Admitting Diagnosis: Diabetes mellitus, new onset
Discharge Diagnosis: Type 1 diabetes mellitus, new onset
History of Present Illness: Patient is a 15-year-old male who presented in the office complaining of increased
appetite, polydipsia, polyuria, and was found to have elevated
blood glucose of 400 and glycosuria. He was
sent to
the hospital for further evaluation and treatment.
Hospital Course: Upon admission, laboratory tests showed electrolytes WNL (within normal limits) and ketones
were negative. Urinalysis showed a trace of glucose and
there was no evidence of acidosis. The patient was
stable
and was started on split-mix insulin dosing. Patient education
was received successfully. By day 5, his polyuria and
polydipsia resolved. When the patient was able to draw
up and self administer insulin and perform his own
fingersticks, he was discharged.
Discharge Instructions: The patient was discharged home with a prescription for a mixture of Humulin L 12 units
and Humiulin R 6 units each morning every morning
and Humulin L 5 units and Humulin R 6 units each afternoon
.
Patient is to follow an ADA 2,000 calorie diet.
Discharge Condition: The patient's overall condition was much improved, and at the time of discharge, BG levels
were stabilized, and he was doing well.


based on the information that has been provided to you regarding ramon gutierrezs current medical condition what might you find in the physical examination portion of his medical record?