History : HPI: History is given by patient's son. 65 yo M c/o confusion. Patient's son reports his father has confusion since last night. Patient is not responding when someone calls him. Patient had cholecystectomy 5 days ago with no complications. Patient was discharged 4 days ago. Patient was fine 3 days after the surgery, passed stool/gas and urine but suddenly last night he became confused. Patient has fever. The surgical site is red and swollen. Patient's daughter reports hyperventilation. Patient had one episode of vomiting last night, containing food particles, no blood, no foul smell. Patient did not pass urine since last night. There is no cough/chest pain/dysuria/hematuria/diarrhea/edema. ROS: no travel/trauma/rash. Patient is only taking soup after the surgery. No change in appetite and weight. PMH: Patient has diabetes for which he takes insulin, last dose of insulin is not known. Hypercholesterolemia Medications: statins, insulin. PSH/FH/Allergies: none S/H: non-smoker, lives alone, retired school teache Physical Examination : Diagnosis 1 : Delirium Diagnosis 2 : Sepsis History Findings Physical Exam Findings 1) Patient has confusion since last night 2) Recent cholecystectomy 5 days ago. 3) Fever 4) Dyspnea 5) inability to pass urine History Findings Physical Exam Findings 1) Patient has confusion since last night 1) vitals: temperature 99 F 2) Recent cholecystectomy 5 days ago. 3) Fever 4) surgical site is red and swollen Diagnosis 3 : Diabetic ketoacidosis Diagnostic Study/Studies - Labs 1) Physical examination 2) CBC with differential 3) S electrolytes, glucose 4) Urine analysis, culture/sensitivity
