View Patient Profiles

Green, David

MRN: 187323

Room: Exam #7

DOB: 8/16/1977

Age: 48

Gender: Male

Allergies: NKDA

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Outpatient Family Medicine Clinic
Scenario	You are rounding as part of the family medicine team. Patient presents to the family medicine clinic as a new patient for a general health maintenance visit.
Admission note taken on 10/19/25
CC	"I'm healthy, I feel fine."
HPI	DG is a 48-year-old white male who is a new patient to our clinic after moving here from out of state. Had received all previous medical care from his primary clinic for 10 years before moving out of the area. Here today requesting medication refills, has appointment with new PCP in 2 weeks.
PMH	Hypertension x 5 years Hyperlipidemia x 1 year (had 6 month trial of diet & exercise before starting drug therapy)
Social History	Tobacco: 1 ppd x25 years, quit 5 years ago, restarted 3 months ago after moving, has tried to quit but can't get through cravings. Alcohol: 1-2 beers most evenings. Caffeine: 2 cups of coffee (AM), 1 can Red Bull (afternoon) daily Occupation: works as an automobile mechanic. Status: married, has 2 teenage children. Physical Activity: no formal exercise, walks the dog occasionally. Diet: follows no perticular diet, eats red meat 2-3 x/week, does not eat the skins of meat, cuts off excess fat, fried foods less than once/week. No sweets. + salt to food.	Family History	Mother alive at age 75, history of hypothyroidism Father alive at age 72, had an acute MI at age 50.
Vaccine History	None on file	Surgical History	None on file
Physical Exam	Gen: well-developed, slightly overweight male in NAD HEENT: PERRLA, conjunctiva WNL. No corneal arcus or xanthelasma. Skin: WNL Neck: WNL Heart: + S1, S2, - S3, - S4; no murmurs Lungs: + breath sounds with good air movement Abdomen: + BS, - splenomegaly, - masses GU: deferred Extremities: WNL Neuro: A & O x 3, CN I-XII intact, motor 5/5. DTR symmetrical and WNL

Clinical Laboratory Report

Test Name	10/19/25	Range
Sodium (Na⁺)	142	136-145 mEq/L
Potassium (K⁺)	4.4	3.5-5 mEq/L
Chloride (Cl^-)	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	28	23-28 mEq/L
Urea nitrogen (BUN)	21	8-20 mg/dL
Creatinine	1.1	0.5-1.3 mg/dL
Glucose	110	70-115 mg/dL
Hemoglobin A1c	5.2	5.3-7.5 %
Calcium,Total	9.3	8.6-10.2 mg/dL
Phosphate	3.9	3-4.5 mg/dL
Magnesium	2.0	1.6-2.6 mEq/L
Protein, total	6.8	5.5-9 g/dL
Albumin	4.1	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	21	10-40 units/L
Aminotransferase,alanine (ALT)	2	10-40 units/L
Lactic dehydrogenase (LDH)	65	80-225 units/L
Alkaline phosphatase	93	30-120 units/L
Bilirubin, Total	0.3	0.3-1 mg/dL
Leukocytes (WBC)	7.6	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.3	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	16.5	14-18 g/dL
Hematocrit, Male	46.2	42-50 %
Mean corpuscular hemoglobin (MCH)	30	27-33 picogram
Mean corpuscular volume (MCV)	82	76-100 mcm³
Platelets	179	150-450 x10³/mcL
International normalized ratio (INR)	1.0	0.8-1.2
Prothrombin time (PT)	9.7	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	30	25-35 sec

Additional Labs:

Fasting Lipids	Today	6 Months Ago	12 Months Ago
TC (mg/dL)	270	255	260
TG (mg/dL)	130	130	130
HDL-C (mg/dL)	42	40	42
LDL-C (mg/dL)	200	190	192
Notes		Step II diet initiated, exercise encouraged, gemfibrozil 600 mg BID started	Step I diet initiated, exercise encouraged

Cultures:

None

Imaging Studies:

None

Vital Sign	10/19/25 07:36
Height (cm)	180
Weight (kg)	82
Body Temperature (°C)	37
Blood Pressure (mmHg)	152 / 96
Heart Rate (bpm)	90
Respiratory Rate (bpm)	18
Oxygen Saturation (%)	99

Current Orders

Medication
History

Patient reports taking medications regularly and having no problems paying for them.

Home Medication List: verified by pharmacy on admit (10/19/25)

Patient Name: Green, David Date of Birth: 8/16/1977 Room#: Exam #7	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Metoprolol tartrate 50 mg tablet	1 PO BID	no	taken x 3 years, previously HCTZ 25 mg QAM was discontinued due to failure to control BP
Aspirin EC 325 mg tablet	1 PO QAM	no	taken x 6 months
Gemfibrozil 600 mg tablet	1 PO BID	no	taken x 6 months
Men's Multivitamin w/ Minerals tablet	1 PO QAM	no	taken x 5 years
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication

10/19/25

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Discharge Planning - Medication List and Instructions

Patient Name:
Admission Date:	Discharge Date:	Service:
Principle Diagnosis on Admission:
Secondary Diagnosis:
Allergies:

Medications ADDED this visit: (begin taking these)	Medications CHANGED this visit: (modify what you were taking)	Medications STOPPED this visit: (stop taking these)

Final Discharge Medication List
Medication/Route/Dosage/Frequency/Duration	Comments	Morning	Afternoon	Evening	Bedtime










As Needed Medications

Medication Reconciliation - Finalized Medication List

Patient Name: Green, David

Date of Birth: 8/16/1977

Room: Exam #7

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	180 cm
Actual Body Weight (ABW)	82 kg
Ideal Body Weight (IBW)	75.3 kg
ABW % of IBW	109 %
Adjusted Body Weight (AjBW)	78 kg
Body Surface Area (BSA)	2.02 m²
Body Mass Index (BMI)	25.3 kg/m²