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Perez, Vasco

MRN: 277689

Room: Exam #3

DOB: 4/10/1968

Age: 57

Gender: Male

Allergies: Diarrhea secondary to metformin administration

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Outpatient Diabetes Clinic
Scenario	You are rounding as part of the diabetes care team. Patient presents to the diabetes clinic after not being seen for 3 months due to his noncompliance with clinic visits.
Admission note taken on 10/20/25
CC	"I don't feel right."
HPI	Patient presents to the diabetes clinic after not being seen for 3 months due to his noncompliance with clinic visits. At his last clinic visit his fasting finger stick revealed to be 155 mg/dL, and he was instructed to take repaglinide 2 mg tid as opposed to bid and start taking exenatide 5 mcg SQ bid to simultaneously assist in weight reduction. In addition amlodipine was increased from 5 mg daily to 10 mg daily for additional blood pressure lowering. He appears anxious, agitated, and sweaty, with edema of the feet.
PMH	Diabetes Type 2 x5 years Hypertension x3 years Dyslipidemia x3 years Cerebrovascular accident–ischemic x2 years Renal Insufficiency x2 years Obesity x6 years
Social History	Tobacco: denies ETOH: denies Illicit Drugs: denies Caffeine: denies Occupation: retired Status: married Children: none Physical Activity: limited ambulation Diet: reports to eat cake a few times a week; wife reports that he does not adhere to diet, and eats anything he wants Other Conditions: dyslexia, low literacy (speaks English fluently, and reading capability is below average)	Family History	Father: alive (age 85); MI at age 65, HTN, dyslipidemia, type 2 diabetes Mother: alive (age 82); type 2 diabetes; hypertension Sister: alive (age 47); HTN, Impaired Fasting Glucose Brother: alive (53); type 2 diabetes; hypertension
Vaccine History	None	Surgical History	None
Physical Exam	General statement: Obese hispanic male appearing anxious, agitated, sweaty, with limited ambulation. SKIN: Normal in appearance and texture; noted sweaty appearance HEENT: Pupils equally round, 4 mm, reactive to light and accommodation, sclera and conjunctiva normal. LUNGS: clear bilaterally with no wheezing, no ronchi, no rales CARDIOVASCULAR: Normal carotid pulsations without bruits. Normal S1 and S2. No S3 or S4. ABDOMEN: normal EXTREMITIES: 2+ pedal edema NEUROLOGICAL: cranial nerves II – XII intact, deep tendon reflexes, muscle tone and strength, coordination and gait, reflexes, and sensory normal

Clinical Laboratory Report

Test Name	10/20/25	07/22/25	Range
Sodium (Na⁺)	142	137	136-145 mEq/L
Potassium (K⁺)	4.0	4.2	3.5-5 mEq/L
Chloride (Cl^-)	103	105	98-106 mEq/L
Bicarbonate (HCO₃^-)	27	31	23-28 mEq/L
Urea nitrogen (BUN)	57	43	8-20 mg/dL
Creatinine	3.5	3.4	0.5-1.3 mg/dL
Glucose	60	155	70-115 mg/dL
Hemoglobin A1c	9.2	9.5	5.3-7.5 %
Calcium,Total	8.4	8.0	8.6-10.2 mg/dL
Phosphate	4.4	4.1	3-4.5 mg/dL
Magnesium	2.2	2.0	1.6-2.6 mEq/L
Protein, total	6.8	6.7	5.5-9 g/dL
Albumin	3.4	3.6	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	25	17	10-40 units/L
Aminotransferase,alanine (ALT)	20	13	10-40 units/L
Lactic dehydrogenase (LDH)	91	87	80-225 units/L
Alkaline phosphatase	55	52	30-120 units/L
Bilirubin, Total	0.2	0.2	0.3-1 mg/dL
Leukocytes (WBC)	5.2	5.3	4.5-11 x10³/mcL
Red blood cells (RBC), Male	5.0	4.8	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	14.8	15.1	14-18 g/dL
Hematocrit, Male	45	44	42-50 %
Mean corpuscular hemoglobin (MCH)	30	31	27-33 picogram
Mean corpuscular volume (MCV)	80	82	76-100 mcm³
Platelets	264	255	150-450 x10³/mcL
International normalized ratio (INR)	1.0	0.9	0.8-1.2
Prothrombin time (PT)	9.9	10.1	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29	30	25-35 sec

Additional Labs:

Fasting	Last Month	3 Months Ago
TC (mg/dL)	267	256
LDL (mg/dL)	-	178
Trigs (mg/dL)	482	280
HDL (mg/dL)	22	22

Cultures:

Urinalysis (today):

Appearance: clear
Color: amber yellow
pH: 6.2
Protein 172 mg
Specific gravity: 1.010
Leukocyte esterase: neg
Ketones: none
Nitrites: none
Glucose: negative

Imaging Studies:

None

Vital Sign	10/20/25 09:11	07/22/25 07:36
Height (cm)	168	168
Weight (kg)	114	107
Body Temperature (°C)	37	37.1
Blood Pressure (mmHg)	146 / 88	158/90
Heart Rate (bpm)	74	78
Respiratory Rate (bpm)	18	16
Oxygen Saturation (%)	99	99

Current Orders

Medication
History

At the last clinic visit 3 months ago, repaglinide was increased from 2 mg bid to tid; exenatide was initiated for the additional benefit of weight loss; amlodipine was increased from 5 mg daily to 10 mg daily.
His wife reports that she gives him his medications whenever she is at home (she works 10 hour days), however he at times opts not to take them.
When she is not there to assist him with taking his medications she feels that he is non compliant, since numerous times she finds his pills for the day left in the medication box that she prepares weekly for him.
Also, she reports that on multiple occasions he refuses his evening exenatide injection.
In addition, she reports that she worries about leaving him home alone because he has experienced hypoglycemic events in the past.
His wife also reports that he took all of his medications this morning. When the patient was queried what his breakfast usually consists of, he reports that usually he skips breakfast (as he did this morning).

Home Medication List: verified by pharmacy on admit (10/20/25)

Patient Name: Perez, Vasco Date of Birth: 4/10/1968 Room#: Exam #3	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
Amlodipine 10 mg tablet	1 PO QD	no
Simvastatin 40 mg tablet	1 PO QD	no
Lisinopril 10 mg tablet	1 PO QD	no
Aspirin 81 mg tablet	1 PO QD	no
Exenatide 5 mcg/0.02 mL pen-injector	5 mcg SC BID	no	receives drug company assistance
Repaglinide 2 mg tablet	1 PO TID	no
Glyburide 5 mg tablet	1 PO BID	no
Pseudoephedrine 30 mg tablet	1 PO PRN	yes, cough/ cold	purchased last week and is currently still taking.
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication

10/20/25

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: Perez, Vasco

Date of Birth: 4/10/1968

Room: Exam #3

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	168 cm
Actual Body Weight (ABW)	114 kg
Ideal Body Weight (IBW)	63.8 kg
ABW % of IBW	179 %
Adjusted Body Weight (AjBW)	83.9 kg
Body Surface Area (BSA)	2.31 m²
Body Mass Index (BMI)	40.4 kg/m²