| Gallegos, Hugo |
| MRN: 422689 | Room: 353 | DOB: 5/1/1970 | Age: 55 | Gender: Male | Allergies: Phenytoin (nystagmus), Lactose (intolerant) |
| Setting | Adult Medicine Unit | ||
| Scenario | Please see clinical note. As a member of the Internal Medicine team please address pharmacotherapy recommendations, including all home medications, you may have to optimize this patient’s care in the hospital and at discharge. | ||
| Admission note taken on 10/20/25 | |||
| CC | “My husband is confused” | ||
| HPI | Mr. Gallegos is a 55 year old male brought to the ED by his wife due to worsening confusion at home for the last 3 days. History is provided by his wife. She noticed that the last three days he seemed to be confused about dates and where he was. Today he was talking about planning his father’s funeral service (father passed away 3 years ago). She states that he is adherent to all his medications. Mrs. Garcia is afraid maybe her husband started drinking alcohol again as the reason for being confused. The last time he drank, he was involved in a motor vehicle accident that caused his traumatic brain injury leading to 2 weeks in the neuro-ICU. She was very proud of her husband when his PCP saw him two weeks ago and said everything looked good except for a low valproic acid level. His only seizure was during his admission for traumatic brain injury (24 months ago). | ||
| PMH |
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam |
Review of Systems (source: wife)
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| Test Name | 10/20/25 | 10/03/25 | Range |
| Sodium (Na+) | 136 | 135 | 136-145 mEq/L |
| Potassium (K+) | 3.8 | 4.2 | 3.5-5 mEq/L |
| Chloride (Cl-) | 100 | 102 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 24 | 21 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 12 | 14 | 8-20 mg/dL |
| Creatinine | 0.88 | 0.94 | 0.5-1.3 mg/dL |
| Glucose | 154 | 162 | 70-115 mg/dL |
| Hemoglobin A1c | 8.6 | 5.3-7.5 % | |
| Calcium,Total | 7.4 | 7.6 | 8.6-10.2 mg/dL |
| Phosphate | 3.4 | 3.2 | 3-4.5 mg/dL |
| Magnesium | 2.0 | 1.8 | 1.6-2.6 mEq/L |
| Protein, total | 5.5-9 g/dL | ||
| Albumin | 2.8 | 2.6 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 100 | 90 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 56 | 62 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 80-225 units/L | ||
| Alkaline phosphatase | 30-120 units/L | ||
| Bilirubin, Total | 1.0 | 0.8 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 5.9 | 6.1 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 3.8-5.1 x108/mcL | ||
| Hemoglobin, Male | 11.9 | 12.3 | 14-18 g/dL |
| Hematocrit, Male | 35.1 | 37.2 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 27-33 picogram | ||
| Mean corpuscular volume (MCV) | 76-100 mcm3 | ||
| Platelets | 100 | 116 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.4 | 0.8-1.2 | |
| Prothrombin time (PT) | 9.5-11.3 sec | ||
| Partial thromboplastin time,activated (aPTT) | 25-35 sec |
| Additional Labs: |
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| Cultures: |
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| Imaging Studies: |
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| Medication History |
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| Patient Name: Gallegos, Hugo Date of Birth: 5/1/1970 Room#: 353 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
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| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
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|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
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| Medication | 10/20/25 |
| Divalproex DR 500 mg PO TID | |
| Furosemide 40 mg PO QD | |
| Spironolactone 50 mg PO QD | |
| Lactulose 10 g /15 mL Sol. 15 mL PO BID | |
| Metoprolol tartrate 12.5 mg PO BID | |
| Docusate sodium 100 mg PO QD | |
| Senna 8.6 mg PO QD | |
| Polyethylene Glycol 3350 17 g PO QD PRN PRN constipation |
| Hospital Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Previous Home Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| 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 | |||||
| Patient Name: Gallegos, Hugo | Date of Birth: 5/1/1970 | Room: 353 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |