View Patient Profiles

Jones, Alan

MRN: 271302

Room: Exam #4

DOB: 4/12/1968

Age: 57

Gender: Male

Allergies: Penicillin (rash), Codeine (stomach upset per patient)

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 for a recheck on his blood pressure and a general health maintenance visit.
Admission note taken on 10/19/25
CC	No complaints, returning for a follow-up visit
HPI	Patient was in to see his doctor 2 weeks ago, at which time his BP was 168/98 mmHg. His blood pressure medications were adjusted by his physician (see current drug therapy) and he was asked to come back in two weeks for a BP recheck. His only complaint is that he feels very fatigued since his visit two weeks ago.
PMH	Hypertension x6 years Dyslipidemia x5 years Osteoarthritis hip and knee x7 years GERD x9 years Obesity
Social History	Tobacco: 1 pack per day for 30 years ETOH: patient states that he stopped drinking alcohol when he stopped using drugs Illicit Drugs: "I used to smoke weed 20 years ago, but not anymore" Caffeine: 3 cans of regular soda daily Occupation: self-employed painter Status: divorced Children: none Physical Activity: only that activity he gets on the job (e.g. walking; climbing ladders to paint) Diet: whatever is "cheap"; usually a burger and fries from McDonalds	Family History	Father: deceased; stroke at age 65 Mother: alive (age 78); type 2 diabetes; hypertension Sister: alive (age 55); prehypertension Brother: alive (53); well
Vaccine History	Last tetanus shot at age 23	Surgical History	None
Physical Exam	General statement: Obese white male who is alert, oriented and cooperative. SKIN: Normal in appearance, texture, and temperature HEENT: Pupils equally round, 4 mm, reactive to light and accommodation, sclera and conjunctivae normal. Funduscopic examination reveals arteriolar narrowing and AV nicking. Tympanic membranes and external auditory canals normal. Nasal mucosa normal. Oral pharynx is normal without erythema or exudate. LUNGS: clear bilaterally with no wheezing, no ronchi, no rales CARDIOVASCULAR: Regular rate and rhythm (RRR). Normal carotid pulsations without bruits. S 1 and S2 normal with physiologic S2 split. No S3 or S4. 2/6 soft crescendo-decrescendo systolic murmur best heard over the left 3rd interspace. ABDOMEN: Obese, nontender, nondistended; no abdominal bruits appreciated GENITOURINARY: patient deferred RECTAL: patient deferred EXTREMITIES: No cyanosis, clubbing, or edema are noted. Peripheral pulses in the femoral, popliteal, anterior tibial, dorsalis pedis, brachia!, and radial areas are 2+. Patient has a reduced range of motion in his hip. Arthritis pain rated at 2/10. NEUROLOGICAL: cranial nerves II- XII intact, deep tendon reflexes normal; No complaints of weakness, numbness, or incoordination.

Clinical Laboratory Report

Test Name	10/19/25	09/19/25	Range
Sodium (Na⁺)		135	136-145 mEq/L
Potassium (K⁺)		4.2	3.5-5 mEq/L
Chloride (Cl^-)		105	98-106 mEq/L
Bicarbonate (HCO₃^-)		25	23-28 mEq/L
Urea nitrogen (BUN)		20	8-20 mg/dL
Creatinine		0.9	0.5-1.3 mg/dL
Glucose		122	70-115 mg/dL
Hemoglobin A1c		7.8	5.3-7.5 %
Calcium,Total		9.2	8.6-10.2 mg/dL
Phosphate		3.9	3-4.5 mg/dL
Magnesium		2.1	1.6-2.6 mEq/L
Protein, total		7.6	5.5-9 g/dL
Albumin		4.0	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)		36	10-40 units/L
Aminotransferase,alanine (ALT)		35	10-40 units/L
Lactic dehydrogenase (LDH)		95	80-225 units/L
Alkaline phosphatase		49	30-120 units/L
Bilirubin, Total		1.1	0.3-1 mg/dL
Leukocytes (WBC)		5.9	4.5-11 x10³/mcL
Red blood cells (RBC), Male		4.5	3.8-5.1 x10⁸/mcL
Hemoglobin, Male		15.8	14-18 g/dL
Hematocrit, Male		45	42-50 %
Mean corpuscular hemoglobin (MCH)		30	27-33 picogram
Mean corpuscular volume (MCV)		87	76-100 mcm³
Platelets		225	150-450 x10³/mcL
International normalized ratio (INR)		1.1	0.8-1.2
Prothrombin time (PT)		10.6	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)		31	25-35 sec

Additional Labs:

Fasting	Last Month	7 Months Ago	13 Months Ago
TC (mg/dL)	205	190	195
LDL (mg/dL)	140	135	130
Trigs (mg/dL)	142	145	140
HDL (mg/dL)	30	32	37

Cultures:

None

Imaging Studies:

None

Vital Sign	10/19/25 09:46	09/19/25 07:16
Height (cm)	178	178
Weight (kg)	99	96
Body Temperature (°C)	37.1	36.4
Blood Pressure (mmHg)	156 / 94	168/98
Heart Rate (bpm)	52	70
Respiratory Rate (bpm)	16	16
Oxygen Saturation (%)	99	98

Current Orders

Medication
History

Metoprolol was increased from 25 mg bid to 50 mg bid at patient's visit 2 weeks ago when his BP was 168/98.
He has taken both Zegerid and Lipitor since initiation, although the patient states that some months, he cannot afford to buy them due to his high co-pay amounts.
The patient used acetaminophen PRN for his arthritis pain but he was advised to begin taking 1,000 mg PO TID when he consistently was having pain rated 6 out of 10.

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

Patient Name: Jones, Alan Date of Birth: 4/12/1968 Room#: Exam #4	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Lopressor 50 mg tablet	1 PO BID	no	increased from 25 mg BID last month
HCTZ 25 mg tablet	1 PO QD	no
Lipitor 10 mg tablet	1 PO QD	no	not taken x3 months due to high cost
Zegerid 20 mg capsule	1 PO QD	yes, GERD	purchases PRN when he can afford it
Tylenol Extra Strength 500 mg tablet	2 PO TID	yes, for arthritis pain
				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: Jones, Alan

Date of Birth: 4/12/1968

Room: Exam #4

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	178 cm
Actual Body Weight (ABW)	99 kg
Ideal Body Weight (IBW)	73 kg
ABW % of IBW	136 %
Adjusted Body Weight (AjBW)	83.4 kg
Body Surface Area (BSA)	2.21 m²
Body Mass Index (BMI)	31.2 kg/m²