Patient Chart
Mr. T.A
58 yrs • Male • 84 kg • 172 cm
Diagnosis
Type 2 diabetes mellitus, Chronic Kidney Disease Stage 3b
Past Medical History
- Type 2 diabetes (8 years)
- Chronic kidney disease
- Hyperlipidaemia
Current Medications
- Atorvastatin 20 mg once daily
- Gliclazide 80 mg once daily
New Prescription
Metformin 1000 mg — Oral, Twice daily
Vitals
BP142/88 mmHgHighBlood PressureReference90–120 / 60–80 mmHgActual142/88 mmHg
HR80 bpmNormalHeart RateReference60–100 bpmActual80 bpm
RR15/minNormalRespiratory RateReference12–20 breaths/minActual15/min
TEMP36.7°CNormalTemperatureReference36.1–37.2°CActual36.7°C
SPO298%NormalOxygen SaturationReference≥ 95%Actual98%
Labs
Serum Creatinine2.1 mg/dLHighSerum CreatinineReference0.5–1.3 mg/dLActual2.1 mg/dL
Creatinine Clearance27 mL/minSevereCreatinine ClearanceReference≥ 50 mL/min (normal/mild impairment)Actual27 mL/min
eGFR28 mL/min/1.73m²SevereeGFRReference≥ 60 mL/min/1.73m²Actual28 mL/min/1.73m²
Liver FunctionWithin normal limitsNormalLiver FunctionReferenceWithin normal limitsActualWithin normal limits
Blood Glucose9.8 mmol/L (random)ElevatedBlood GlucoseReference4.0–7.8 mmol/LActual9.8 mmol/L (random)
HbA1c8.4%HighHbA1cReference< 5.7% normal · ≥ 6.5% diabetic rangeActual8.4%
Allergies & Status
No known drug allergies (NKDA)
Not applicable
Clinical Notes
Referred from outpatient diabetes clinic for glycaemic control. Metformin initiated at standard adult dose without renal function being cross-checked against the most recent labs.
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