01 · Patient summary
Verified 2026-07-19 08:12 Reconciled- Legal name
- Achebe, Rosalind Mercy
- Medical record no.
- 884-2201 Primary
- Date of birth
- 1961-03-14 64 years 4 months
- Sex / blood type
- Female · O RhD positive
- Primary provider
- Dr. Anaïs Varga, MD — Endocrinology
- Insurance
- Cascadia Mutual, Plan G-2 Active
- Preferred language
- English · Interpreter not required
- Emergency contact
- T. Achebe (spouse) · +1 503 555 0148
- Code status
- Full code Reaffirmed 2026-04-30
- Chart risk score
- 2.4 / 10 Low Model CRS-v6, 90-day horizon
02 · Vitals — most recent
Taken 2026-07-19 07:55 · seated · left arm03 · Laboratory results
Panel: Comprehensive metabolic + HbA1c · collected 2026-07-18 3 out of range| Analyte | Result | Units | Reference | Position | Flag |
|---|---|---|---|---|---|
| Hemoglobin A1c | 8.1 | % | 4.0 – 5.6 | High | |
| Glucose, fasting | 168 | mg/dL | 70 – 99 | High | |
| Creatinine | 0.94 | mg/dL | 0.60 – 1.10 | Normal | |
| eGFR | 78 | mL/min | ≥ 60 | Normal | |
| Potassium | 3.3 | mmol/L | 3.5 – 5.1 | Low | |
| Sodium | 139 | mmol/L | 135 – 145 | Normal | |
| LDL cholesterol | 96 | mg/dL | < 100 | At goal | |
| TSH | 2.10 | µIU/mL | 0.45 – 4.50 | Normal | |
| ALT | 27 | U/L | 7 – 56 | Normal |
04 · Active medications
6 active · 1 pending renewal- Metformin HCl ER 500 mg tab Active 1 tablet twice daily with meals · 60 tab / 30 d · 3 refills Started 2021-09-02 · Prescriber Dr. Varga · Last filled 2026-07-05
- Semaglutide 0.5 mg / 0.375 mL pen Active 0.5 mg subcutaneous once weekly (Sundays) · 4 pens / 28 d Dose escalated 2026-05-14 from 0.25 mg. Tolerating well; mild early nausea resolved.
- Lisinopril 20 mg tab Renewal due 1 tablet each morning · 30 tab / 30 d · 0 refills Renewal request received 2026-07-17. Requires BP re-check before authorization.
- Apixaban 5 mg tab High alert 1 tablet twice daily · 60 tab / 30 d · 5 refills Anticoagulant. Hold 48 h before any invasive procedure. Renal dosing reviewed 2026-07-18.
- Atorvastatin 40 mg tab Active 1 tablet at bedtime · 90 tab / 90 d · 1 refill LDL at goal. Continue current dose; recheck lipids at 6 months.
- Cholecalciferol 2000 IU cap OTC 1 capsule daily · patient-supplied Reported by patient 2026-07-02. Not dispensed by this pharmacy.
05 · Problem list
Coded to ICD-10-CM · 4 active, 1 resolved- E11.65
- Type 2 diabetes mellitus with hyperglycemia Uncontrolled Onset 2019-06
- I10
- Essential hypertension Suboptimal Onset 2016-11
- I48.91
- Atrial fibrillation, unspecified Rate controlled Onset 2023-02
- E78.5
- Hyperlipidemia, unspecified At goal Onset 2016-11
- M54.5
- Low back pain Resolved 2025-08
06 · Encounter history
Most recent first · 12 months-
Critical laboratory value reported
Fasting glucose 168 mg/dL and HbA1c 8.1 % called to Dr. Varga. Patient contacted by nurse line; instructed to continue current regimen pending review.
-
Office visit — Endocrinology follow-up
30-minute established patient visit. Reviewed glucose log, medication adherence, and dietary changes. Blood pressure elevated at 146/90; recheck scheduled.
-
Telehealth — Medication titration
Semaglutide escalated to 0.5 mg weekly. Injection technique reviewed by video. No adverse events reported since initiation.
-
Diabetic retinal screening
No evidence of diabetic retinopathy in either eye. Repeat screening recommended in 12 months.
-
Annual wellness visit
Immunizations updated (influenza, RSV). Depression and fall-risk screening completed; fall risk noted as moderate. Advance directive reaffirmed.
-
Emergency department visit
Presented with palpitations. Rate-controlled atrial fibrillation confirmed; discharged same day on existing anticoagulation. No admission.
07 · Clinical note
Progress note · 2026-07-02 · signed Signed & lockedSubjective
64-year-old woman with type 2 diabetes, hypertension, and rate-controlled atrial fibrillation presents for routine endocrine follow-up. She reports good adherence to metformin and weekly semaglutide, with home fasting readings ranging from 150 to 180 mg/dL over the past six weeks. Denies polyuria, blurred vision, chest pain, or palpitations. Reports increased walking — approximately four kilometres, five days per week — and a deliberate reduction in evening carbohydrate intake.
Objective
- Blood pressure 146/90 seated, repeat 142/88 after five minutes rest.
- Weight 171 lb, down 6 lb from the 90-day prior measurement.
- Cardiovascular: irregularly irregular rhythm, no murmur, no peripheral edema.
- Feet: intact monofilament sensation bilaterally, no ulceration or deformity.
Assessment
Type 2 diabetes remains above target with HbA1c trending from 7.6 % to 8.1 % over two quarters despite documented lifestyle improvement and confirmed adherence. Hypertension is suboptimally controlled and likely contributing to overall cardiovascular risk. Atrial fibrillation remains rate controlled on apixaban with no bleeding events. Hyperlipidemia is at goal.
Plan
- Escalate semaglutide to 1.0 mg weekly after a further four weeks at the current dose, contingent on tolerance.
- Continue metformin ER 500 mg twice daily without change.
- Recheck blood pressure within 30 days; consider adding a thiazide if readings remain above 140/90.
- Repeat comprehensive metabolic panel and HbA1c in three months.
- Referral placed to clinical nutrition for structured carbohydrate counting.
Electronically signed by Anaïs Varga, MD — Endocrinology
2026-07-02 16:41 PDT · Note ID NT-77120 · Co-signature not required