View Patient Profiles

King, Whitney

MRN: 200536

Room: 522

DOB: 4/17/1974

Age: 51

Gender: Female

Allergies: NKDA

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Adult Medicine Unit
Scenario	Today, you are on rounds with the Internal Medicine team outside the room of a patient who was admitted from the emergency department for management of an acute DVT.
Admission note taken on 10/19/25
CC	pain and swelling of her left lower extremity
HPI	A patient with a history or coronary artery disease and angine reports that in frustration over angina associated with moderate physical activity, she decided to spend the weekend in bed reading and watching television. This morning she awakened with significant pain and swelling of her left lower extremity, which on inspection is warm and erythematous. She presented to the emergency room, and a duplex ultrasound was postive fer deep vein thrombosis.
PMH	Coronary artery disease described as microvascular disease not amenable to intervention s/p cardiac catheterization 3 months ago Angina with moderate exertion
Social History	Tobacco: Does not and never has smoked. Alcohol: Drinks 1-2 alcoholic beverages per day. Caffeine: 2 cups of coffee, 2 Diet Cokes daily Occupation: Works as a systems analyst for a computer company. Status: Lives alone with no children or pets. Pt has a large support system of friends and colleagues. Physical Activity: Previously enjoyed'an active lifestyle but has experienced a dramatic decline in physical activity due to angina associated with moderate exertion. Pt is extremely frustrated by her inability to participate in usual activities and reports that she feels depressed and discouraged, which in part led to her decision to spend the weekend in bed. She is also frustrated with her cardiologist, who she feels has not offered her appropriate therapy for control of angina. Diet: Does not follow any special diet.	Family History	Mother alive at age 82 with HTN Father died at age 66 of acute MI.
Vaccine History	None on file	Surgical History	None on file
Physical Exam	Gen: Pleasant but concerned woman in NAD HEENT: deferred Skin: Pale and dry; no tumors, moles, or lesions Neck: No JVD, lymphadenopathy, or thyromegaly Cor: RRR; normal Sl and S2, no S3 or S4; no m/r/g Lungs: CTA & P Abdomen: Deferred GU: Deferred Extremities: LLE warm, swollen, erythematous, no obvious cord; normal ROM; no evidence of arthritis; pulses 2+ Neuro: A & O x 3; CN II-XII intact; DTRs 2+ throughout; negative Babinsk

Clinical Laboratory Report

Test Name	10/20/25	10/19/25	Range
Sodium (Na⁺)	137	132	136-145 mEq/L
Potassium (K⁺)	4.8	4.8	3.5-5 mEq/L
Chloride (Cl^-)	96	93	98-106 mEq/L
Bicarbonate (HCO₃^-)	26	26	23-28 mEq/L
Urea nitrogen (BUN)	14	14	8-20 mg/dL
Creatinine	0.7	0.7	0.5-1.3 mg/dL
Glucose	82	82	70-115 mg/dL
Hemoglobin A1c		5.5	5.3-7.5 %
Calcium,Total	9.2	9	8.6-10.2 mg/dL
Phosphate	4.1	4.2	3-4.5 mg/dL
Magnesium	1.9	2	1.6-2.6 mEq/L
Protein, total	7.2	7.3	5.5-9 g/dL
Albumin	4.3	4.3	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	16	15	10-40 units/L
Aminotransferase,alanine (ALT)	12	12	10-40 units/L
Lactic dehydrogenase (LDH)	84	82	80-225 units/L
Alkaline phosphatase	74	71	30-120 units/L
Bilirubin, Total	0.7	0.7	0.3-1 mg/dL
Leukocytes (WBC)	6.3	6.3	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.1	4	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	14.8	15.1	12-16 g/dL
Hematocrit, Female	38	37.2	37-47 %
Mean corpuscular hemoglobin (MCH)	28	28	27-33 picogram
Mean corpuscular volume (MCV)	89	88	76-100 mcm³
Platelets	362	360	150-450 x10³/mcL
International normalized ratio (INR)	1.7	1.0	0.8-1.2
Prothrombin time (PT)	18.8	14.2	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	68	28	25-35 sec

Additional Labs:

Fasting Lipids	Yesterday
TC (mg/dL)	198
TG (mg/dL)	160
HDL-C (mg/dL)	31
LDL-C (mg/dL)	135

Cultures:

None

Imaging Studies:

Venous Duplex Ultrasound: results are positive for deep vein thrombosis (DVT)

Vital Sign	10/20/25 07:23	22:49	15:30	10/19/25 07:22
Height (cm)	168			168
Weight (kg)	78			78
Body Temperature (°C)	37.2	36	37.5	37.1
Blood Pressure (mmHg)	128 / 72	131/71	127/68	130/70
Heart Rate (bpm)	72	70	67	68
Respiratory Rate (bpm)	18	20	19	20
Oxygen Saturation (%)	99	98	98	98

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			continue until INR > 2.0

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			continue until INR > 2.0

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			Increased from 60 mg q6h prior to admission

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN GERD
USE	START DATE	STOP DATE	NOTES
			Pt self initiated due to periodic GI upset associated with ASA use

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

Isosorbide dinitrate was originally prescribed as 20mg TID; pt has increased dose and frequency on her own
Pt self initiated cimetidine due to periodic GI upset associated with ASA use

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

Patient Name: King, Whitney Date of Birth: 4/17/1974 Room#: 522	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Isosorbide dinitrate 60 mg tablet	1 PO QID	no
Aspirin EC 325 mg tablet	1 PO QD	no
Diltiazem CD 180 mg capsule	1 PO QD	no
Cimetidine 200 mg tablet	1 PO BID	yes, GERD
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25	10/19/25
Heparin 1,400 units/hr IV continuous Rate: 14 mL/hr		7:52
Warfarin 10 mg PO QAM		9:49
Isosorbide dinitrate 80 mg PO Q6H	00:19	00:45 6:39 12:50 18:58
Aspirin EC 325 mg PO QD		9:47
Diltiazem CD 180 mg PO QD		9:10
Cimetidine 200 mg PO BID PRN PRN GERD		9:10 21:53
Heparin 6,000 units IV STAT x1 Rate: push over 2 minutes		6:54

Clinical Notes

Impressions/Plan:
1. Admit to hospital for management of acute DVT
2. Start IV heparin and initiate warfarin therapy
3. Increase anti-anginal therapy
4. Psychiatry consult for depression

Admission Orders:
1. Admit to internal medicine service
2. Complete bed rest
3. Elevate LLE
4. Heart Healthy diet
5. Vital signs Q shift
6. Obtain daily I & O and body weight
7. qam Chem 7, PT/aPTT
8. Meds:
• Unfractionated heparin 80 U/kg bolus, 18 U/kg/hr and adjust per protocol to maintain aPTT 60-100 seconds
• warfarin 10mg po qpm
• continue pre-admission meds
• increase isosorbide to 80mg q6h

Dr. James Warren

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: King, Whitney

Date of Birth: 4/17/1974

Room: 522

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	168 cm
Actual Body Weight (ABW)	78 kg
Ideal Body Weight (IBW)	59.3 kg
ABW % of IBW	132 %
Adjusted Body Weight (AjBW)	66.8 kg
Body Surface Area (BSA)	1.91 m²
Body Mass Index (BMI)	27.6 kg/m²