View Patient Profiles

Moore, Samuel

MRN: 236749

Room: 350

DOB: 11/8/1962

Age: 63

Gender: Male

Allergies: Codeine (itching)

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 treatment of cellulitis.
Admission note taken on 10/20/25
CC	tender, swollen & painful right foot
HPI	SM is brought into the ER this morning by his son because his right foot is tender and painful and appears to be swollen. SM first noticed some redness a couple of days ago and it continued to progressively worsen. He noticed a small ulceration on the bottom of his right foot several weeks ago and the only thing he can attribute it to is his worn out shoes. He did not see a physician for the ulcer because he thought it would heal on its own. He noticed the redness a few days ago when examining his feet. He has also been feeling very fatigued (especially in the morning) and has complained of frequent urination and thirst. SM was given a tetanus shot in the ER and was admitted to the floor through the ER.
PMH	Type 2 Diabetes Mellitus x 6 years Hyperlipidemia x 5 years Hypertension x 6 years Peripheral Neuropathy x 3 years Depression x 2 years Erectile Dysfunction x 6 years Obesity
Social History	Tobacco: 1 ppd x 45 years ETOH: Denies use Illicit Drugs: Denies use Caffeine: 2 cups decaffeinated coffee every morning Occupation: Retired electrician Status: Divorced x 20 years; lives alone but has a girlfriend of 10 years. Children: 1 daughter & 1 son. Both reside locally. Daughter is a nurse and son is an accountant. Physical Activity: No regular exercise routine. Cannot walk great distances because of the burning sensation in his feet and fatigue. He was bowling twice a week but lately he is finding little pleasure in his bowling league and does not feel like socializing. Diet: Eats a lot of frozen meals and canned soups because he lives alone and is not fond of cooking. Does not pay attention to food labels, fat or carbohydrate content. The only time he received nutritional counseling was upon diagnosis of diabetes when he attended a three-day diabetes education course.	Family History	Father: deceased at age 63 secondary MI Mother: deceased at age 67 secondary MI, also had Type 2 DM and HTN Sister: alive at age 63 with hyperlipidemia and HTN Brother: alive at age 67 with history colon cancer, Type 2 DM, and GERD Brother: alive at age 58 with Type 2 DM, HTN, hyperlipidemia with 2 children in good health
Vaccine History	Tetanus (Tdap) shot 12 years ago Pneumovax (PPSV23) given 2 years ago	Surgical History	None on file
Physical Exam	Gen: WDWN obese, Caucasian male in NAD HEENT: PERRLA, EOMI, R & L fundus exam without retinopathy, sclera without icterus, mucus membranes moist, no oral lesions, poor dentition. Skin: dry skin, no rashes Neck: No JVD appreciated, no carotid bruits, no thyromegaly Heart: RRR, no S3, S4. 2/6 systolic murmur heard at left sternal border without radiation Lungs: CTA Abdomen: soft, obese, symmetrical, nontender, nondistended, + BS, liver and spleen not palpable GU: deferred Extremities: Trace edema bilaterally in lower extremities. Dorsal area of right foot is erythematous, edematous, tender, warm to touch, an ulcer is noted with poorly demarcated borders (approximately 3 x 4 cm). Marked diminished sensation in both feet. Dry, scaly skin present on feet bilaterally. Normal range of motion. Tinea pedis between toes bilaterally.

Clinical Laboratory Report

Test Name	10/20/25	05/23/25	Range
Sodium (Na⁺)	140	139	136-145 mEq/L
Potassium (K⁺)	5.2	4.5	3.5-5 mEq/L
Chloride (Cl^-)	102	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	26	22	23-28 mEq/L
Urea nitrogen (BUN)	34	28	8-20 mg/dL
Creatinine	2.5	1.7	0.5-1.3 mg/dL
Glucose	280	176	70-115 mg/dL
Hemoglobin A1c	10.2	8.2	5.3-7.5 %
Calcium,Total	9.2	9.6	8.6-10.2 mg/dL
Phosphate	3.9	4.1	3-4.5 mg/dL
Magnesium	2.2	2.1	1.6-2.6 mEq/L
Protein, total	7.0	7.1	5.5-9 g/dL
Albumin	4.2	4.2	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	34	32	10-40 units/L
Aminotransferase,alanine (ALT)	26	22	10-40 units/L
Lactic dehydrogenase (LDH)	94	92	80-225 units/L
Alkaline phosphatase	65	67	30-120 units/L
Bilirubin, Total	0.7	0.6	0.3-1 mg/dL
Leukocytes (WBC)	14.2	9.9	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.9	4.8	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	13.2	13.8	14-18 g/dL
Hematocrit, Male	40	42	42-50 %
Mean corpuscular hemoglobin (MCH)	29	31	27-33 picogram
Mean corpuscular volume (MCV)	92	91	76-100 mcm³
Platelets	360	387	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.0	0.8-1.2
Prothrombin time (PT)	10.6	9.9	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29.1	29	25-35 sec

Additional Labs:

Hematology	Today	5 Months Ago
PMNs (%)	74
Bands (%)	8
Lymphs (%)	13
Monos (%)	6

Ancillary Labs	Today	5 Months Ago
TSH (mcU/mL)	3.8
PSA (ng/mL)	1.3

Fasting Lipids	Today	5 Months Ago
TC (mg/dL)		230
TG (mg/dL)		280
HDL-C (mg/dL)		35
LDL-C (mg/dL)		136

Cultures:

Culture and sensitivity from deep culture pending (R foot).
Blood cultures and sensitivity pending.

Urinalysis	Today	5 Months Ago
Glucose	pos	neg
Ketones	neg	neg
Specific Gravity	1.045	1.017
pH	6.2	6.4
Bacteria	neg	neg
WBC	neg	neg
RBC	neg	neg
Protein	1+	1+
Leuk Est	neg	neg
Nitrite	neg	neg

Imaging Studies:

X-ray of bone to rule out osteomyelitis pending.

Vital Sign	10/20/25 08:39	05/23/25 08:10
Height (cm)	178	178
Weight (kg)	113	114
Body Temperature (°C)	37.8	37.2
Blood Pressure (mmHg)	154 / 92	146/84
Heart Rate (bpm)	78	82
Respiratory Rate (bpm)	18	16
Oxygen Saturation (%)	99	98

Current Orders

Medication
History

Medication list confirmed with patient and community pharmacy records.
SM states he is adherent to his medication regimen but he is not sure he understood the role of each medication.
Denies any adverse effects except occasional GI upset.

Home Medication List: verified by pharmacy on admit (10/20/25)

Patient Name: Moore, Samuel Date of Birth: 11/8/1962 Room#: 350	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Metformin 500 mg tablet	2 PO BID	no
Glipizide 10 mg tablet	1 PO BID	no
Lovastatin 20 mg tablet	1 PO HS	no
Lisinopril 10 mg tablet	1 PO QAM	no
Amitriptyline 25 mg tablet	1 PO HS	no
Sertraline 50 mg tablet	1 PO QD	no
Triamterene/HCTZ 75 mg/50 mg tablet	1 PO QAM	no
St. John’s Wort 300 mg capsule	1 PO TID	no
Yohimbine 5.4 mg capsule	1 PO TID	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication

10/20/25

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: Moore, Samuel

Date of Birth: 11/8/1962

Room: 350

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	178 cm
Actual Body Weight (ABW)	113 kg
Ideal Body Weight (IBW)	73 kg
ABW % of IBW	155 %
Adjusted Body Weight (AjBW)	89 kg
Body Surface Area (BSA)	2.36 m²
Body Mass Index (BMI)	35.7 kg/m²