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Heyward, Precious

MRN: 254201

Room: Exam #2

DOB: 9/1/1960

Age: 65

Gender: Female

Allergies: enalapril and lisinopril (cough), amitriptyline and desipramine (sedation and dry mouth)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Outpatient Diabetes Clinic
Scenario	You are rounding as part of the diabetes care team. Patient presents to the diabetes clinic today for a yearly follow-up appointment.
Admission note taken on 10/20/25
CC	Diabetes control and nerve pain
HPI	PH is 65-year-old woman who measures her BP and BG values at home frequently. Home BG log show measuring BG 2 to 3 times daily; values consistently between 140 and 199. Her average AM fasting is 153, average pre-evening meal is 158, and average bedtime is 162. Has been seen by a Certified Diabetes Educator several times in the past and is very educated and compliant with her ADA diet (says she limits carbohydrates), monitoring, checking of feet, etc. Has had proteinuria in the past. Measures BP daily in the morning, average values are 146/80 with a high of 170/92 and low of 120/74. Peripheral neuropathy with 3 or 4 out of 10 pain on most days and experiences intense lancinating 7 or 8 out of 10 pain when putting on her shoes. Acetaminophen only partially relieves pain on days when pain is more intense. Reports no chest pain or sublingual nitroglycerin use over the past 6 months. She recently had a bone densitometry test measured to assess bone health.
PMH	Type 2 Diabetes Mellitus x 4 years Hypertension x 7 years Dyslipidemia x 5 years Diabetic Nephropathy x 2 years Peripheral Neuropathy x 2 years Status-post Myocardial Infarction x 5 years Chronic Stable Angina x 5 years
Social History	Smoking: none ETOH: one glass of red wine most days/week Illicit Drugs: none Caffeine: coffee 2 cups/day Occupation: clerical worker Status: married, husband is age 66 with hypertension and arthritis Children: 3 sons, 7 grandchildren Physical Activity: walks her dog 2 to 3 miles daily Diet: following ADA diet	Family History	Father: deceased, myocardial infarction at age 50 Mother: deceased, type 2 diabetes, died of kidney failure at age 61 Sister: alive, type 2 diabetes, chronic stable angina, age 68 Brother: alive, hypertension, age 62
Vaccine History	None on file	Surgical History	total abdominal hysterectomy (30 years ago)
Physical Exam	GENERAL: Overweight female appearing to be older than stated age SKIN: overall dry but intact HEENT: some chronic ophthalmic changes (cotton wool exudates. AV nicking). neck supple. thyroid palpated with no mass noted BREASTS: normal, patient performs self-breast examinations LUNGS: clear bilaterally with no wheezing, no ronchi, no rales CARDIOVASCULAR: normal rate, S1 and S2, no S3, no gallop noted ARDOMEN: normal GENITOURINARY: patient deterred RECTAL: patient deterred EXTREMITITIES: no pitting edema, 10-guage monofilament test: 3 of 10 tested sites without sensation bilaterally, 6 of 10 tingling and burning pain bilaterally that is worse with touch, dorsal and pedal pulses present bilaterally, skin intact with no ulcerations NEUROLOGICAL: cranial nerves II - XII intact, deep tendon reflexes normal

Clinical Laboratory Report

Test Name	10/20/25	10/15/24	Range
Sodium (Na⁺)	139	140	136-145 mEq/L
Potassium (K⁺)	4.6	4.5	3.5-5 mEq/L
Chloride (Cl^-)	100	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	24	23-28 mEq/L
Urea nitrogen (BUN)	20	30	8-20 mg/dL
Creatinine	1.6	1.8	0.5-1.3 mg/dL
Glucose	152	187	70-115 mg/dL
Hemoglobin A1c	7.8	9.1	5.3-7.5 %
Calcium,Total	9.1	9.0	8.6-10.2 mg/dL
Phosphate	3.9	4.0	3-4.5 mg/dL
Magnesium	1.9	1.9	1.6-2.6 mEq/L
Protein, total	8.2	8.1	5.5-9 g/dL
Albumin	3.7	3.6	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	19	20	10-40 units/L
Aminotransferase,alanine (ALT)	18	19	10-40 units/L
Lactic dehydrogenase (LDH)	91	88	80-225 units/L
Alkaline phosphatase	54	57	30-120 units/L
Bilirubin, Total	1.0	1.0	0.3-1 mg/dL
Leukocytes (WBC)	5.9	6.2	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.8	4.9	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	15.3	15.1	12-16 g/dL
Hematocrit, Female	43	42	37-47 %
Mean corpuscular hemoglobin (MCH)	30	31	27-33 picogram
Mean corpuscular volume (MCV)	89	91	76-100 mcm³
Platelets	311	298	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.0	0.8-1.2
Prothrombin time (PT)	10.1	9.9	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	28.3	29	25-35 sec

Additional Labs:

Fasting	Today	6 Months Ago	12 Months Ago
Total Cholesterol (mg/dL)	197	207	222
Triglycerides (mg/dL)	240	250	260
HDL-C (mg/dL)	41	42	40
LDL-C (mg/dL)	108	115	130

Other Tests	Today	12 Months Ago
Albumin:Creatinine Ratio	320	330
Thyroid Stimulating Hormone	1.8	2.0

Cultures:

None

Imaging Studies:

Central Bone Densitometry (DXA)	6 Days Ago
T Score: Left Hip	-2.8
T Score: Lumbar Spine	-2.5

Echocardiography	6 Days Ago
Findings	Ejection Fraction is 55%, normal appearing mitral valve, no doppler evidence of mitral stenosis, normal left atrial size, normal right heart size and function, mild concentric LVH and global hypokinesis
Impression	1) Preserved lett ventricular systolic function despite mild LVH, 2) apparentlv normal diastolic function, 3) no signifinant valve abnormality or prolapse.

Vital Sign	10/20/25 09:45	10/15/24 07:23
Height (cm)	163	163
Weight (kg)	77	76
Body Temperature (°C)	37	37.2
Blood Pressure (mmHg)	130 / 78	154/86
Heart Rate (bpm)	62	70
Respiratory Rate (bpm)	16	18
Oxygen Saturation (%)	99	98

Current Orders

Medication
History

Diabetes has been managed with oral agents: last year glyburide/metformin was increased from 5/500 mg, 1 tab BID to 2 tabs BID and pioglitazone was increased from 30 mg daily to 45 mg daily.
Amlodipine started last year for blood pressure lowering, has been intolerant to two ACE-inhibitors.
Simvastatin has been the only agent used for dyslipidemia and has been increased to present dose of 40 mg daily.
Gabapentin started at lower dose and titrated up to current dose.
Acetaminophen used as needed for several years, and experienced intolerable side effects to amitriptyline line and desipramine.

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

Patient Name: Heyward, Precious Date of Birth: 9/1/1960 Room#: Exam #2	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Glyburide/ Metformin 5/500 mg tablet	2 PO BID	no
Pioglitazone 45 mg tablet	1 PO QD	no
Amlodipine 10 mg tablet	1 PO QD	no
HCTZ 12.5 mg capsule	1 PO QD	no
Metoprolol 100 mg XL tablet	1 PO QD	no
Simvastatin 40 mg tablet	1 PO QD	no
Gabapentin 400 mg capsule	1 PO BID	no
Acetaminophen 500 mg caplet	1-2 PO QID	no
Aspirin 325 mg EC tablet	1 PO QD	no
Nitroglycerin 0.4 mg tablet	1 SL PRN	yes, chest pain
Calcium Carbonate/Vit D 600 mg/200 IU tablet	1 PO BID	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: Heyward, Precious

Date of Birth: 9/1/1960

Room: Exam #2

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	163 cm
Actual Body Weight (ABW)	77 kg
Ideal Body Weight (IBW)	54.7 kg
ABW % of IBW	141 %
Adjusted Body Weight (AjBW)	63.6 kg
Body Surface Area (BSA)	1.87 m²
Body Mass Index (BMI)	29 kg/m²