View Patient Profiles

Wagner, Maxwell

MRN: 193224

Room: 321

DOB: 6/21/1957

Age: 68

Gender: Male

Allergies: No Known Drug Allergies

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Inpatient Cardiology Unit
Scenario	Mr. Wagner is initially admitted to the cardiac ICU under the care of the general cardiology team. The advanced heart failure team has also been consulted to assist with evaluating the patient for potential advanced therapies (left ventricular assist device, heart transplant) in the future. The patient is slowly weaned off intravenous nitroprusside, being switched back to oral afterload reduction with valsartan (160 mg twice daily, prior home dose) and transferred to the general cardiology floor. The patient is also switched back to rivaroxaban, following Swan-Ganz catheter removal. All other home medications are resumed except metformin. Furosemide has been switched back to oral (patient currently at 161 pounds). On hospital day #4, the general cardiology attending asks you to do a thorough review of the patient’s case and make recommendations for the patient’s CHF, CAD, and DMT2 therapies, as well as any other recommendations you may have related to this patient’s care.
Admission note taken on 10/17/25
CC	“I’m unable to sleep at night, can barely get around the house, and have had a relentless cough that has not stopped for a few weeks. I’m sick of spending time in the hospital because of my heart. Three times in three months is exhausting.”
HPI	Mr. Wagner was recently seen in the heart failure clinic 2 weeks ago during which his valsartan was increased from 80mg twice daily to 160mg twice daily. He was noted to have a productive cough and 2+ pitting edema bilaterally in his lower extremities at this time for which his furosemide dose was also increased from 20mg once daily to 40mg once daily. He presents to our medical center 4 days ago with the chief complaint noted above and was found to be warm on touch with a blood pressure of 116/60 mmHg. On assessment Mr. Wagner is noted to have 3+ pitting edema in his lower extremities. His weight at intake is 172 pounds. He has also developed an acute kidney injury with a previous baseline creatinine of 1.5 mg/dL. Given his presentation, the referring team started Mr. Wagner on a furosemide infusion of 10 mg/hr and sodium nitroprusside drip at 0.5 mcg/kg/min. A Swan-Ganz catheter was placed to help guide hemodynamic therapy. As such, the patient’s rivaroxaban was stopped and a heparin drip was initiated.
PMH	Heart Failure with a Reduced Ejection Fraction (HFrEF), NYHA Class II Coronary Artery Disease (s/p STEMI with LAD stenting in January 2019, one 2mm stent placed) Diabetes Mellitus Type II Hypertension Atrial Fibrillation (permanent) GI Bleed (6 months ago)
Social History	Alcohol: drinks socially, 2-4 drinks per week Tobacco: denies smoking or chewing Illicit drugs: none Employment: executive salesman for a biopharmaceutical company Marital status: married, two adult children Sexual history: single partner	Family History	Father died of a myocardial infarction (45 years old) Mother is still alive; no siblings
Vaccine History	Received all recommended childhood and adolescent immunizations through age 18 Tdap (3 years ago) Influenza (last season)	Surgical History	Appendectomy (31 years ago)
Physical Exam	ROS: Positive for wet, productive cough w/rales; shortness of breath; denies chest pain General: appears in moderate distress HEENT: PERRLA Chest: rales present bilaterally; tachypnea Cardiovascular: JVP 10 cm, S3 gallop Abdomen: positive bowel sounds Genitourinary: WNL Extremities: 3+ pitting edema; capillary refill > 2 seconds Neuro: AO X 3 Psych: normal

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	10/17/25	10/15/25	Range
Sodium (Na⁺)	138	133	135	142	136-145 mEq/L
Potassium (K⁺)	5.9	5.7	5.8	5.2	3.5-5 mEq/L
Chloride (Cl^-)	100	100	97	102	98-106 mEq/L
Bicarbonate (HCO₃^-)	30	30	30	24	23-28 mEq/L
Urea nitrogen (BUN)	30	29	29	18	8-20 mg/dL
Creatinine	1.7	1.8	1.8	2.4	0.5-1.3 mg/dL
Glucose	140	141	137	170	70-115 mg/dL
Hemoglobin A1c				8.8	5.3-7.5 %
Calcium,Total	8.9	8.8	8.6	9.5	8.6-10.2 mg/dL
Phosphate	4.1	4.1	4.1	4.2	3-4.5 mg/dL
Magnesium	2.2	2.2	2.3	2.4	1.6-2.6 mEq/L
Protein, total	5.4	5.5	5.5	6.1	5.5-9 g/dL
Albumin	4.7	4.7	4.6	4.8	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	18	17	17	75	10-40 units/L
Aminotransferase,alanine (ALT)	30	30	29	100	10-40 units/L
Lactic dehydrogenase (LDH)	91	93	93	104	80-225 units/L
Alkaline phosphatase	49	49	48	62	30-120 units/L
Bilirubin, Total	0.8	0.8	0.8	2.2	0.3-1 mg/dL
Leukocytes (WBC)	4.4	4.5	4.5	4.3	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.3	4.4	4.2	4.2	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	7.5	7.4	7.5	7.4	14-18 g/dL
Hematocrit, Male	26	25.5	25.5	26	42-50 %
Mean corpuscular hemoglobin (MCH)	31	31	30	28	27-33 picogram
Mean corpuscular volume (MCV)	89	86	91	82	76-100 mcm³
Platelets	362	362	351	360	150-450 x10³/mcL
International normalized ratio (INR)	1.6	1.6	1.6	1.6	0.8-1.2
Prothrombin time (PT)	16	16.2	15.8	16	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	34	34	35	34	25-35 sec

Additional Labs:

Fasting Lipid Panel (4 days ago)	Result
Total cholesterol (mg/dL)	208
LDL (mg/dL)	160
HDL (mg/dL)	48
Triglycerides (mg/dL)	128

Other Labs	Date	Result
Total Iron (ug/dL)	4 days ago	30
Ferritin (ng/mL)	4 days ago	8
BNP (pg/mL)	4 days ago	2,481

Cultures:

None

Imaging Studies:

Test	Date	Result
Chest X-Ray	4 days ago	cardiomegaly noted
Chest X-Ray	today	cardiomegaly now absent from prior imaging (4 days ago)
EKG	4 days ago	atrial fibrillation; QTc = 435 ms
EKG	today	atrial fibrillation; peaked t-waves
Bedside Echocardiogram (TTE)	4 days ago	Ejection Fraction – 25% (previously 40%, 1 year ago)

Vital Sign	10/19/25 07:53	23:16	15:28	10/18/25 09:19	22:35	16:57	10/17/25 08:44	10/15/25 09:29
Height (cm)	177.8			177.8			177.8	177.8
Weight (kg)	72.7			71			71	71.8
Body Temperature (°C)	37.6	36.5	38.4	37.2	38.4	36.8	37.2	37.8
Blood Pressure (mmHg)	128 / 86	128/86	128/86	129/83	125/86	128/85	125/87	114/80
Heart Rate (bpm)	84	84	86	86	81	84	85	88
Respiratory Rate (bpm)	12	11	12	12	11	12	11	18
Oxygen Saturation (%)	98	98	97	99	98	98	98	90

Current Orders

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?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			For blood glucose < 151 mg/dL give no additional units; For blood glucose 151-200 mg/dL give 1 unit; For blood glucose 201-250 mg/dL give 2 units; For blood glucose 251-300 mg/dL give 3 units; For blood glucose 301-350 mg/dL give 4 units; For blood glucose 351-400 mg/dL give 5 units.

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?

USE	START DATE	STOP DATE	NOTES

Medication
History

Mr. Wagner maintains that he rarely, if ever, misses any doses of his medications. His wife nodded in agreement.

Home Medication List: verified by pharmacy on admit (10/17/25)

Patient Name: Wagner, Maxwell Date of Birth: 6/21/1957 Room#: 321	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Valsartan 160 mg tablet	1 PO BID	no
Furosemide 40 mg tablet	1 PO QD	no
Metoprolol succinate 200 mg tablet	1 PO QD	no
Aspirin 81 mg tablet	1 PO QD	no
Atorvastatin 80 mg tablet	1 PO QD	no
Rivaroxaban 20 mg tablet	1 PO QD	no
Clopidogrel 75 mg tablet	1 PO BID	no
Metformin 1,000 mg tablet	1 PO BID	no
Pantoprazole 40 mg tablet	1 PO QD	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25	10/17/25
Aspirin 81 mg PO QD	08:56	08:33	08:30
Atorvastatin 80 mg PO QD	08:47	08:45	08:25
Clopidogrel 75 mg PO QD	08:44	08:41	08:24
Furosemide 40 mg PO BID	08:12 14:44	08:33 14:15	08:33 14:28
Insulin, lispro (100 units/mL) Sliding Scale SC TID AC & HS	8:13 12:19 18:54	8:53 12:11 18:47 22:52	8:11 12:58 18:54 22:16
Metoprolol succinate 200 mg PO QD	08:53	08:47	08:11
Rivaroxaban 20 mg PO QD	8:33	8:58	8:28
Valsartan 160 mg PO BID	8:54 20:35	8:50 20:44	8:55 20:40

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: Wagner, Maxwell

Date of Birth: 6/21/1957

Room: 321

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	177.8 cm
Actual Body Weight (ABW)	72.7 kg
Ideal Body Weight (IBW)	73 kg
ABW % of IBW	100 %
Adjusted Body Weight (AjBW)	72.9 kg
Body Surface Area (BSA)	1.89 m²
Body Mass Index (BMI)	23 kg/m²