View Patient Profiles

Garcia, Ana

MRN: 306596

Room: 325

DOB: 01/17/1968

Age: 57

Gender: Female

Allergies: NKDA, flu vaccine makes her sick

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Inpatient Renal Unit
Scenario	Patient admitted to hospital 2 days ago for DKA, which was treated in ICU. She was found to have decreased renal function and was admitted to the renal unit for further treatment after blood sugars under control. Home meds were held in ICU.
Admission note taken on 10/17/25
CC	Patient was brought to the ER 2 days ago by her husband because she was disoriented and didn’t feel well. She has been very thirsty lately so drinking more and needing to go to the bathroom frequently.
HPI	Patient was diagnosed with diabetes 10 years ago. She started taking metformin, but it upset her stomach, so she quit. She has been taking glyburide since then but was told not to take it if she had alcohol, so she skips it frequently at dinner since she usually has a drink with dinner. She also frequently misses morning doses when she is running late and doesn’t make breakfast at home. She doesn’t check her blood sugar and has not been to her primary care provider in a few years because she hasn’t been sick. Her pharmacist just calls for refills when she runs out.
PMH	hypertension diabetes (type 2) hyperlipidemia
Social History	Works in an office Married 40 years next year with 3 grown children and 4 grandkids Does not use tobacco Usually has a glass of wine or cocktail with dinner Occasionally smokes marijuana to relax Drinks a couple of cups of coffee daily Goes for a walk with her husband every evening after dinner No illicit drugs (marijuana is not really a drug)	Family History	Mother - died of stroke at age 77 Father - had heart attack at age 65 but still alive at age 80
Vaccine History	Usual childhood vaccines Td 9 years ago Shingrix (2 doses) 2 years ago No flu vaccine—makes her sick COVID fully vaccinated and boostedd	Surgical History	Not on file
Physical Exam	HEENT: Blurry vision, dizziness is better Neck: supple, no JVD or HJR Lungs: CTA Heart: RRR Abdomen: obese, soft, nontender, +BS, nausea has resolved Extremities: Decreased pulses and sensation in lower extremities Neurological: A&Ox3 Cranial nerves II-XII are grossly intact

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	10/17/25	Range
Sodium (Na⁺)	144	146	144	136-145 mEq/L
Potassium (K⁺)	4.9	4.9	4.9	3.5-5 mEq/L
Chloride (Cl^-)	98	98	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	18	18	17	23-28 mEq/L
Urea nitrogen (BUN)	42	42	42	8-20 mg/dL
Creatinine	2.8	2.9	2.7	0.5-1.3 mg/dL
Glucose	248	240	252	70-115 mg/dL
Hemoglobin A1c			8.9	5.3-7.5 %
Calcium,Total	8.8	8.9	9	8.6-10.2 mg/dL
Phosphate	3.9	3.9	3.9	3-4.5 mg/dL
Magnesium	2.1	2.2	2.1	1.6-2.6 mEq/L
Protein, total	5.9	6.1	6.1	5.5-9 g/dL
Albumin	4.8	4.9	4.9	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	22	22	22	10-40 units/L
Aminotransferase,alanine (ALT)	11	11	10	10-40 units/L
Lactic dehydrogenase (LDH)	93	92	91	80-225 units/L
Alkaline phosphatase	59	58	59	30-120 units/L
Bilirubin, Total	0.38	0.4	0.4	0.3-1 mg/dL
Leukocytes (WBC)	7.65	7.8	7.7	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.9	5	4.8	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	13.5	13.5	13.4	12-16 g/dL
Hematocrit, Female	33	33.7	32.3	37-47 %
Mean corpuscular hemoglobin (MCH)	31	31	30	27-33 picogram
Mean corpuscular volume (MCV)	80	78	79	76-100 mcm³
Platelets	270	278	275	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1	1	0.8-1.2
Prothrombin time (PT)	10.1	10.2	10.4	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	33	32	32	25-35 sec

Additional Labs:	None
Cultures:	None
Imaging Studies:	None

Vital Sign	10/19/25 09:56	23:48	15:54	10/18/25 09:15	23:34	17:13	10/17/25 09:58
Height (cm)	165			165			165
Weight (kg)	86			86			85
Body Temperature (°C)	36.8	37.5	37.5	35.7	36.1	37.5	36.1
Blood Pressure (mmHg)	145 / 90	142/90	143/88	147/88	142/90	146/89	149/90
Heart Rate (bpm)	82	79	79	81	80	82	84
Respiratory Rate (bpm)	16	15	16	16	15	15	15
Oxygen Saturation (%)	99	98	100	100	100	98	99

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			adjust using sliding scale

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN nausea
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-2) or fever 37.2-38.5°C
USE	START DATE	STOP DATE	NOTES

Medication
History

Not on file

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

Patient Name: Garcia, Ana Date of Birth: 01/17/1968 Room#: 325	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Glyburide 5 mg tablet	1 PO BID AC	no	for diabetes
Benazepril 10 mg tablet	1 PO HS	no	for blood pressure
Rosuvastatin 20 mg tablet	1 PO HS	no	for cholesterol
Black Cohosh unknown capsule	2 PO HS	no	for menopause
Women’s multi-vitamin with iron tablet	1 PO HS	no
Cinnamon 1,000 mg tablet	1 PO QD	no	for diabetes
Fish Oil 1,000 mg capsule	1 PO QD	no	for cholesterol
Famotidine 20 mg tablet	1 PO HS	yes, for GERD
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25	10/17/25
D5W-1/2 NS IV continuous infusion	4:24	4:15	4:38
Insulin Glargine 15 units SC HS		22:55	22:56
Insulin Lispro 5 units SC TID AC	7:33 11:10	7:22 11:13 17:48	7:29 11:40 17:39
Enoxaparin 40 mg SQ q24Hr	9:41	9:25	9:10
Famotidine 20 mg PO q12Hr	9:25	9:41 21:54	9:28 21:54
Ondansetron 4 mg PO q4Hr PRN PRN nausea			21:45
Acetaminophen 650 mg PO q4Hr PRN PRN pain (1-2) or fever 37.2-38.5°C

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
D5W-1/2 NS	continuous infusion, 60 mL/hr	stop IV prior to discharge
Insulin Glargine	15 units SC HS daily
Insulin Lispro	5 units SC TID AC
Enoxaparin	40 mg SC daily	used for prophylaxis in hospital — DC on discharge
Famotidine	20 mg PO BID	used for prophylaxis in hospital — resume home dose
Acetaminophen	650 mg PO q4h prn	for pain or fever - has not used for 24 hr
Ondansetron	4 mg PO q4h prn	for nausea/vomiting — has not used for 24 hr

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Glyburide	5 mg PO BID AC	Now taking insulin
Benazepril	10 mg PO HS	for blood pressure
Rosuvastatin	20 mg PO HS	for cholesterol
Black Cohosh	2 capsules PO HS	for menopause
Women’s multi-vitamin with iron	1 tablet PO HS
Cinnamon	1,000 mg PO daily	for diabetes
Fish oil	1,000 mg PO daily	for cholesterol
Famotidine	20 mg PO HS PRN	for GERD

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: Garcia, Ana

Date of Birth: 01/17/1968

Room: 325

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	165 cm
Actual Body Weight (ABW)	86 kg
Ideal Body Weight (IBW)	57 kg
ABW % of IBW	151 %
Adjusted Body Weight (AjBW)	68.6 kg
Body Surface Area (BSA)	1.99 m²
Body Mass Index (BMI)	31.6 kg/m²