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Crabbins, Elliott

MRN: 313102

Room: ED9

DOB: 06/30/1953

Age: 72

Gender: Male

Allergies: penicillin (rash 5 years ago)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Emergency Department
Scenario	Patient presents with a diabetic foot wound.
Admission note taken on 10/19/25
CC	"I have a sore on my foot that just keeps getting worse."
HPI	EC is a 72-year-old male who presents to the ED with a non-healing wound to his right foot. Patient states that he has had this for several weeks and has tried topical OTC creams with no improvement. It looks worse and has started to smell bad. He couldn’t get an appointment with his primary care physician for a couple of months, so he came to the ED. He denies pain.
PMH	Diabetes x 20 yrs, insulin dependent x 10 years Peripheral vascular disease (PVD) Glaucoma Diabetic retinopathy s/p bilat laser surgery Hx partial right foot amputation, well healed Possible stroke or TIA affecting left side; regained full function.
Social History	Retired from construction work Married 44 yr with grown children and grandchildren in area Smokes 2-3 ppd, up from 1-2 ppd when working Quit drinking alcohol 20 yr ago Does not use illicit drugs Drinks 1-2 cups coffee in morning Unable to exercise due to wheelchair bound Eats what wife cooks—meat & potatoes, some vegetables and fruits daily	Family History	Father - lived into his 90s and died of atherosclerotic disease Mother - died of complications related to hip fracture Brothers — 1 died of emphysema, 1 died from MI, 1 died from multiple MIs and related complications
Vaccine History	Had measles, mumps, and chicken pox as a child Tdap 8 years ago Shingrix (2 doses) 9 years ago Flu last Fall COVID fully vaccinated and boosted	Surgical History	Not on file
Physical Exam	HEENT: Normocephalic, atraumatic. Right eye shows cloudy cataract. Oral mucosa is pink and patient is wearing dentures. Tobacco stains noted on lip margins. Neck: positive bruit noted on left carotid high in neck Lungs: bilateral breath sounds +, no rales, rhonchi, or wheezesr Heart: RRR w/faint systolic ejection murmur at left sternal border Abdomen: nontender, non-distended, + bowel sounds Extremities: Dark brown tobacco stains noted on nails of right hand. Distal legs are dry, scaley, and show mild atrophic appearance to calves. Well healed amputation site to right foot. Right lateral foot shows discoid ulcerative wet lesion with odor. Pulses: Femoral left 2, right 1. No distal pulses palpable distal to femoral arteries. Good capillary refill noted to left toes. Neurological: A&Ox3. Cranial nerves II-XII are grossly intact. Grips are 4/4 and muscle groups 4/4.

Clinical Laboratory Report

Test Name	10/19/25	Range
Sodium (Na⁺)	144	136-145 mEq/L
Potassium (K⁺)	4.8	3.5-5 mEq/L
Chloride (Cl^-)	108	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	23-28 mEq/L
Urea nitrogen (BUN)	29	8-20 mg/dL
Creatinine	11	0.5-1.3 mg/dL
Glucose	138	70-115 mg/dL
Hemoglobin A1c	7.6	5.3-7.5 %
Calcium,Total	8.9	8.6-10.2 mg/dL
Phosphate	4.1	3-4.5 mg/dL
Magnesium	1.9	1.6-2.6 mEq/L
Protein, total	7.7	5.5-9 g/dL
Albumin	4.6	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	11	10-40 units/L
Aminotransferase,alanine (ALT)	13	10-40 units/L
Lactic dehydrogenase (LDH)	93	80-225 units/L
Alkaline phosphatase	69	30-120 units/L
Bilirubin, Total	0.5	0.3-1 mg/dL
Leukocytes (WBC)	6.4	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.3	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	14.4	14-18 g/dL
Hematocrit, Male	42.4	42-50 %
Mean corpuscular hemoglobin (MCH)	32	27-33 picogram
Mean corpuscular volume (MCV)	82	76-100 mcm³
Platelets	197	150-450 x10³/mcL
International normalized ratio (INR)	0.9	0.8-1.2
Prothrombin time (PT)	9.6	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	25-35 sec

Additional Labs:	None
Cultures:	None
Imaging Studies:	None

Vital Sign	10/19/25 08:53
Height (cm)	175
Weight (kg)	74
Body Temperature (°C)	37.2
Blood Pressure (mmHg)	145 / 56
Heart Rate (bpm)	69
Respiratory Rate (bpm)	18
Oxygen Saturation (%)	97

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

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

Medication
History

None

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

Patient Name: Crabbins, Elliott Date of Birth: 06/30/1953 Room#: ED9	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Insulin Lantus 300 units/mL insulin pen	50 units SC HS	no
Insulin Novolog 100 units/mL insulin pen	10 units SC with breakfast and lunch, 30 units with supper	no
Metformin 1,000 mg ER tablet	1 PO BID	no
Lisinopril 5 mg tablet	1 PO QD	no
Atorvastatin 40 mg tablet	1 PO QD	no
Aspirin 325 mg tablet	1 PO QD	no
Timoptic 0.5% ophthalmic solution	1 gtt OU BID	no
Mens multivitamin/ mineral tablet	1 PO QD	no
Neosporin cream	apply TOP 3-4x/day	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Dextrose 5%/Nacl 0.225% 75 mL/hr IV continuous infusion	10:30
Vancomycin 1 g IV x1 stat Rate: 200 mL/hr	11:24
Piperacillin/tazobactam 3.375 g IV q6Hr Rate: 300 mL/hr	9:33 13:30 17:50
Lorazepam 1 mg PO on call to MRI	10:47

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Dextrose 5%/Nacl 0.225%	75 mL/hr continuous infusion
Vancomycin	1 g IV x1 stat
Piperacillin/tazobactam	3.375 g IV q6Hr	switch to ciprofloxacin 500 mg PO BID x10 days
Lorazepam	1 mg PO on call to MRI
Nicotine Transdermal Patch	21 mg/24 hr	begin using 1 patch to skin QD for smoking cessation

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Insulin Lantus	50 units SC HS
Insulin Novolog	10 units SC with breakfast and lunch, 30 units with supper
Metformin	1,000 mg ER PO BID
Lisinopril	5 mg PO QD
Atorvastatin	40 mg PO QD
Aspirin	325 mg PO QD
Timoptic 0.5%	1 gtt OU BID
Mens multivitamin/ mineral	1 tab PO QD
Neosporin cream	apply TOP 3-4x/day	switch to Dakins 1/2 strength solution applied to dressing and changed daily

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: Crabbins, Elliott

Date of Birth: 06/30/1953

Room: ED9

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	175 cm
Actual Body Weight (ABW)	74 kg
Ideal Body Weight (IBW)	70.7 kg
ABW % of IBW	105 %
Adjusted Body Weight (AjBW)	72 kg
Body Surface Area (BSA)	1.9 m²
Body Mass Index (BMI)	24.2 kg/m²