View Patient Profiles

Anderson, Ruby

MRN: 132819

Room: 646

DOB: 1/8/1996

Age: 28

Gender: Female

Allergies: nausea from warfarin

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	RA was diagnosed with DVT and pulmonary embolism. She was given 70 mg of enoxaparin in the Emergency Department and recommended for admission to the medical floor for observation overnight because of her dyspnea on exertion. She is not currently using her oxygen. An alcohol withdrawal assessment was negative. The hospitalist has consulted the pharmacy anticoagulation service for recommendations and follow-up.
Admission note taken on 05/14/24
CC	Shortness of breath, chest tightness, light-headedness
HPI	RA presented to the emergency department this morning stating “I feel like I can’t breathe right”. She complained of dyspnea, chest tightness, and light headedness on exertion.
PMH	Lower extremity deep vein thrombosis (DVT) 8 years ago treated with warfarin for 6 months. Seasonal allergic rhinitis
Social History	Smokes 1.5 PPD x 10 years Drinks 5-6 drinks/night on most weekends She is unmarried, a salesperson for a national publisher, travels regionally 2-3 times/month.	Family History	Father: 56, alive, seasonal allergies, Type 2 diabetes Mother: 57, alive, hypercholesterolemia, gout Brother: 24, alive, no significant history
Vaccine History	Completed childhood series. Has already had Influenza vaccine this season.	Surgical History	None
Physical Exam	General: overweight young woman generally well-appearing HEENT: PERRLA, EOMI, mildly inflamed nares Chest: CTA bilaterally; tachypneic, good air movement in all lobes CV: tachycardia, regular rhythm, no murmurs, rubs, gallops Abd: soft, tender, bowel sounds present GU: Deferred, Last menstrual period 2 weeks ago Ext: no edema, pain or redness in any extremities, cap refill 3 seconds Neuro: A&O x 3, CII-XII intact, (-) clonus

Clinical Laboratory Report

Test Name	05/14/24	Range
Sodium (Na⁺)	134	136-145 mEq/L
Potassium (K⁺)	4.1	3.5-5 mEq/L
Chloride (Cl^-)	98	98-106 mEq/L
Bicarbonate (HCO₃^-)	27	23-28 mEq/L
Urea nitrogen (BUN)	22	8-20 mg/dL
Creatinine	1.1	0.5-1.3 mg/dL
Glucose	110	70-115 mg/dL
Hemoglobin A1c	5.8	5.3-7.5 %
Calcium,Total	9.2	8.6-10.2 mg/dL
Phosphate	3.7	3-4.5 mg/dL
Magnesium	1.9	1.6-2.6 mEq/L
Protein, total	6.0	5.5-9 g/dL
Albumin	3.8	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	32	10-40 units/L
Aminotransferase,alanine (ALT)	34	10-40 units/L
Lactic dehydrogenase (LDH)	190	80-225 units/L
Alkaline phosphatase	80	30-120 units/L
Bilirubin, Total	0.6	0.3-1 mg/dL
Leukocytes (WBC)	7.4	4.5-11 x10³/mcL
Red blood cells (RBC), Female	3.4	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	13	12-16 g/dL
Hematocrit, Female	40	37-47 %
Mean corpuscular hemoglobin (MCH)	30	27-33 picogram
Mean corpuscular volume (MCV)	90	76-100 mcm³
Platelets	354	150-450 x10³/mcL
International normalized ratio (INR)	1.1	0.8-1.2
Prothrombin time (PT)	12.4	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	22.8	25-35 sec

Additional Labs:	Other (today) D-dimer (ng/mL) 4300 Troponin (ng/mL) 0.01 Urine Pregnancy test Negative Blood alcohol (mg/dL) 0.0
Cultures:	None
Imaging Studies:	CT Angiogram of chest: Positive for pulmonary embolus, negative for edema, infiltrates, or structural abnormality. Venous Doppler ultrasound: Small partially occluding thrombus in left femoral vein. Cardiac Echo: Slight right ventricle dilation, otherwise normal. EKG: Sinus tachycardia

Vital Sign	05/14/24 09:17
Height (cm)	157
Weight (kg)	67
Body Temperature (°C)	37.3
Blood Pressure (mmHg)	102 / 82
Heart Rate (bpm)	102
Respiratory Rate (bpm)	22
Oxygen Saturation (%)	93-95% on room air

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, dyspnea or SaO2 < 90%
USE	START DATE	STOP DATE	NOTES

Medication
History

RA was diagnosed with a symptomatic DVT 8 years ago while attending college. At that point she was taken off of her oral contraceptives and treated with “some kind of shot” and warfarin for 6 months. She reports that the warfarin made her nauseated but she “knows she is not allergic.”
Last year, she moved to New York City and she admits that she did not tell her new OB/GYN about her DVT because she wanted to start birth control again. She also binge drinks at weekend parties, and takes Blowfish (Aspirin and Caffeine) for her hangovers at least once a week.

Compliance/dosing issue: none

Home Medication List: verified by pharmacy on admit (05/14/24)

Patient Name: Anderson, Ruby Date of Birth: 1/8/1996 Room#: 646	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	LAST DOSE (date/time)	ADVERSE EFFECTS	ADHERENCE	NOTES	MED REC ACTION
Yaz 3 mg/0.02 mg tablet	1 PO HS	no	23:00 05/13/24	none	never misses
Advil Allergy Sinus 200 mg/30 mg/2 mg caplet	1 PO QD	no	9:00 05/13/24	none	misses 1-2x/week	OTC, for allergy symptoms
Blowfish (Aspirin/Caffeine) 500 mg/60 mg tablet	1 PO HS	yes	21:00 05/13/24	none	N/A	OTC, as needed for hangovers 1-2x/week
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	05/14/24
Enoxaparin 70 mg SUBCUT BID	07:48 09:58
Oxygen 2 liters by nasal cannula INH PRN PRN yes, dyspnea or SaO2 < 90%

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: Anderson, Ruby

Date of Birth: 1/8/1996

Room: 646

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	157 cm
Actual Body Weight (ABW)	67 kg
Ideal Body Weight (IBW)	50.1 kg
ABW % of IBW	134 %
Adjusted Body Weight (AjBW)	56.9 kg
Body Surface Area (BSA)	1.71 m²
Body Mass Index (BMI)	27.2 kg/m²