View Patient Profiles

McCray, Jacob

MRN: 109716

Room: 469

DOB: 4/24/1973

Age: 52

Gender: Male

Allergies: penicillin/beta-lactams (hives)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Burn Unit
Scenario	The patient arrived in the burn unit yesterday and was immediately assessed for the degree of skin involvement. The patient was sedated and given pain medication, brought to surgery for debridement of nonviable tissue, and started on crystalloid fluids at a rate of 4 mL/kg/%TBSA (Parkland Formula) for the first 24 hours. Other treatments are listed in the medication list below. Today, on morning rounds the patient is reassessed during his daily bath. He reports his pain to be 4 out of 10 prior to going for his bath. His wounds are unwrapped, washed, and examined. Fluids and medication management are currently being discussed. The patient has a nasogastric tube and a foley catheter.
Admission note taken on 10/19/25
CC	blisters over entire body with areas of skin epidermal looseness
HPI	JM was evaluated by his primary physician on 3 days ago for fever, suprapubic tenderness, and dysuria and received a course of Trimethoprim/Sulfamethoxazole. After the third dose (2 days ago), the patient noticed a blister on his left neck with more blisters developing last night. The patient continued to have vague symptoms including fever, tremor, vomiting, and loss of appetite when he was seen at 10 am in the Emergency Department at an outside hospital yesterday. He was transferred that day to University Hospital for specialized treatment at the Burn Center. He was noted to be responsive and anxious. His wounds showed large thin-walled blisters in his oral mucosa, tongue, neck, his entire back, right flank, buttocks, and areas of the right thigh with areas of skin epidermal looseness. The patient was admitted yesterday to the Burn Center with a diagnosis of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis involving 25% total body surface area.
PMH	Significant for hypertension for the last 5 years
Social History	Tobacco: Nonsmoker ETOH: None Illicit Drugs – None Caffeine: 1 cup of coffee/day Occupation: Restaurant owner Status: Married Children: 2 (2 males 26 yrs, 28 yrs) Physical Activity: No regular exercise Diet: No specifics	Family History	Father: 71, alive, hypertension Mother: 69, alive, hypertension, osteoarthritis Sister: 38, alive, nothing significant history Brother: 44, alive, nothing significant
Vaccine History	Not available	Surgical History	None
Physical Exam	General: No acute distress but appears uncomfortable Skin: Swelling around the eyes, tongue, left posterior neck, central back, right flank, right chest, genitals, outer right thigh Musc/Ext: Normal except for skin findings HEENT: PERRLA, EOMI, blistering to oral mucosa, mouth, and throat Chest/Resp: CTA bilaterally CV: RRR, S1S2, no murmurs, rubs, gallops Abd: Soft, nontender, bowel sounds heard GU: Suprapubic pain Neuro: A&O x 3, pain score 8/10

Clinical Laboratory Report

Test Name	10/20/25	10/19/25	Range
Sodium (Na⁺)	129	138	136-145 mEq/L
Potassium (K⁺)	3.8	4.4	3.5-5 mEq/L
Chloride (Cl^-)	101	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	25	25	23-28 mEq/L
Urea nitrogen (BUN)	14	15	8-20 mg/dL
Creatinine	0.87	0.83	0.5-1.3 mg/dL
Glucose	110	115	70-115 mg/dL
Hemoglobin A1c		7.2	5.3-7.5 %
Calcium,Total	8.7	8.6	8.6-10.2 mg/dL
Phosphate	2.4	2.2	3-4.5 mg/dL
Magnesium	2.1	2.1	1.6-2.6 mEq/L
Protein, total	5.5	5.6	5.5-9 g/dL
Albumin	3.7	4.0	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	38	39	10-40 units/L
Aminotransferase,alanine (ALT)	36	36	10-40 units/L
Lactic dehydrogenase (LDH)	187	181	80-225 units/L
Alkaline phosphatase	74	72	30-120 units/L
Bilirubin, Total	0.6	0.6	0.3-1 mg/dL
Leukocytes (WBC)	7.2	10.3	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.7	4.9	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	15.0	15.1	14-18 g/dL
Hematocrit, Male	45.0	45.3	42-50 %
Mean corpuscular hemoglobin (MCH)	28	28	27-33 picogram
Mean corpuscular volume (MCV)	81	82	76-100 mcm³
Platelets	179	196	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.1	0.8-1.2
Prothrombin time (PT)	10.2	10.3	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	31	25-35 sec

Additional Labs:

Urinalysis	Result (today)
Specific gravity	1.013
Protein	30 mg/dL
Glucose	Negative
WBC	>4000 cells/μL
RBC	60 cells/μL
Bacteria	2920 CFU/μL
pH	6.0
Nitrite	Negative
Leucocyte esterase	large hyaline casts
Osmolarity	500 mOsm/L
Sodium	10 mEq/L

Other (today)

12 Hour Urine Output: 1.8 L

Cultures:

Urine culture: pending

Imaging Studies:

none

Vital Sign	10/20/25 08:52	22:37	16:46	10/19/25 09:16
Height (cm)	185			185
Weight (kg)	93.2			93
Body Temperature (°C)	38.4	37.1	37.5	37.9
Blood Pressure (mmHg)	152 / 90	148/91	150/93	150/92
Heart Rate (bpm)	80	83	81	84
Respiratory Rate (bpm)	18	24	24	24
Oxygen Saturation (%)	97	96	98	98

Current Orders

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?

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
			give 30 min prior to morphine

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?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			after bath with wound dressing

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?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, pain (4-6)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, pain (7-10)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, pain with debridement
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

Not available

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

Patient Name: McCray, Jacob Date of Birth: 4/24/1973 Room#: 469	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
Trimethoprim/Sulfamethoxazole 160 mg/800 mg tablet	1 PO BID	no	18:00 10/18/25	none	N/A	took 3 doses before admission
HCTZ 25 mg tablet	1 PO QD	no	8:00 10/18/25	none	never misses
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25	10/19/25
Morphine 2 mg IV QID Rate: injection		05:23 11:30 17:18 24:43
Enoxaparin 40 mg Subcut QD		08:25
Gammagard Liquid (IVIG) 45 g IV QD Rate: 190 mL/hr		08:28
Methylprednisolone Succinate 100 mg IV TID Rate: 200 mL/hr		8:26 12:30 20:45
Diphenhydramine 50 mg PO QID		04:28 10:11 16:55 22:41
Docusate 100 mg PO TID		8:31 12:22 20:17
Lactated Ringers IV continuous Rate: 400 mL/hr	00:58	00:34 05:43 10:39 15:42 20:55
Lacri-Lube apply to both eyes OPH QID		08:32 12:58 17:37 21:45
Silver sulfadiazine 1% TOP QD
Famotidine 20 mg IV BID Rate: 100 mL/hr		08:30 20:22
Hydrochlorothiazide 25 mg PO QD		08:25
Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO BID		08:17 20:10
Oxycodone/APAP 5 mg/325 mg PO QID PRN PRN yes, pain (4-6)
Oxycodone/APAP 10 mg/650 mg PO QID PRN PRN yes, pain (7-10)		09:13 15:18 22:21
Morphine 10 mg IV QD PRN PRN yes, pain with debridement Rate: injection		08:59

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: McCray, Jacob

Date of Birth: 4/24/1973

Room: 469

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	185 cm
Actual Body Weight (ABW)	93.2 kg
Ideal Body Weight (IBW)	79.9 kg
ABW % of IBW	117 %
Adjusted Body Weight (AjBW)	85.2 kg
Body Surface Area (BSA)	2.19 m²
Body Mass Index (BMI)	27.2 kg/m²