View Patient Profiles

Johnson, Jevonte

MRN: 113817

Room: Exam #5

DOB: 10/11/1962

Age: 63

Gender: Male

Allergies: hydromorphone (itch, nausea), glipizide (rash)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Outpatient Family Medicine Clinic
Scenario	You are rounding as part of the family medicine team. The patient presents to the family medicine clinic for follow-up of a recent hospitalization for a left hip fracture/osteoporosis evaluation.
Admission note taken on 10/20/25
CC	intermittent pain from left hip fracture
HPI	JJ presents to the family medicine clinic today for follow-up of a recent hospitalization for a left hip fracture/osteoporosis evaluation. His fracture occurred on 9-1-11 when he fell while walking in a physical rehabilitation center. JJ was in rehabilitation following an ischemic stroke. He currently has intermittent pain when ambulating (4 out of 10) in his left hip. The patient self started acetaminophen as needed for pain, but has not had satisfactory pain resolution with this regimen. The patient complained of hip pain earlier in the year which prompted a work up including a DXA scan. The results of this scan were not followed up on with the patient. The patient states that recently he always seems to have a tickling sensation in the back of his throat and a dry cough. He has been in “good spirits” and is very determined to resume the level of independence he had prior to his stroke.
PMH	Hip Fracture (2 weeks ago) Ischemic stroke (1 month ago) Type 2 diabetes Hypertension CHF Dyslipidemia Generalized Anxiety Disorder
Social History	Tobacco: Denies ETOH: Social Illicit Drugs – Denies Caffeine: 1-2 cups coffee a day Occupation: Welder Status: Married Children: 3 children Physical Activity: Sedentary Diet: Nothing notable	Family History	Father: DM, HTN, Colon cancer dx at age 66 Mother: Died CVA age 59
Vaccine History	Patient reports having all childhood vaccines. Received flu vaccine for current season. Has completed COVID-19 (Moderna) 2 primary, and 2 booster shots.	Surgical History	Open reductions and internal fixation of left hip (2 weeks ago)
Physical Exam	GENERAL: Obese African American male appearing to be older than stated age and using a walker. SKIN: overall dry but intact HEENT: PERRLA, neck supple, thyroid palpated with no mass noted LUNGS: clear bilaterally with no wheezing, no rhonchi, no rales, dry cough noted CARDIOVASCULAR: normal rate, rhythm, no gallops or murmurs noted ABDOMEN: normal GENITOURINARY: patient deferred RECTAL: patient deferred EXTREMITIES: no pitting edema, skin intact with no ulcerations, left hip ROM limited – 20 degree hip flexion with some pain (as expected with healing fracture) upon internal and external rotation, feet have appropriate sensation and blood flow NEUROLOGICAL: cranial nerves II – XII intact, deep tendon reflexes 2+ on left, 1+ on right, strength 4/5 RUE, 4/5 RLE

Clinical Laboratory Report

Test Name	10/20/25	10/06/25	Range
Sodium (Na⁺)	140	142	136-145 mEq/L
Potassium (K⁺)	3.6	4.0	3.5-5 mEq/L
Chloride (Cl^-)	110	107	98-106 mEq/L
Bicarbonate (HCO₃^-)	29	24	23-28 mEq/L
Urea nitrogen (BUN)	15	8	8-20 mg/dL
Creatinine	1.1	1.2	0.5-1.3 mg/dL
Glucose	112	172	70-115 mg/dL
Hemoglobin A1c	8.6	8	5.3-7.5 %
Calcium,Total	9.0	9.0	8.6-10.2 mg/dL
Phosphate	3.3	3.5	3-4.5 mg/dL
Magnesium	2.2	2.1	1.6-2.6 mEq/L
Protein, total	7.9	8.1	5.5-9 g/dL
Albumin	4.5	4.5	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	12	12	10-40 units/L
Aminotransferase,alanine (ALT)	16	16	10-40 units/L
Lactic dehydrogenase (LDH)	162	157	80-225 units/L
Alkaline phosphatase	77	80	30-120 units/L
Bilirubin, Total	1.0	1.0	0.3-1 mg/dL
Leukocytes (WBC)	6.0	7.0	4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.6	3.7	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	12	12	14-18 g/dL
Hematocrit, Male	38	38	42-50 %
Mean corpuscular hemoglobin (MCH)	31.2	30.5	27-33 picogram
Mean corpuscular volume (MCV)	80	82	76-100 mcm³
Platelets	375	400	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1.0	0.8-1.2
Prothrombin time (PT)	9.9	9.7	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	30	27	25-35 sec

Additional Labs:

Fasting Lipid Panel (today)

TC (mg/dL) 226
LDL (mg/dL) 136
HDL (mg/dL) 30
TG (mg/dL) 302

Other (today)

Testosterone Level: Pending
Vitamin D Level: Pending

Cultures:

None

Imaging Studies:

2 weeks ago: ECHO LVEF 33%

Central Bone Densitometry (DXA) (3 mo. ago)

T-score: Left hip -2.8
T-score: Lumbar spine -2.5

Vital Sign	10/20/25 09:34	10/06/25 08:29
Height (cm)	183
Weight (kg)	112
Body Temperature (°C)	37	37.2
Blood Pressure (mmHg)	138 / 86	161/95
Heart Rate (bpm)	75	65
Respiratory Rate (bpm)	12	10
Oxygen Saturation (%)	96	96

Current Orders

Medication
History

None

Home Medication List: verified by pharmacy on admit (10/20/25)

Patient Name: Johnson, Jevonte Date of Birth: 10/11/1962 Room#: Exam #5	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
Metformin 1,000 mg tablet	1 PO BID	no	17:00 10/19/25	occasional GI upset	misses evening dose 1-2x/week	Increased from QD 1 month ago
Escitalopram 10 mg tablet	1 PO QD	no	9:00 10/19/25	none	never misses
Metoprolol ER 100 mg tablet	1 PO QD	no	9:00 10/19/25	none	never misses
Aspirin 325 mg tablet	1 PO QD	no	9:00 10/19/25	none	never misses
Clopidogrel 75 mg tablet	1 PO QD	no	9:00 10/19/25	none	never misses
Alprazolam 0.25 mg tablet	1 PO PRN	yes, anxiety	22:00 10/19/25	none	never misses
Rosuvastatin 20 mg tablet	1 PO QD	no	20:00 10/19/25	none	misses evening dose 1-2x/week	changed from simvastatin (1 mo. ago)
Furosemide 20 mg tablet	1 PO QD	no	9:00 10/19/25	none	never misses
HCTZ 25 mg tablet	1 PO QD	no	9:00 10/19/25	none	never misses
Ramipril 5 mg capsule	1 PO QD	no	9:00 10/19/25	none	never misses	added during hospital stay (1 mo. ago)
Omeprazole 20 mg capsule	1 PO QD	no	9:00 10/19/25	none	never misses	added during hospital stay (2 weeks ago)
Insulin aspart 100 units/mL injection pen	Sliding Scale Subcut QID	no	21:00 10/19/25	none	never misses	2 units for FSBG 200-250, 4 units for FSBG 251-300, 6 units for FSBG 301-350, 8 units for FSBG 351-400
Acetaminophen 325 mg tablet	2 PO QID	yes, pain	22:30 10/19/25	none	N/A	mild-moderate hip pain
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication

10/20/25

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: Johnson, Jevonte

Date of Birth: 10/11/1962

Room: Exam #5

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	183 cm
Actual Body Weight (ABW)	112 kg
Ideal Body Weight (IBW)	77.6 kg
ABW % of IBW	144 %
Adjusted Body Weight (AjBW)	91.4 kg
Body Surface Area (BSA)	2.39 m²
Body Mass Index (BMI)	33.4 kg/m²