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Lopez, Renata

MRN: 148720

Room: 803

DOB: 11/13/1943

Age: 82

Gender: Female

Allergies: Sulfa drugs (rash)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Medical ICU (MICU)
Scenario	RL is diagnosed with meningitis, and the Medical ICU (MICU) team is consulted for admission given the need for mechanical ventilation. The only antibiotic that has been given is piperacillin/tazobactam 3.375 gram x 1. The MICU team has consulted the pharmacist for recommendations regarding empiric antimicrobial therapy as well as any other suggestions regarding this critically ill patient.
Admission note taken on 10/20/25
CC	Altered mental status (AMS), neck pain
HPI	RL was brought to the emergency department from home this morning by her daughter who stated: “My mother has been very confused since she woke up. I’m not sure if it’s all of her medications or if something else is wrong.” The daughter reports that RL complained of neck pain, headache, and nausea/vomiting prior to leaving for the hospital. RL has no recent hospitalizations. The only identifiable sick contacts include RL’s granddaughter who she babysat 5 days ago. As the ED physician is examining RL, she has a tonic-clonic seizure which resolved with the administration of 4 mg IV lorazepam. She is subsequently intubated due to her AMS and concern for her ability to protect her airway.
PMH	Gastroesophageal reflux disease (GERD) Heart failure (HF) NYHA Class II Seasonal allergic rhinitis
Social History	Non-smoker Drinks 1 glass of red wine per week She is recently widowed, retired, and still highly functional living at home	Family History	Father: Deceased, hypertension, gout Mother: Deceased, hypertension, hyperlipidemia No siblings
Vaccine History	Completed childhood series and was up to date through age 50. Patient’s daughter reports she hasn’t received any vaccinations in over 10 years.)	Surgical History	Knee Replacement (13 years ago) Hip Replacement (7 years ago)
Physical Exam	Prior to intubation General: elderly female appearing slightly frail HEENT: PERRLA, nuchal rigidity, + Babinski sign, mildly inflamed tympanic membranes Chest: CTA bilaterally, good air movement in all lobes CV: tachycardia, regular rhythm, no murmurs, rubs, gallops Abd: soft, tender, bowel sounds present GU: Deferred Ext: no edema, pain or redness in any extremities, cap refill 2 seconds Neuro: EMV 3-5-3 (GCS 11)

Clinical Laboratory Report

Test Name	10/20/25	Range
Sodium (Na⁺)	132	136-145 mEq/L
Potassium (K⁺)	4.1	3.5-5 mEq/L
Chloride (Cl^-)	98	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	23-28 mEq/L
Urea nitrogen (BUN)	18	8-20 mg/dL
Creatinine	0.5	0.5-1.3 mg/dL
Glucose	298	70-115 mg/dL
Hemoglobin A1c	5.4	5.3-7.5 %
Calcium,Total	9.3	8.6-10.2 mg/dL
Phosphate	3.3	3-4.5 mg/dL
Magnesium	2.1	1.6-2.6 mEq/L
Protein, total	5.6	5.5-9 g/dL
Albumin	3.4	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	28	10-40 units/L
Aminotransferase,alanine (ALT)	25	10-40 units/L
Lactic dehydrogenase (LDH)	120	80-225 units/L
Alkaline phosphatase	70	30-120 units/L
Bilirubin, Total	0.5	0.3-1 mg/dL
Leukocytes (WBC)	19.1	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.7	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	13.5	12-16 g/dL
Hematocrit, Female	41.4	37-47 %
Mean corpuscular hemoglobin (MCH)	28	27-33 picogram
Mean corpuscular volume (MCV)	83	76-100 mcm³
Platelets	252	150-450 x10³/mcL
International normalized ratio (INR)	0.9	0.8-1.2
Prothrombin time (PT)	10.2	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	22	25-35 sec

Additional Labs:	Lumbar Puncture and Cytology (today) CSF Appearance: Pale yellow CSF Protein: 280 mg/dL CSF Glucose: <20 mg/dL Gram stain: Pending HSV PCR: Negative WBC: 1250 cells/mm³ RBC: 2 cells/mm³ % Neutrophils: 94% % Lymphocytes: 1%
Cultures:	Blood Cultures: Pending
Imaging Studies:	Chest x-ray: Clear bilaterally, no opacities or other irregularities noted. The endotracheal tube is appropriately positioned 5 cm above the carina. CT head: unremarkable; no evidence of acute hemorrhage nor acute infarct Cardiac Echo: Left ventricular hypertrophy with estimated EF of 35% EKG: Sinus tachycardia

Vital Sign	10/20/25 08:57
Height (cm)	165
Weight (kg)	62
Body Temperature (°C)	38.9
Blood Pressure (mmHg)	116 / 74
Heart Rate (bpm)	112
Respiratory Rate (bpm)	18
Oxygen Saturation (%)	Mechanical ventilation: FiO2 40%

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

Medication
History

RL has prescriptions from two different physicians: her primary care physician and her cardiologist.
She has been struggling with insomnia for the past three months. She has been attempting to self-treat using OTC medications with some success, although the additional medications have at times caused her to be confused and feel “hungover.”
RL’s daughter worries that she is on too many medications for her age.

Compliance/dosing issue:

None. The patient’s daughter prepares a pillbox to assist her mother.

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

Patient Name: Lopez, Renata Date of Birth: 11/13/1943 Room#: 803	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
Diphenhydramine 25 mg capsule	2 PO HS	yes, insomnia	22:30 10/19/25	hungover feeling	take most nights past 3-4 weeks	OTC
Famotidine 20 mg tablet	1 PO BID	no	17:30 10/19/25	none	misses 2-3 doses per week	OTC, taken for 9 months
Cetirizine 10 mg tablet	1 PO QD	no	08:00 10/19/25	none	never misses	OTC
Metoprolol succinate 50 mg tablet	1 PO QD	no	08:00 10/19/25	none	never misses
Aspirin (enteric coated) 81 mg tablet	1 PO QD	no	08:00 10/19/25	none	never misses	OTC
Pantoprazole 40 mg tablet	1 PO QD	no	08:00 10/19/25	none	never misses
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25
Piperacillin/Tazobactam 3.375g IV STAT x1 Rate: 100 mL/hr	06:44
Etomidate 20 mg IV Push STAT x1	06:50
Succinylcholine 100 mg IV Push STAT x1	06:35
Dextrose 5% IV continuous Rate: 75 mL/hr	06:21

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Piperacillin/Tazobactam	3.375 g IV STAT x1	100 ml/hr
Etomidate	20 mg STAT IV push x1
Succinylcholine	100 mg IV STAT IV push x1
Dextrose 5%	Continuous IV infusion	75 ml/hr
Vancomycin	1000 mg IV q12h	Infuse over 2 hr
Ceftriaxone	1000 mg IV q12h	Infuse over 30 min
Enoxaparin	40 mg SC daily	For DVT prophylaxis
Famotidine	20 mg IV BID	For stress ulcer prophylaxis
Lisinopril	20 mg PO daily	For heart failure

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Diphenhydramine 25 mg	1 cap PO HS	Causes hungover feeling
Famotidine 20 mg	1 tab PO BID	For GERD
Cetirizine 10 mg	1 tab PO daily
Metoprolol succ. 50 mg	1 tab PO daily
Aspirin EC 81 mg	1 tab PO daily	No longer recommended
Pantoprazole 40 mg	1 tab PO daily	Decrease dose and wean off

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: Lopez, Renata

Date of Birth: 11/13/1943

Room: 803

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	165 cm
Actual Body Weight (ABW)	62 kg
Ideal Body Weight (IBW)	57 kg
ABW % of IBW	109 %
Adjusted Body Weight (AjBW)	59 kg
Body Surface Area (BSA)	1.69 m²
Body Mass Index (BMI)	22.8 kg/m²