| Allen, Paige |
| MRN: 174639 | Room: 455 | DOB: 11/2/1953 | Age: 72 | Gender: Female | Allergies: amlodipine (ankle swelling), metronidazole (hives) |
| Setting | Adult Medicine Unit | ||
| Scenario | PA is admitted to the general medical floor and was started on empiric antibiotics for treatment of pneumonia by the medical resident on call. The resident mentions that he calculated a CURB-65 score for this patient to make his decision to admit her for treatment of her pneumonia.
The medical resident asks you to review the patient’s report and make recommendations for empiric antibiotic therapy as well as any other suggestions regarding this patient’s care. |
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| Admission note taken on 10/20/25 | |||
| CC | "I’m having a hard time breathing and it hurts when I cough" | ||
| HPI | PA arrives in the emergency department at 18:00 yesterday via private vehicle. PA’s
daughter brought her to the ED from the patient’s home because she believes "something is really wrong with Mom’s
breathing again." PA complains of shortness of breath, dyspnea with cough and inspiration, and feeling unusually
fatigued. PA’s daughter reports encouraging her mother to use her albuterol inhaler every six hours since she thought
her current problems could be related to her COPD. PA reports that this helped her breathing "a little" but did not
provide full relief. When PA’s daughter stopped by to check on her mother after work, PA was "a bit confused and
clammy" which led her daughter to bring her to the ED for evaluation. Patient’s daughter reports that PA had a recent admission to another local hospital for a COPD exacerbation about 4 months ago. She remembers that PA received prednisone and doxycycline outpatient. She finished the course of these prescribed medications at that time. She recalls having previous COPD exacerbations prior to the one 4 months ago and remembers being treated similarly. In the ED, PA presents as oriented to person and place but not time. Upon further review of her medical history, PA reports that she has COPD, hypertension, and insomnia. She reports rarely missing doses of her medications, and she states that she has taken all of medications today except her sleeping pill. |
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| PMH |
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam |
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| Test Name | 10/20/25 | Range |
| Sodium (Na+) | 135 | 136-145 mEq/L |
| Potassium (K+) | 4.2 | 3.5-5 mEq/L |
| Chloride (Cl-) | 101 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 30 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 20 | 8-20 mg/dL |
| Creatinine | 1.2 | 0.5-1.3 mg/dL |
| Glucose | 85 | 70-115 mg/dL |
| Hemoglobin A1c | 5.5 | 5.3-7.5 % |
| Calcium,Total | 8.6 | 8.6-10.2 mg/dL |
| Phosphate | 3.1 | 3-4.5 mg/dL |
| Magnesium | 1.6 | 1.6-2.6 mEq/L |
| Protein, total | 5.5 | 5.5-9 g/dL |
| Albumin | 3.6 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 22 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 34 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 155 | 80-225 units/L |
| Alkaline phosphatase | 61 | 30-120 units/L |
| Bilirubin, Total | 1.3 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 19.2 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Female | 4.6 | 4.3-5.7 x108/mcL |
| Hemoglobin, Female | 13 | 12-16 g/dL |
| Hematocrit, Female | 39 | 37-47 % |
| Mean corpuscular hemoglobin (MCH) | 31 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 85 | 76-100 mcm3 |
| Platelets | 300 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.0 | 0.8-1.2 |
| Prothrombin time (PT) | 12 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 28 | 25-35 sec |
| Additional Labs: |
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| Cultures: |
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| Imaging Studies: |
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| Medication History |
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| Patient Name: Allen, Paige Date of Birth: 11/2/1953 Room#: 455 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
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| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
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|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
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| Medication | 10/20/25 |
| Vancomycin 1,000 mg IV x1 now, then dose per pharmacy Rate: 200 mL/hr | 00:40 |
| Piperacillin/tazobactam 3.375 g IV x1 now, then dose per pharmacy Rate: 100 mL/hr | 01:38 |
| Fluticasone/salmeterol 250/50 mcg INH BID | |
| Lisinopril 40 mg PO QD | |
| Acetaminophen 500 mg PO Q6H PRN PRN fever or pain | |
| Clonazepam 1 mg PO HS PRN PRN insomnia | |
| Ondansetron 4 mg IV Push QD PRN PRN nausea |
| Hospital Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Previous Home Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| 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 | |||||
| Patient Name: Allen, Paige | Date of Birth: 11/2/1953 | Room: 455 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |