View Patient Profiles

Duncan, Daphne

MRN: 198212

Room: 537

DOB: 2/28/1993

Age: 32

Gender: Female

Allergies: Codeine and Morphine (nausea)

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	Today, you are on rounds with the inpatient Hospice team outside the room of a patient with a history of metastatic cervical cancer and has chosen to stop chemotherapy.
Admission note taken on 10/20/25
CC	"I have stabbing pain on my left side."
HPI	Presents to ER with fever and chills and decreased alertness that started about 2 days ago. Drank a little fluid today. C/O LLQ pain for past 24 hours. Right sub clavian vein central line with mild purulent drainage from exit site. Patient has chosen no additional chemotherapy treatment and has a DNR order.
PMH	Acute and Chronic Medical Problems Febrile illness, r/o bacteria Pain management Metastatic Cervical Cancer, palliative care Anemia Hypokalemia Nutritional status History of Seizures Timeline 16 months ago: Metastatic cervical CA Stage I-B squamous cell, radical hysterectomy. 10 months ago: Vaginal biopsy-infiltrating reoccurrence of CA, received pelvic radiation & cisplatin x4. 4 months ago: Hospitalized for back pain/seizures, received cisplatin & paclitaxel x2. 6 weeks ago: Chemo stopped since CA progressing despite treatment.
Social History	Tobacco: denies Alcohol: denies Caffeine: 1 cup of coffee daily Occupation: works as an accountant, however, has been on medical leave of absence for 1 month. Status: single mother with a 4 year old son, lives with mother. Physical Activity: limited to activities of daily living. Diet: Does not follow any special diet.	Family History	Mother alive at age 58 Father died at age 59 of acute MI. 4-year-old healthy son
Vaccine History	None on file	Surgical History	None on file
Physical Exam	Gen: distressed female who looks older than stated age HEENT: deferred Skin: deferred Neck: deferred Heart: deferred Lungs: deferred Abdomen: deferred GU: deferred Extremities: deferred Neuro: deferred

Clinical Laboratory Report

Test Name	10/20/25	Range
Sodium (Na⁺)	144	136-145 mEq/L
Potassium (K⁺)	3.1	3.5-5 mEq/L
Chloride (Cl^-)	103	98-106 mEq/L
Bicarbonate (HCO₃^-)	25	23-28 mEq/L
Urea nitrogen (BUN)	19	8-20 mg/dL
Creatinine	1.2	0.5-1.3 mg/dL
Glucose	83	70-115 mg/dL
Hemoglobin A1c	5.9	5.3-7.5 %
Calcium,Total	9.1	8.6-10.2 mg/dL
Phosphate	4.3	3-4.5 mg/dL
Magnesium	2.1	1.6-2.6 mEq/L
Protein, total	5.2	5.5-9 g/dL
Albumin	2.1	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	37	10-40 units/L
Aminotransferase,alanine (ALT)	29	10-40 units/L
Lactic dehydrogenase (LDH)	89	80-225 units/L
Alkaline phosphatase	124	30-120 units/L
Bilirubin, Total	0.8	0.3-1 mg/dL
Leukocytes (WBC)	11.3	4.5-11 x10³/mcL
Red blood cells (RBC), Female	3.8	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	9.4	12-16 g/dL
Hematocrit, Female	27.4	37-47 %
Mean corpuscular hemoglobin (MCH)	29	27-33 picogram
Mean corpuscular volume (MCV)	81	76-100 mcm³
Platelets	253	150-450 x10³/mcL
International normalized ratio (INR)	1.0	0.8-1.2
Prothrombin time (PT)	9.8	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	25-35 sec

Additional Labs:

Hematology	Today
Reticulocyte count (%)	2.7

Cultures:

None

Imaging Studies:

None

Vital Sign	10/20/25 07:37
Height (cm)	157
Weight (kg)	51.7
Body Temperature (°C)	39.2
Blood Pressure (mmHg)	84 / 54
Heart Rate (bpm)	144
Respiratory Rate (bpm)	24
Oxygen Saturation (%)	98

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			Pkinetic consult

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

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?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN temp > 37.7°C
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN temp > 37.7°C and unable to take PO
USE	START DATE	STOP DATE	NOTES

Medication
History

None on file

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

Patient Name: Duncan, Daphne Date of Birth: 2/28/1993 Room#: 537	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Dexamethasone 4 mg tablet	1 PO QD	no
Sulfasalazine 500 mg tablet	1 PO BID	no
Gabapentin 300 mg capsule	1 PO TID	no
Oxycodone ER 60 mg tablet	1 PO TID	no
Baclofen 20 mg tablet	1 PO TID	no
Hydromorphone 4 mg tablet	1 PO PRN	break- through pain
Amoxicillin/Clavulanate Potassium 500 mg/125 mg tablet	1 PO PRN	used for sup- pressive Tx
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25
Gentamicin 100 mg IV Loading Dose Rate: Pkinetic consult
Ampicillin/Sulbactam 3 g IV Q6H Rate: 200 mL/hr	00:28 6:25
Potassium Chloride 10 mEq IV continuous Rate: 150 mL/hr	8:29
Baclofen 20 mg PO TID
Oxycodone ER 60 mg PO TID
Gabapentin 300 mg PO TID
Clonazepam 0.5 mg PO BID
Dexamethasone 4 mg PO QD
Acetaminophen 650 mg PO Q4H PRN PRN temp > 37.7°C
Acetaminophen 650 mg PR Q4H PRN PRN temp > 37.7°C and unable to take PO

Clinical Notes

ADMIT ORDERS:

Vital signs q2h; clear liquid diet as tolerated; bed rest

LABS:
CBC, Basic metabolic profile (Chem 7), C&S catheter drainage, blood culture x2.

FLUIDS:
1 L NS over 6 hours, then D5/.45NS+KCl 1O mEq/L @ 150 cc/hr.

MEDS: 
Unasyn 3 g IVPB q6h
Gentamicin 100mg IVPB now f/u pkinetic consult
APAP 650mg po/PR q4h PRN T>100°F
Baclofen 20 mg po TID
Oxycontin 60 mg po TID
Neurontin 300 mg po TID
Klonopin 0.5 mg po BID
Dexamethasone 4 mg po QD

Dr. Cynthia McDonald

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: Duncan, Daphne

Date of Birth: 2/28/1993

Room: 537

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	157 cm
Actual Body Weight (ABW)	51.7 kg
Ideal Body Weight (IBW)	50.1 kg
ABW % of IBW	103 %
Adjusted Body Weight (AjBW)	50.7 kg
Body Surface Area (BSA)	1.5 m²
Body Mass Index (BMI)	21 kg/m²