View Patient Profiles

Hayes, Jane

MRN: 301837

Room: 467

DOB: 07/13/1943

Age: 82

Gender: Female

Allergies: penicillin, cephalosporins, sulfa drugs (rash to all)

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	Patient was admitted yesterday from Jayhawk Sunset Acres nursing home.
Admission note taken on 10/19/25
CC	Patient presented to ED yesterday with severe abdominal pain.
HPI	Patient is an 82-year-old female who was brought to the ED yesterday with severe abdominal pain. She was diagnosed with appendicitis and was taken to surgery for appendectomy. Today is post-op day (POD) 1.
PMH	Stroke last year that led to admission at nursing home. Hypertension x 10 years
Social History	Retired school teacher Never married; no children Never smoked Used to drink occasionally but not in NH Does not use illicit drugs Drinks 1-2 cups coffee in morning Participates in group exercise and social activities at the nursing home Eats low salt diet as prescribed	Family History	Mother - died of stroke at age 76 Father - died of heart attack at age 64
Vaccine History	Usual childhood vaccines Tdap 2 years ago Shingrix (2 doses) 12 years ago Flu last Fall COVID fully vaccinated and boosted	Surgical History	Not on file
Physical Exam	HEENT: PERRLA, EOMI. Patient wears glasses and bilat hearing aids. Neck: supple without lymphadenopathy Lungs: CTA Heart: RRR, no MRG Abdomen: distended, pain on pressure or movement, decreased bowel sounds, incision appears clean with no drainage Extremities: pulses 2+ throughout, normal appearance Neurological: disoriented to date and location. Cranial nerves II-XII are grossly intact. Able to follow commands.

Clinical Laboratory Report

Test Name	10/20/25	10/19/25	Range
Sodium (Na⁺)	139	141	136-145 mEq/L
Potassium (K⁺)	4	3.9	3.5-5 mEq/L
Chloride (Cl^-)	100	99	98-106 mEq/L
Bicarbonate (HCO₃^-)	25	24	23-28 mEq/L
Urea nitrogen (BUN)	16	15	8-20 mg/dL
Creatinine	0.8	0.8	0.5-1.3 mg/dL
Glucose	101	101	70-115 mg/dL
Hemoglobin A1c		7.4	5.3-7.5 %
Calcium,Total	8.8	8.5	8.6-10.2 mg/dL
Phosphate	3.9	3.9	3-4.5 mg/dL
Magnesium	2.1	2.2	1.6-2.6 mEq/L
Protein, total	8.1	8.3	5.5-9 g/dL
Albumin	4.8	4.9	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	14	14	10-40 units/L
Aminotransferase,alanine (ALT)	17	17	10-40 units/L
Lactic dehydrogenase (LDH)	91	90	80-225 units/L
Alkaline phosphatase	64	65	30-120 units/L
Bilirubin, Total	0.4	0.4	0.3-1 mg/dL
Leukocytes (WBC)	12.4	12	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.2	4.2	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	13.5	13.2	12-16 g/dL
Hematocrit, Female	38	38	37-47 %
Mean corpuscular hemoglobin (MCH)	29	29	27-33 picogram
Mean corpuscular volume (MCV)	80	80	76-100 mcm³
Platelets	275	275	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.1	0.8-1.2
Prothrombin time (PT)	9.7	9.5	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	32	32	25-35 sec

Current Orders

Medication
History

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

Patient Name: Hayes, Jane Date of Birth: 07/13/1943 Room#: 467	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Amlodipine 5 mg tablet	1 PO QD	no
Plavix 75 mg tablet	1 PO QD	no
Aspirin 81 mg tablet	1 PO QD	no
Milk Of Magnesia 400 mg/5 mL suspension	30 mL PO QD	yes, constipation
Acetaminophen 325 mg tablet	1-2 PO TID	yes, pain or fever
Senior adult multivitamin/mineral tablet	1 PO QD	no
Loratadine 10 mg tablet	1 PO QD	yes, allergies
Melatonin 3 mg tablet	1 PO HS	yes, sleep
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25	10/19/25
Sodium Chloride 0.9% 65 mL/hr IV continuous infusion		8:32
Piperacillin/tazobactam 3.375 g IV q8Hr Rate: 300 mL/hr
Pantoprazole 20 mg IV q24Hr Rate: 200 mL/hr		8:39
Acetaminophen 650 mg PO q6Hr PRN PRN pain (1-6) or fever >38.5°C		8:19
Morphine 1 mg IV q4Hr PRN PRN pain (7-10) Rate: injection

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Sodium Chloride 0.9%	65 mL/hr continuous infusion
Piperacillin/tazobactam	3.375 g IV q8Hr	switch to moxifloxacin 400 mg PO QD x7 days
Pantoprazole	20 mg IV q24Hr	switch to 20 mg PO QD
Acetaminophen	650 mg q6Hr PRN pain (1-6) or fever >38.5°C
Morphine	1 mg IV q4Hr PRN pain (7-10)

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Amlodipine	5 mg PO QD
Plavix	75 mg PO QD
Aspirin	81 mg PO QD
Milk Of Magnesia	30 mL PO QD PRN constipation
Acetaminophen 325 mg	1-2 PO TID PRN pain or fever
Senior adult multivitamin/mineral	1 tab PO QD
Loratadine	10 mg PO QD PRN allergies
Melatonin	3 mg PO HS PRN sleep

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: Hayes, Jane

Date of Birth: 07/13/1943

Room: 467