| Jackson, Tom |
| MRN: 302399 | Room: 513 | DOB: 03/10/1970 | Age: 55 | Gender: Male | Allergies: Codeine (rash), Bee pollen (hives), Tetracycline (rash) |
| Setting | Adult Medicine Unit | ||
| Scenario | Patient was admitted to the hospital from the ED. | ||
| Admission note taken on 10/21/25 | |||
| CC | Patient presented to ED with severe abdominal pain. | ||
| HPI | Patient has had stomach pain for the past 2 weeks, but it felt better with OTC medications. Today the pain became much worse and he vomited what looked like coffee grounds. Patient diagnosed with NSAID-induced ulcer. | ||
| 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+) | 140 | 136-145 mEq/L |
| Potassium (K+) | 4.3 | 3.5-5 mEq/L |
| Chloride (Cl-) | 104 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 26 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 20 | 8-20 mg/dL |
| Creatinine | 1.2 | 0.5-1.3 mg/dL |
| Glucose | 124 | 70-115 mg/dL |
| Hemoglobin A1c | 7.8 | 5.3-7.5 % |
| Calcium,Total | 9.2 | 8.6-10.2 mg/dL |
| Phosphate | 3.9 | 3-4.5 mg/dL |
| Magnesium | 2.1 | 1.6-2.6 mEq/L |
| Protein, total | 7.9 | 5.5-9 g/dL |
| Albumin | 4.7 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 16 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 12 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 92 | 80-225 units/L |
| Alkaline phosphatase | 67 | 30-120 units/L |
| Bilirubin, Total | 0.4 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 7.1 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 3.8 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 8.7 | 14-18 g/dL |
| Hematocrit, Male | 27 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 29 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 81 | 76-100 mcm3 |
| Platelets | 379 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.1 | 0.8-1.2 |
| Prothrombin time (PT) | 9.9 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 30 | 25-35 sec |
| Additional Labs: | None |
| Cultures: | Serology positive but rapid urease test of gastric biopsy negative for H. pylor. |
| Imaging Studies: | None |
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| Medication History |
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| Patient Name: Jackson, Tom Date of Birth: 03/10/1970 Room#: 513 |
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 |
| Sodium Chloride 0.9% 75 mL/hr IV continuous infusion | |
| Pantoprazole 8 mg/hr IV continuous infusion Rate: 10 mL/hr | |
| Ondansetron 4 mg IV q6Hr PRN PRN nausea Rate: injection | |
| Acetaminophen 1,000 mg PO q6Hr PRN PRN pain (4-6) | |
| Hydromorphone 1 mg IV q4Hr PRN PRN pain (7-10) Rate: injection |
| 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: Jackson, Tom | Date of Birth: 03/10/1970 | Room: 513 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |