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Lee, Huan

MRN: 305007

Room: 333

DOB: 04/22/1968

Age: 57

Gender: Male

Allergies: sulfa

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Inpatient Renal Unit
Scenario	Patient was admitted yesterday for treatment of acute kidney injury related to use of NSAIDs, lisinopril, diuretic & caffeine.
Admission note taken on 10/18/25
CC	Nausea/vomiting and fatigue
HPI	Patient presented to the ED yesterday with a 2 day history of nausea/vomiting and fatigue. He thought it might be a stomach bug but when it didn’t go away, he came to the hospital to be evaluated. He notes that he has been urinating less frequently over the past few weeks and has not urinated much at all over the past couple of days.
PMH	osteoarthritis hypertension
Social History	Department store manager Married with 2 grown children Used to smoke 1-2 ppd but quit 10 yr ago Drinks coffee all day at work Drinks 1-2 cocktails or beers most nights Denies use of illegal drugs (tried marijuana as a teenager)	Family History	Father - has heart disease, still alive at age 86 Mother - has arthritis, still alive at age 80
Vaccine History	Usual childhood vaccines Tdap 2 years ago Shingrix (2 doses) this year Flu annually, last dose this season COVID fully vaccinated and boosted	Surgical History	Not on file
Physical Exam	HEENT: PERRLA, EOMI. Patient wears glasses. Neck: supple, no JVD or HJR Lungs: CTA Heart: tachycardia with regular rhythm Abdomen: soft, nontender, +BS Extremities: 2+ edema Neurological: A&Ox3 Cranial nerves II-XII are grossly intact

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	Range
Sodium (Na⁺)	148	149	136-145 mEq/L
Potassium (K⁺)	5.2	5.4	3.5-5 mEq/L
Chloride (Cl^-)	105	107	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	24	23-28 mEq/L
Urea nitrogen (BUN)	49	47	8-20 mg/dL
Creatinine	3.4	3.5	0.5-1.3 mg/dL
Glucose	108	111	70-115 mg/dL
Hemoglobin A1c		7.1	5.3-7.5 %
Calcium,Total	9.3	9.1	8.6-10.2 mg/dL
Phosphate	3.8	3.9	3-4.5 mg/dL
Magnesium	1.9	1.9	1.6-2.6 mEq/L
Protein, total	6.5	6.3	5.5-9 g/dL
Albumin	5.1	5.1	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	30	30	10-40 units/L
Aminotransferase,alanine (ALT)	21	20	10-40 units/L
Lactic dehydrogenase (LDH)	99	99	80-225 units/L
Alkaline phosphatase	71	72	30-120 units/L
Bilirubin, Total	0.45	0.5	0.3-1 mg/dL
Leukocytes (WBC)	6.5	6.6	4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.9	3.8	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	9.2	9.4	14-18 g/dL
Hematocrit, Male	28	28.3	42-50 %
Mean corpuscular hemoglobin (MCH)	30	29	27-33 picogram
Mean corpuscular volume (MCV)	82	80	76-100 mcm³
Platelets	289	280	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.1	0.8-1.2
Prothrombin time (PT)	9.9	9.8	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	31	25-35 sec

Additional Labs:	None
Cultures:	None
Imaging Studies:	None

Vital Sign	10/19/25 09:48	23:51	16:31	10/18/25 08:49
Height (cm)	175			175
Weight (kg)	78			78
Body Temperature (°C)	37	37.4	37	37.4
Blood Pressure (mmHg)	98 / 50	98/49	96/49	100/48
Heart Rate (bpm)	88	88	88	87
Respiratory Rate (bpm)	26	26	25	26
Oxygen Saturation (%)	98	99	98	97

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

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?

USE	START DATE	STOP DATE	NOTES
			pharmacy to adjust dose for renal function

DRUG	DOSE	FREQ & TIME	PRN?
			PRN nausea
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-5)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain >5
USE	START DATE	STOP DATE	NOTES
			pharmacy to adjust dose for renal function

Medication
History

Patient often confused on allergies.
According to PCP, patient has allergy to penicillin (rash 2 years ago) but no sulfa allergy - his father has this but he doesn’t.

Home Medication List: verified by pharmacy on admit (10/18/25)

Patient Name: Lee, Huan Date of Birth: 04/22/1968 Room#: 333	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Celecoxib 100 mg capsule	1 PO BID	no	for arthritis x 15 years
Acetaminophen 500 mg caplet	2 PO QID	yes, arthritis	uses a few times a day x several years
Lisinopril 20 mg tablet	1 PO QD	no	for hypertension x 5 years
HCTZ 25 mg tablet	1 PO QD	no	started one month ago for hypertension
Ginseng strength unknown capsule	2 PO BID	no	for general health and energy x many years
Tums Antacid 500 mg tablet	1 or 2 PO HS	yes, for heart-burn	uses occasionally
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25
Sodium Chloride 0.9% 100 mL/hr IV continuous infusion	8:23	8:38
Furosemide 40 mg IV q12Hr Rate: injection	9:33 13:18	9:33 13:27
Dopamine 2 mcg/kg/min IV continuous infusion Rate: pharmacy to determine	8:15	8:25
Famotidine 20 mg IV q12Hr	7:45 17:41	7:19 17:15
Ondansetron 4 mg IV q4Hr PRN PRN nausea	7:33
Acetaminophen 650 mg PO q4Hr PRN PRN pain (1-5)
Tramadol 50 mg PO q4Hr PRN PRN pain >5	8:35 14:52	8:44 14:29

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Sodium Chloride 0.9%	100 ml/hr	continuous infusion
Furosemide	40 mg IV BID	change to PO
Dopamine	2 mcg/kg/min	continuous infusion
Tramadol	50 mg PO q6h prn pain	adjusted for renal function
Acetaminophen	650 mg PO q4h prn	for pain, change to scheduled dose since discontinued other pain med (keep dose <3,000 mg)
Ondansetron	4 mg IV q4h prn	for nausea - change to ODT
Famotidine	10 mg IV BID	adjusted for renal function

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Celecoxib	100 mg PO BID
Acetaminophen	1,000 mg PO q6h prn arthritis	change to inpatient dose
Lisinopril	20 mg PO daily	discuss lifestyle modifications (decreased caffeine, increased exercise) and change to other BP med if still needed w/ furosemide.
HCTZ	25 mg PO daily	change to furosemide
Ginseng	2 capsules BID
Tums Antacid	1-2 tablets PO HS prn	for heartburn

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: Lee, Huan

Date of Birth: 04/22/1968

Room: 333

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	175 cm
Actual Body Weight (ABW)	78 kg
Ideal Body Weight (IBW)	70.7 kg
ABW % of IBW	110 %
Adjusted Body Weight (AjBW)	73.6 kg
Body Surface Area (BSA)	1.95 m²
Body Mass Index (BMI)	25.5 kg/m²