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Case, Justin

MRN: 310718

Room: 816

DOB: 8/11/1965

Age: 60

Gender: Male

Allergies: penicillins, cephalosporins (rash to both)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Medical ICU (MICU)
Scenario	Patient came in 2 days ago for elective surgery. Meds were brought from home due to outpatient status. He had planned to go home yesterday, but he developed fever and started having shortness of breath so was kept another night for observation. Patient was transferred to ICU, and Pharmacy was called to do med rec so home meds can be sent from hospital pharmacy.
Admission note taken on 10/20/25
CC	"This cough is getting worse, and I can’t catch my breath."
HPI	Patient’s surgery was successful, recovery progressing without complications, and he was preparing to discharge home when he developed respiratory distress this morning. A rapid response was called and patient was transferred to ICU and intubated. Blood and sputum cultures were collected.
PMH	CAD s/p MI 3 yrs ago, no surgical intervention
Social History	Lives with wife Works in construction Smokes 1 ppd x 40 yr Denies alcohol or illicit drug use	Family History	Mother—alive at age 89, heart disease Father—died 2 years ago at age 88, heart disease
Vaccine History	Not on file	Surgical History	None
Physical Exam	HEENT: PERRLA; moist mucous membranes Neck: Supple, no lymphadenopathy Lungs: Scattered rhonchi with expiratory wheezing, diffuse bilat crackles, decreased breath sounds bilat bases; right IJ port-a-cath intact without erythema Heart: Tachycardic with regular rhythm; no MRG Abdomen: Soft, mildly distended, hypoactive BS, large liver palpated in RUQ, ileostomy in RLQ is pink and functioning, surgical incision is C/D/L Extremities: 1+ pitting edema, 2+ pulses bilat, good peripheral perfusion Neurological: Patient was A & O x3; CN II-XII intact; patient is currently intubated and sedated

Clinical Laboratory Report

Test Name	10/20/25	Range
Sodium (Na⁺)	141	136-145 mEq/L
Potassium (K⁺)	5.1	3.5-5 mEq/L
Chloride (Cl^-)	110	98-106 mEq/L
Bicarbonate (HCO₃^-)	19	23-28 mEq/L
Urea nitrogen (BUN)	34	8-20 mg/dL
Creatinine	1.1	0.5-1.3 mg/dL
Glucose	148	70-115 mg/dL
Hemoglobin A1c	6.9	5.3-7.5 %
Calcium,Total	9.2	8.6-10.2 mg/dL
Phosphate	4.1	3-4.5 mg/dL
Magnesium	2.2	1.6-2.6 mEq/L
Protein, total	6.7	5.5-9 g/dL
Albumin	3.9	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	22	10-40 units/L
Aminotransferase,alanine (ALT)	31	10-40 units/L
Lactic dehydrogenase (LDH)	78	80-225 units/L
Alkaline phosphatase	99	30-120 units/L
Bilirubin, Total	0.4	0.3-1 mg/dL
Leukocytes (WBC)	17	4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.9	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	12.4	14-18 g/dL
Hematocrit, Male	37	42-50 %
Mean corpuscular hemoglobin (MCH)	32	27-33 picogram
Mean corpuscular volume (MCV)	82	76-100 mcm³
Platelets	584	150-450 x10³/mcL
International normalized ratio (INR)	0.9	0.8-1.2
Prothrombin time (PT)	9.9	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	25-35 sec

Additional Labs:

None

Cultures:

On Admission (today)

Blood culture x2 pending with results expected in 5 days
Sputum culture pending with results expected in 2 days

Sputum Gram stain (today)

>25 WBC/hpf
<10 epithelial cells/hpf
1+ (few) gram + cocci
3+ (many) gram - rods

Imaging Studies:

Chest X-ray shows new bilateral opacities in left upper lobe and right middle lobe; likely infectious process. Increased alveolar infiltrates in the perihilar location and involving lower lobes.
CT shows no evidence of pulmonary embolism. Heart size normal. Small mediastinal and axillary lymph nodes; none are pathologically enlarged. There are small bilateral pleural effusions with adjacent atelectasis. There are pleural-based airspace opacities bilaterally consistent with acute infectious process.

Vital Sign	10/20/25 07:25
Height (cm)	168
Weight (kg)	70
Body Temperature (°C)	38.5
Blood Pressure (mmHg)	142 / 93
Heart Rate (bpm)	130
Respiratory Rate (bpm)	43
Oxygen Saturation (%)	87

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			per protocol

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			adjust per protocol

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
			pharmacy to dose

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?

VOL	RATE
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN fever <100.5℉ or mild pain (1-4)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN fever >100.5℉ or moderate pain (5-6)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN severe pain (7-10)
USE	START DATE	STOP DATE	NOTES

Medication
History

Not on file.

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

Patient Name: Case, Justin Date of Birth: 8/11/1965 Room#: 816	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Rosuvastatin 20 mg tablet	1 PO QD	no
Metoprolol succinate 100 mg ER tablet	1 PO QD	no
Aspirin 81 mg tablet	1 PO QD	no
Nitroglycerin 0.4 mg sublingual tablet	1 SL q5 min x3	yes, chest pain
Co-Q-10 100 mg capsule	1 PO QD	no
Fish Oil 1,000 mg capsule	1 PO QD	no




			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25
Albuterol/ipratropium 2.5/0.5 mg per 3 mL via neb q 4 Hr while awake
Propofol 1% (10 mg/mL) IV continuous infusion
Piperacillin/tazobactam 3.375 g IV QID
Levofloxacin 750 mg IV QD
Vancomycin 1 g IV BID
Methylprednisolone 125 mg IV QID
Enoxaparin 40 mg SC QD
Pantoprazole 20 mg IV QD
Dextrose 5%/Sod. Chloride 0.45% IV continuous Rate: 50 mL/Hr
Acetaminophen 650 mg PR q4Hr PRN PRN fever <100.5℉ or mild pain (1-4)
Ibuprofen 400 mg q4Hr PRN PRN fever >100.5℉ or moderate pain (5-6)
Hydromorphone 1 mg IV q4Hr PRN PRN severe pain (7-10)

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Albuterol/ ipratropium neb sol	2.5/0.5 mg in 3 ml via neb while awake	change to q4h prn
Propofol 1% (10 mg/ml)	0.3 mg/kg/hr IV continuous infusion	weaned and discontinued when extubated
Levofloxacin	750 mg IV q24h	change to PO, need 7 more days
Vancomycin	1 gram IV q12h	Last culture showed sensitive to levofloxacin
Methylprednisolone	125 mg IV daily	tapered dose—last dose on day of discharge
Hydromorphone	1 mg IV q4h prn severe pain	has not needed for a few days
Acetaminophen	650 mg PO q6h prn	has not needed
Ibuprofen	400 mg IV q4h prn fever, moderate pain	has not needed for a few days
Enoxaparin	40 mg SC daily	for DVT prophylaxis
Pantoprazole	20 mg IV daily	for GI prophylaxis
D5W - 1/2 NS	50 ml/hr IV continuous infusion

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Aspirin 81 mg	PO daily
Rosuvastatin 20 mg	PO daily
Metoprolol succinate 100 mg	PO daily
Nitroglycerin 0.4 mg	SL q5min x3 prn chest pain
Co-Q-10 100 mg	PO daily
Fish oil 1000 mg	PO daily

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: Case, Justin

Date of Birth: 8/11/1965

Room: 816

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	168 cm
Actual Body Weight (ABW)	70 kg
Ideal Body Weight (IBW)	63.8 kg
ABW % of IBW	110 %
Adjusted Body Weight (AjBW)	66.3 kg
Body Surface Area (BSA)	1.81 m²
Body Mass Index (BMI)	24.8 kg/m²