View Patient Profiles

Jean-Baptiste, Jahmal

MRN: 110617

Room: ED5

DOB: 10/11/1962

Age: 63

Gender: Male

Allergies: hydromorphone (rash and shortness of breath), glipizide (rash)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Stroke Team in Emergency Department
Scenario	As part of stroke team you are in the ED room with the patient. The patient’s symptoms are not improving since the patient has returned from CT scan 30 minutes ago. The stroke team is discussing recommendations for pharmacotherapy and would like your recommendations.
Admission note taken on 10/19/25
CC	acute onset of right-sided weakness, decreased consciousness, and blurred vision
HPI	JJ is a 62 yo male who presents to the ED today with acute onset of right-sided weakness, decreased consciousness, and blurred vision that started exactly 1 hour ago when he was eating dinner. The patient’s wife reports he is normally very talkative at dinner and he has never had symptom like this before. The ED physician calls a code stroke overhead. The neurologist evaluates the patient to have a NIHSS (National Institutes of Health Stroke Score) of 19. A CT scan was performed and based on the results the patient is diagnosed with an acute ischemic stroke.
PMH	Type 2 diabetes Hypertension Myocardial infarction (2 yr. ago) CHF Dyslipidemia Generalized Anxiety Disorder
Social History	Tobacco: Denies ETOH: Social Illicit Drugs – Denies Caffeine: 1-2 cups coffee a day Occupation: Welder Status: Married Children: 3 children Physical Activity: Sedentary Diet: Nothing notable	Family History	Father: DM, HTN, Colon cancer dx at age 66 Mother: Died CVA age 59
Vaccine History	Not available	Surgical History	Not available
Physical Exam	General: Obese African American male in severe neurologic distress Skin: Cool, dry 2 + pitting edema bilateral lower extremities HEENT: leftward gaze, (+) gag reflex Chest: Rales bilaterally at both bases CV: Sinus, S1S2 (+), S3S4 (-) Abd: Soft Non-tender, Non-distended, +BS GI/GU: Stool guaiac (-), normal rectal tone Neuro: NIHSS 19, 1/5 RUE, 1/5 RLE, Right Sided facial droop

Clinical Laboratory Report

Test Name	10/19/25	07/21/25	Range
Sodium (Na⁺)	140	142	136-145 mEq/L
Potassium (K⁺)	3.6	4.0	3.5-5 mEq/L
Chloride (Cl^-)	110	107	98-106 mEq/L
Bicarbonate (HCO₃^-)	29	24	23-28 mEq/L
Urea nitrogen (BUN)	15	8	8-20 mg/dL
Creatinine	1.3	1.2	0.5-1.3 mg/dL
Glucose	190	172	70-115 mg/dL
Hemoglobin A1c	8.6	8.5	5.3-7.5 %
Calcium,Total	9.0	9.0	8.6-10.2 mg/dL
Phosphate	3.3	3.5	3-4.5 mg/dL
Magnesium	2.2	2.1	1.6-2.6 mEq/L
Protein, total	7.9	8.1	5.5-9 g/dL
Albumin	4.5	4.5	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	12	12	10-40 units/L
Aminotransferase,alanine (ALT)	16	16	10-40 units/L
Lactic dehydrogenase (LDH)	162	157	80-225 units/L
Alkaline phosphatase	77	80	30-120 units/L
Bilirubin, Total	1.0	1.0	0.3-1 mg/dL
Leukocytes (WBC)	6.0	7.0	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.1	3.9	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	15	12	14-18 g/dL
Hematocrit, Male	45	38	42-50 %
Mean corpuscular hemoglobin (MCH)	31.2	30.5	27-33 picogram
Mean corpuscular volume (MCV)	80	82	76-100 mcm³
Platelets	375	400	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1.0	0.8-1.2
Prothrombin time (PT)	9.9	9.7	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	30	27	25-35 sec

Additional Labs:

Urinalysis & Drug screen	Result
Appearance	Clear, yellow
Specific gravity	1.010
Blood	None
Ketones	None
Leukocyte esterase	None
Nitrites	Negative
Protein	3+
Glucose	1+
RBCs	2 per HPF
WBCs	4 per HPF
Bacteria	Few per HPF
Amphetamines	Negative
Barbiturates	Negative
Benzodiazepines	Negative
Cocaine	Negative
Marijuana	Negative
Opiates	Negative
Blood EtOH	0 mg/dL

Fasting Lipid Panel (today)

TC (mg/dL) 226
LDL (mg/dL) 136
HDL (mg/dL) 30
TG (mg/dL) 302

Cultures:

None

Imaging Studies:

CT Scan: No evidence of hemorrhage or masses, evidence of chronic ischemic disease
EKG: Sinus rhythm @ 77 bpm
3 mo. ago: ECHO LVEF 33%

Vital Sign	10/19/25 07:14	07/21/25 07:57
Height (cm)	183
Weight (kg)	112
Body Temperature (°C)	37	37.2
Blood Pressure (mmHg)	225 / 120	161/95
Heart Rate (bpm)	75	65
Respiratory Rate (bpm)	12	10
Oxygen Saturation (%)	96	96

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			may repeat in 10 min

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
			after BP<185/110, give 9 mg over 1 min followed by 81 mg over 1 hr infusion

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
			to start 24 hr after alteplase

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

Medication
History

Not available

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

Patient Name: Jean-Baptiste, Jahmal Date of Birth: 10/11/1962 Room#: ED5	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	LAST DOSE (date/time)	ADVERSE EFFECTS	ADHERENCE	MED REC ACTION
Metformin Extended-Release 1,000 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
Escitalopram 10 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
Metoprolol ER 100 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
Aspirin 81 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
Clopidogrel 75 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
Alprazolam 0.25 mg tablet	1 PO PRN	yes, anxiety	22:00 10/18/25	not available	not available
Simvastatin 80 mg tablet	1 PO QD	no	20:00 10/18/25	not available	not available
Furosemide 20 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
HCTZ 25 mg tablet	1 PO QD	no	9:00 10/18/25	not available	not available
						Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Labetolol 20 mg IV x1 dose Rate: injection
Nicardipine IV continuous Rate: 5 mg/hr
Alteplase 90 mg (0.9 mg/kg) IV x1 dose Rate: see notes
Furosemide 40 mg IV QD Rate: injection
Aspirin 325 mg PO QD
Atovastatin 80 mg PO QD (statin)

Clinical Notes

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: Jean-Baptiste, Jahmal

Date of Birth: 10/11/1962

Room: ED5

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	183 cm
Actual Body Weight (ABW)	112 kg
Ideal Body Weight (IBW)	77.6 kg
ABW % of IBW	144 %
Adjusted Body Weight (AjBW)	91.4 kg
Body Surface Area (BSA)	2.39 m²
Body Mass Index (BMI)	33.4 kg/m²