Johnson, Jevonte |
MRN: 113817 | Room: Exam #5 | DOB: 10/11/1962 | Age: 63 | Gender: Male | Allergies: hydromorphone (itch, nausea), glipizide (rash) |
Setting | Outpatient Family Medicine Clinic | ||
Scenario | You are rounding as part of the family medicine team. The patient presents to the family medicine clinic for follow-up of a recent hospitalization for a left hip fracture/osteoporosis evaluation. | ||
Admission note taken on 10/19/25 | |||
CC | intermittent pain from left hip fracture | ||
HPI | JJ presents to the family medicine clinic today for follow-up of a recent hospitalization for a left hip fracture/osteoporosis evaluation. His fracture occurred on 9-1-11 when he fell while walking in a physical rehabilitation center. JJ was in rehabilitation following an ischemic stroke. He currently has intermittent pain when ambulating (4 out of 10) in his left hip. The patient self started acetaminophen as needed for pain, but has not had satisfactory pain resolution with this regimen. The patient complained of hip pain earlier in the year which prompted a work up including a DXA scan. The results of this scan were not followed up on with the patient. The patient states that recently he always seems to have a tickling sensation in the back of his throat and a dry cough. He has been in “good spirits” and is very determined to resume the level of independence he had prior to his stroke. | ||
PMH |
|
||
Social History |
|
Family History |
|
Vaccine History |
|
Surgical History |
|
Physical Exam |
|
Test Name | 10/19/25 | 10/05/25 | 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 | 1.1 | 1.2 | 0.5-1.3 mg/dL |
Glucose | 112 | 172 | 70-115 mg/dL |
Hemoglobin A1c | 8.6 | 8 | 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 | 3.6 | 3.7 | 3.8-5.1 x108/mcL |
Hemoglobin, Male | 12 | 12 | 14-18 g/dL |
Hematocrit, Male | 38 | 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: | Fasting Lipid Panel (today)
|
Cultures: |
|
Imaging Studies: |
|
|
Medication History |
|
Patient Name: Johnson, Jevonte Date of Birth: 10/11/1962 Room#: Exam #5 |
Allergies: |
Immunization History: |
Community Rx Info: Rx Insurance: |
Social History: |
|
Additional Notes: |
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
|||
---|---|---|---|---|---|---|---|---|
Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
Medication | 10/19/25 |
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: Johnson, Jevonte | Date of Birth: 10/11/1962 | Room: Exam #5 |
Medication (name/strength) | Dose | Route | Frequency | Notes |