| Davidson, Kaylee |
| MRN: 117517 | Room: 205 | DOB: 3/21/1994 | Age: 31 | Gender: Female | Allergies: PCN (rash) |
| Setting | Inpatient Obstetrics Unit | ||
| Scenario | 48 hours after admission, patient's BP has continued to increase and her headache is back. The obstetrician has requested pharmacy’s recommendations for medication management with anticipated delivery of the baby by Cesarean section tomorrow morning. In addition to new therapy recommendations, Dr. Moore requests you look at her current medication profile to determine if changes are needed with any of those medications. | ||
| Admission note taken on 10/17/25 | |||
| CC | headache different from typical migraine and the feeling that “something isn’t right” | ||
| HPI | KD presented to the OB clinic two days ago for her monthly appointment complaining of headache different from her typical migraine and the feeling that “something isn’t right.” She also reported a “small fluid gush” that she attributed to loss of bladder control that morning. She is 34 weeks pregnant. She has had routine prenatal care throughout the pregnancy which has been otherwise unremarkable. A 20 week ultrasound showed a normally developed fetus. Due to an elevated blood pressure reading and c/o headache, she was admitted to Labor and Delivery for observation. After two more consecutive elevated blood pressures and documented premature rupture of membranes, she was changed to inpatient status.
Admit orders:
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Family History |
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Surgical History |
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| Physical Exam |
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| Test Name | 10/19/25 | 10/18/25 | 10/17/25 | Range |
| Sodium (Na+) | 138 | 140 | 136-145 mEq/L | |
| Potassium (K+) | 4.0 | 3.8 | 3.5-5 mEq/L | |
| Chloride (Cl-) | 103 | 101 | 98-106 mEq/L | |
| Bicarbonate (HCO3-) | 25 | 26 | 23-28 mEq/L | |
| Urea nitrogen (BUN) | 35 | 20 | 8-20 mg/dL | |
| Creatinine | 1.1 | 0.7 | 0.5-1.3 mg/dL | |
| Glucose | 75 | 80 | 70-115 mg/dL | |
| Hemoglobin A1c | 5.5 | 5.3-7.5 % | ||
| Calcium,Total | 9.7 | 9.8 | 8.6-10.2 mg/dL | |
| Phosphate | 3.5 | 3.6 | 3-4.5 mg/dL | |
| Magnesium | 2.0 | 1.6 | 1.6-2.6 mEq/L | |
| Protein, total | 6.8 | 6.7 | 5.5-9 g/dL | |
| Albumin | 4.0 | 4.1 | 3.5-5.5 g/dL | |
| Aminotransferase,aspartate (AST) | 80 | 34 | 10-40 units/L | |
| Aminotransferase,alanine (ALT) | 120 | 40 | 10-40 units/L | |
| Lactic dehydrogenase (LDH) | 230 | 205 | 80-225 units/L | |
| Alkaline phosphatase | 123 | 108 | 30-120 units/L | |
| Bilirubin, Total | 1.2 | 0.9 | 0.3-1 mg/dL | |
| Leukocytes (WBC) | 10.7 | 9.8 | 4.5-11 x103/mcL | |
| Red blood cells (RBC), Female | 3.2 | 3.4 | 4.3-5.7 x108/mcL | |
| Hemoglobin, Female | 10.9 | 11.2 | 12-16 g/dL | |
| Hematocrit, Female | 27 | 28 | 37-47 % | |
| Mean corpuscular hemoglobin (MCH) | 30 | 29 | 27-33 picogram | |
| Mean corpuscular volume (MCV) | 88 | 90 | 76-100 mcm3 | |
| Platelets | 95 | 155 | 150-450 x103/mcL | |
| International normalized ratio (INR) | 1.2 | 1.1 | 0.8-1.2 | |
| Prothrombin time (PT) | 13.4 | 13 | 9.5-11.3 sec | |
| Partial thromboplastin time,activated (aPTT) | 34 | 33 | 25-35 sec |
| Additional Labs: |
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| Medication History |
Prior to pregnancy, patient previously used hydrocodone 7.5 mg/acetaminophen 325 mg PO q4-6h as needed at onset of migraine headache, but has only had one headache early in the pregnancy and took acetaminophen 1000 mg PO x 1 with relief. |
| Patient Name: Davidson, Kaylee Date of Birth: 3/21/1994 Room#: 205 |
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 | 10/19/25 | 10/18/25 | 10/17/25 |
| Lactated Ringers IV continuous Rate: 125 ml/hr | 08:23 15:57 | 08:43 15:53 22:33 | 08:12 15:50 22:31 |
| Prenatal Vitamin 1 tablet PO QD | 08:48 | 08:42 | 08:40 |
| Ferrous Sulfate 325 mg PO QD | 08:50 | 08:40 | 08:52 |
| Fluticasone MDI 1 puff (110 mcg) INH BID | 08:14 | 08:37 20:36 | 08:12 20:57 |
| Albuterol Sulfate MDI 2 puffs (216 mcg) INH QID PRN PRN yes, SOB, cough | |||
| Acetaminophen 1,000 mg PO QID PRN PRN yes, pain (1-5) | 08:21 13:24 16:41 | 08:20 13:40 16:38 20:43 | 08:38 13:50 16:30 20:45 |
| Famotidine 20 mg PO BID PRN PRN yes, reflux | 08:11 20:44 |
| 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: | ||
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| 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: Davidson, Kaylee | Date of Birth: 3/21/1994 | Room: 205 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |