View Patient Profiles

Thompson, Taylor

MRN: 139419

Room: 284

DOB: 8/15/1967

Age: 58

Gender: Female

Allergies: varenicline (nightmares)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Adult Oncology Unit
Scenario	You and your treatment team are seeing TT for the first time this morning. You are asked to make recommendations for all of TT’s medical conditions. Of note: The oncology team would like to start TT on a thalidomide-based regimen for 3 cycles prior to autologous stem cell transplant.
Admission note taken on 10/18/25
CC	“Worsening shortness of breath, wheezing, productive cough, on-and-off chest pain for the last 2 days”
HPI	TT presented to her primary care provider 2 days ago with progressive dyspnea, wheezing, and cough with occasional yellowish mucus. It was felt that the patient had a chronic obstructive pulmonary disease (COPD) exacerbation. She was given prescriptions for albuterol nebs, moxifloxacin, prednisone, and hydrocodone/acetaminophen to be used as needed. She was starting to feel better with her newly prescribed medications, but this morning when she tried to go to the restroom she noted worsening dyspnea, wheezing and recurrence of chest pain. She asked her husband to bring her to the ER. In the ER, TT was given nebulization treatment with albuterol/ipratropium, one dose of methylprednisolone 125 mg IV and IV fluids. She is currently feeling significantly better with less dyspnea and wheezing.
PMH	COPD: TT was told she had COPD a year ago based on chest x-ray results however no formal pulmonary function tests were performed. At her June office visit, mMRC = 2, FEV1 = 75% Previous hospitalization for pneumonia (3 months ago).At that time, she had episodes of left rib, and lower thoracic and lumbar pain. Depression: Started 1 year ago after she was laid-off from her job Hypertension: TT was told she had high blood pressure about 5 years ago Postmenopausal: Experienced menopause at age 52
Social History	1.5 pack per day current smoker. No illicit drug or alcohol use. Married with 2 grown children. Used to work as an office administrative assistant but was laid off last year. Had recently been asked to return to work but has been feeling ill.	Family History	Parents’ cause of death unknown One brother died of myocardial infarction, at 67 years old One sister in good health.
Vaccine History	Does not remember receiving any vaccinations as an adult but received all childhood vaccinations.	Surgical History	Appendectomy at age 20
Physical Exam	Review of Systems Has had on and off episodes of weakness, dyspnea, and cough, over the last 5 months Denies fever, chills, headache, vomiting, diarrhea, or urinary complaints No recent falls or trauma within the last year Denies numbness, altered sensation, or pain in the feet and lower extremities Pain 7/10 in chest and back. Physical Exam General: Well-nourished, well-developed, weak looking, not in acute respiratory distress. HEENT: Pink conjunctivae. Anicteric sclerae. Slightly dry oral mucosa. Neck: Supple. No jugular venous distention, bruit or lymphadenopathy. Lungs: Decreased breath sounds with occasional rhonchi. No wheezes appreciated. Occasional basal crackles. Some minimal tenderness in the right and left lower rib cage areas. Heart: S1, S2, tachycardic. No murmur. Abdomen: Slightly distended. Bowel sounds present. Minimal tenderness right and left upper quadrant areas. No rebound. No guarding. No CVA tenderness. Extremities: No edema. Dorsalis pedis pulse +2. Straight leg raise testing negative. Back is tender in the lower thoracic upper lumbar area. Motor strength equal and symmetrical. Neurologic: Alert, oriented x 3

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	Range
Sodium (Na⁺)	140	139	136-145 mEq/L
Potassium (K⁺)	4.2	4.3	3.5-5 mEq/L
Chloride (Cl^-)	106	104	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	28	23-28 mEq/L
Urea nitrogen (BUN)	23	22	8-20 mg/dL
Creatinine	1.5	1.7	0.5-1.3 mg/dL
Glucose	163	140	70-115 mg/dL
Hemoglobin A1c		5.8	5.3-7.5 %
Calcium,Total	11	11.1	8.6-10.2 mg/dL
Phosphate	3.8	3.4	3-4.5 mg/dL
Magnesium	2.0	2.2	1.6-2.6 mEq/L
Protein, total	5.9	5.9	5.5-9 g/dL
Albumin	3.7	3.8	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	13	15	10-40 units/L
Aminotransferase,alanine (ALT)	30	30	10-40 units/L
Lactic dehydrogenase (LDH)	140	144	80-225 units/L
Alkaline phosphatase	60	59	30-120 units/L
Bilirubin, Total	0.5	0.7	0.3-1 mg/dL
Leukocytes (WBC)	13.1	13.9	4.5-11 x10³/mcL
Red blood cells (RBC), Female	3.25	3.58	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	10.3	11.1	12-16 g/dL
Hematocrit, Female	30.7	33.2	37-47 %
Mean corpuscular hemoglobin (MCH)	91	93	27-33 picogram
Mean corpuscular volume (MCV)	31.3	31	76-100 mcm³
Platelets	299	297	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1	0.8-1.2
Prothrombin time (PT)	9.9	9.7	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29	28	25-35 sec

Additional Labs:

Fasting Lipid Panel (today)

TC (mg/dL) 264
LDL (mg/dL) 163
HDL (mg/dL) 48
TG (mg/dL) 265

Other (today)

CRP (mg/dL) 0.88
TSH (mcIU/mL) 4.03
M-Protein (g/dL) 4.8
β-2 Microglobulin (mg/L) 3.8

Cultures:

None

Imaging Studies:

Chest X-Ray

Multiple compression deformities of lower midthoracic spine. Multiple small lucencies throughout visualized bones

Skeletal Survey

Extensive lytic lesions involving the skull, clavicles, humeri, and femurs predominantly

Bone Marrow

50% cellular bone marrow with 50% involvement by intermediate grade plasma cell dyscrasia
Cytogenetics normal

Vital Sign	10/19/25 08:43	22:41	16:57	10/18/25 08:40
Height (cm)	175			175
Weight (kg)	77			78
Body Temperature (°C)	36.2	35.3	36.4	36.4
Blood Pressure (mmHg)	142 / 83	148/93	148/93	148/95
Heart Rate (bpm)	88	105	105	105
Respiratory Rate (bpm)	18	19	19	20
Oxygen Saturation (%)	95	94	95	95

Current Orders

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?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, SOB
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, SOB
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, pain (5-10)
USE	START DATE	STOP DATE	NOTES

Medication
History

None

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

Patient Name: Thompson, Taylor Date of Birth: 8/15/1967 Room#: 284	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	NOTES	MED REC ACTION
Moxifloxacin 400 mg tablet	1 PO QD x5 days		9:00 10/17/25	none	taken for past 2 days	for COPD exacerbation
Albuterol Sulfate 2.5 mg/3 mL nebulization solution	3 mL INH QID	yes, SOB	21:00 10/17/25	none	used once daily past 2 days	for COPD exacerbation
Prednisone 40 mg tablet	1 PO QD x 5 days	no	9:00 10/17/25	none	taken for past 2 days	for COPD exacerbation
Hydrocodone/Acetaminophen 5 mg/325 mg tablet	1-2 tabs PO QID	yes, pain	21:00 10/17/25	none	used 7 tabs in past 2 days
Citalopram 40 mg tablet	1 PO QD	no	9:00 10/17/25	none	never misses
Lisinopril 20 mg tablet	1 PO QD	no	9:00 10/17/25	none	never misses
Albuterol Sulfate 108 mcg/puff HFA inhaler	1-2 puffs PO q4H	yes, SOB	17:00 10/17/25	none	uses 1-3 puffs daily
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25
Moxifloxacin 400 mg PO QD	08:51	08:43
Prednisone 40 mg PO QD	08:42	08:48
Citalopram 40 mg PO QD	08:13	08:47
Lisinopril 20 mg PO QD	08:42	08:23
Albuterol Sulfate 108 mcg/puff 1 puff PO q4H PRN PRN yes, SOB
Albuterol Sulfate nebulization solution 2.5 mg/3 mL INH QID PRN PRN yes, SOB	08:32 12:47 16:41 20:19	08:25 12:31 16:41 20:30
Hydrocodone/APAP 5 mg/325 mg PO QID PRN PRN yes, pain (5-10)	08:55 12:36 16:19 20:55	08:49 12:43 16:41 20:31

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: Thompson, Taylor

Date of Birth: 8/15/1967

Room: 284

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	175 cm
Actual Body Weight (ABW)	77 kg
Ideal Body Weight (IBW)	66.2 kg
ABW % of IBW	116 %
Adjusted Body Weight (AjBW)	70.5 kg
Body Surface Area (BSA)	1.93 m²
Body Mass Index (BMI)	25.1 kg/m²