View Patient Profiles

Goodman, Madeline

MRN: 144220

Room: 319

DOB: 9/2/1953

Age: 72

Gender: Female

Allergies: Strawberries (throat swells), Lisinopril (cough)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Inpatient Cardiology Unit
Scenario	MG is admitted to your general cardiology medicine unit and is diagnosed with recurrent idiopathic pericarditis.
Admission note taken on 10/19/25
CC	“I feel like I am having a heart attack.”
HPI	MG presents to the Emergency Department with chest pain upon inspiration that resolves when sitting forward and pain that radiates to her shoulders. The patient also reports a productive cough (white sputum), sneezing, a runny nose, headache, and a stuffy nose; patient is afebrile. Records indicate 6 weeks ago, MG reported similar symptoms and was diagnosed with acute idiopathic pericarditis at that time. You notice that she had been prescribed ibuprofen 600 mg PO TID PRN. MG claims that this has not helped her “inflammation around the heart,” and is still in pain. The patient also reports that she has gained about 4 lbs in the last week and a half, and is unsure as to why. Blood and sputum cultures were obtained this visit.
PMH	Heart Failure with Reduced Ejection Fraction (HFrEF), diagnosed over a year ago Diabetes Mellitus Type 2, diagnosed 7 years ago Hypertension, diagnosed at age 58 years old COPD, diagnosed 7 years ago Dyslipidemia, diagnosed last year Obesity Upper GI Bleed 5 years ago Chronic Stable Angina, diagnosed last year
Social History	Current smoker; 15 pack year cigarette smoking history Denies any illicit drug or alcohol use	Family History	Mother died of a heart attack at the age of 50 years old Father died of heart failure at the age of 75 years old
Vaccine History	Completed childhood series Varicella, Zoster, Tdap, and MMR up-to-date Influenza vaccine 2 years ago COVID-19 (Pfizer) 2 primary, 2 boosters	Surgical History	None
Physical Exam	General: obese, distressed, Caucasian female Integumentary: warm and dry lower and upper extremities; no finding of rash, lesions, eczema, nodules, or neoplasms; exam unremarkable HEENT: no visual changes or dysphagia; patient complains of rhinitis Cardiovascular: pericardial friction rub; 2 + pitting edema in both lower extremities; JVD: 5 cm; EKG shows ST segment elevations and PR segment depressions consistent with pericarditis Endocrine: no overt symptoms of hyperglycemia Gastrointestinal: abdomen is soft and non-tender with audible bowel sounds; patient had 2 bowel movements today; stool formed and free of pus or blood; exam unremarkable Genitourinary: no irritation or obstructive symptoms; menopause; exam unremarkable Neurological: A&O X 3; no complaints of headaches, paresthesia, ataxia, or weakness; exam unremarkable Musculoskeletal: patient complains of chest pain radiating to trapezius ridges; patient reports pain resolves upon sitting up-right Renal: In -1250 mL / Out - 500 mL Pulmonary: Pulse oximetry: 95% on room air; FEV1/FVC=58%; unchanged from 8 months ago; CXR showed cardiomegaly suggestive of a “water-bottle heart”

Clinical Laboratory Report

Test Name	10/19/25	Range
Sodium (Na⁺)	138	136-145 mEq/L
Potassium (K⁺)	3.9	3.5-5 mEq/L
Chloride (Cl^-)	102	98-106 mEq/L
Bicarbonate (HCO₃^-)	25	23-28 mEq/L
Urea nitrogen (BUN)	22	8-20 mg/dL
Creatinine	1.0	0.5-1.3 mg/dL
Glucose	302	70-115 mg/dL
Hemoglobin A1c	11.2	5.3-7.5 %
Calcium,Total	9.2	8.6-10.2 mg/dL
Phosphate	3.9	3-4.5 mg/dL
Magnesium	2.0	1.6-2.6 mEq/L
Protein, total	7.2	5.5-9 g/dL
Albumin	3.9	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	28	10-40 units/L
Aminotransferase,alanine (ALT)	43	10-40 units/L
Lactic dehydrogenase (LDH)	175	80-225 units/L
Alkaline phosphatase	75	30-120 units/L
Bilirubin, Total	0.7	0.3-1 mg/dL
Leukocytes (WBC)	8.5	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.0	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	13	12-16 g/dL
Hematocrit, Female	31	37-47 %
Mean corpuscular hemoglobin (MCH)	29	27-33 picogram
Mean corpuscular volume (MCV)	86	76-100 mcm³
Platelets	298	150-450 x10³/mcL
International normalized ratio (INR)	1.1	0.8-1.2
Prothrombin time (PT)	10.1	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	22	25-35 sec

Additional Labs:

CBC (today)

Neutrophils (%) 50
Lymphocytes (%) 55
Eosinophils (%) 1
Bands (%) 0

Fasting Lipid Panel (today)

TC (mg/dL) 254
LDL (mg/dL) 185
HDL (mg/dL) 38
TG (mg/dL) 198

Other (today)

CPK (mcg/L) 24
hs-CRP (mg/dL) 7
D-dimer (ng/mL) 16
Troponin I (mcg/L) 3
Lactate (mEq/L) 0.4
BNP (ng/mL) 264

Cultures:

Blood Cultures: Gram stain showed no growth x 4 bottles
Sputum Culture: No growth

Imaging Studies:

Transthoracic Echocardiogram (6 months ago):

LVEF of 35-40% ; dilated ventricle
Hypokinetic left ventricle

Transthoracic Echocardiogram (today):

LVEF: 20-25%; dilated ventricle
Trace mitral regurgitation

Cardiac Magnetic Resonance (CMR) (today):

Ruled out cardiac tamponade
Small pericardial effusions present 8 mm

Vital Sign	10/19/25 07:19
Height (cm)	155
Weight (kg)	75
Body Temperature (°C)	37.8
Blood Pressure (mmHg)	162 / 94
Heart Rate (bpm)	88
Respiratory Rate (bpm)	18
Oxygen Saturation (%)	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?

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 pain (scale 1-5)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN shortness of breath
USE	START DATE	STOP DATE	NOTES

Medication
History

MG admits to occasionally missing doses of her medications, but is adamant that she is 100% compliant with her hypertension medications because of her family history of heart disease.
When she remembers to take her inhalers, she always rinses her mouth out with water after each puff.
She states that her chest pain is very controlled since being started on her medication for angina and has no issues with her other medications.

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

Patient Name: Goodman, Madeline Date of Birth: 9/2/1953 Room#: 319	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
Pioglitazone 30 mg tablet	1 PO qAM	no	7:30 10/18/25	none	never misses
Pravastatin 10 mg tablet	1 PO qHS	no	22:30 10/18/25	none	misses dose 1-2x/week
Metformin 1,000 mg tablet	1 PO BID w/meal	no	18:30 10/18/25	none	misses pm dose 1-2x/week
Hydralazine 10 mg tablet	1 PO BID	no	18:30 10/18/25	none	never misses
Metoprolol tartrate 25 mg tablet	1/2 tab PO BID	no	18:30 10/18/25	none	never misses
Fluticasone/Salmeterol 250 mcg/50 mg diskus inhaler	1 puff PO BID	no	21:00 10/18/25	none	misses pm dose 1-2x/week
Tiotropium 18 mcg HandiHaler	1 puff PO qAM	no	7:30 10/18/25	none	never misses
Ranolazine 500 mg ER tablet	1 PO BID	no	18:30 10/18/25	none	never misses
Albuterol sulfate 108 mcg/puff HFA inhaler	2 puffs PO QID	yes, shortness of breath		none	uses 2-3x/week
Ibuprofen 600 mg tablet	1 PO TID	yes, heart pain		none	taking 3x/day	currently not relieving pain
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Pioglitazone 30 mg PO Daily	09:35
Metformin 1,000 mg PO BID	08:53
Pravastatin 10 mg PO Bedtime
Hydralazine 10 mg PO BID	08:43
Metoprolol tartrate 12.5 mg PO BID	08:46
Ranolazine 500 mg PO BID	08:10
Tiotropium 18 mcg INH Daily	09:51
Fluticasone/Salmeterol 250 mcg/50 mg INH BID	08:20
Ibuprofen 600 mg PO TID PRN PRN pain (scale 1-5)	12:17
Albuterol sulfate 108 mcg/puff INH QID PRN PRN shortness of breath	08:59 12:40

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: Goodman, Madeline

Date of Birth: 9/2/1953

Room: 319

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	155 cm
Actual Body Weight (ABW)	75 kg
Ideal Body Weight (IBW)	47.8 kg
ABW % of IBW	157 %
Adjusted Body Weight (AjBW)	58.7 kg
Body Surface Area (BSA)	1.8 m²
Body Mass Index (BMI)	31.2 kg/m²