| Townes, Nelson |
| MRN: 152344 | Room: 720 | DOB: 6/5/2017 | Age: 8 | Gender: Male | Allergies: Morphine (rash, hives) |
| Setting | Inpatient Pediatric Unit | ||
| Scenario | You are a pharmacist rounding as part of the inpatient pediatrics team. This patient (NT) is be admitted to the general pediatric unit after being seen in the Emergency Department and being diagnosed with sickle cell crisis. | ||
| Admission note taken on 10/19/25 | |||
| CC | "My leg hurts and I feel short of breath." | ||
| HPI | NT presents to the Emergency Department complaining of pain in left leg and difficulty breathing. NT’s pain began 2 days ago and has gotten progressively worse, despite the use of oxycodone and ibuprofen. His pain is currently rated as 9 out of 10 and has been fluctuating between 6 and 9. The pain is primarily between his left hip and left knee, but radiates both below the knee and above the hip at various points throughout the day. NT is also presenting with shortness of breath and a complaint of mild chest pain which began this morning in conjunction with his increasing leg pain. | ||
| PMH |
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam |
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| 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-) | 20 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 20 | 8-20 mg/dL |
| Creatinine | 0.5 | 0.5-1.3 mg/dL |
| Glucose | 111 | 70-115 mg/dL |
| Hemoglobin A1c | 5.8 | 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 | 6.9 | 5.5-9 g/dL |
| Albumin | 4.1 | 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) | 130 | 80-225 units/L |
| Alkaline phosphatase | 75 | 30-120 units/L |
| Bilirubin, Total | 0.4 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 15.5 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 3.9 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 7.1 | 14-18 g/dL |
| Hematocrit, Male | 22 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 30 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 82 | 76-100 mcm3 |
| Platelets | 231 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.0 | 0.8-1.2 |
| Prothrombin time (PT) | 10.1 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 27.3 | 25-35 sec |
| Additional Labs: |
Other (today)
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| Cultures: | Results (today)
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| Imaging Studies: | Chest X-ray (taken in emergency department today)
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| Medication History |
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| Patient Name: Townes, Nelson Date of Birth: 6/5/2017 Room#: 720 |
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 |
| 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: Townes, Nelson | Date of Birth: 6/5/2017 | Room: 720 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |