View Patient Profiles

Putnam, Simon

MRN: 166098

Room: 634

DOB: 2/24/1990

Age: 35

Gender: Male

Allergies: Ciprofloxacin (trouble breathing and full body rash), Naproxen (GI upset and acute kidney injury)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Adult Medicine Unit
Scenario	SP is admitted to the general medical floor and diagnosed with presumptive spontaneous bacterial peritonitis and started on empiric vancomycin. A paracentesis was performed but gram stain and culture results are pending. A presumptive respiratory infection and/or asthma exacerbation have been ruled out. The medical resident asks you to review the patient’s report and make recommendations for definitive antibiotic therapy as well as any other suggestions regarding this patient’s care.
Admission note taken on 10/19/25
CC	"I have a fever, my belly hurts, and I am having a harder time breathing."
HPI	SP arrives in the emergency department at 23:30 yesterday after his wife called 911 since he wasn’t answering questions appropriately at home. SP complains of progressive shortness of breath, his head feeling hot, and abdominal pain that has progressively worsened over the last 2 days. He used his albuterol inhaler twice with no improvement in symptoms. Last evening he wouldn’t get out of bed secondary to abdominal pain, fatigue, and being slightly unsteady on his feet. He states that he has never had these symptoms before and it feels different than his previous admissions for heart failure exacerbation (2 months and 5 months prior). In the emergency department, SP presents as somnolent but alert and oriented to person and place. Upon further review of his medical history, SP reports that he has cirrhosis, heart failure, and a distant history of a single seizure when he used to drink bunches of alcohol but never misses any doses of his medications.
PMH	History of alcoholic cirrhosis Asthma Remote history of alcohol withdrawal seizures (last was 4 years ago) Heart failure with reduced ejection fraction Erectile Dysfunction
Social History	Alcohol intake: heavy drinker until 4 years ago, no drinks since then (patient is very proud of this) Tobacco: 15 pack years, none for past 4 years Illicit drugs: history of cocaine use, none for past 4 years Employment: Works as a server at the Hard Rock Cafe Married for 4 years	Family History	Father died of liver failure at 54 Mother still alive with a history of hypertension and COPD Brother died in motor vehicle accident at age 22
Vaccine History	Up to date on all vaccinations, hepatitis A and B vaccine series, and had flu shot for current season.	Surgical History	Humerus fracture repair at age 26 Large volume therapeutic paracentesis (4 months and 2 months ago)
Physical Exam	General: Middle-aged male in moderate distress ROS: Positive for dyspnea, febrile, abdominal tenderness with guarding, A&O x 2 HEENT: Mild scleral icterus, minimal nystagmus, gums have mild swelling Chest: CTA bilaterally, good air movement in all lobes, no rhonchi/rales/crackles, dyspnea Cardiovascular: negative JVD, no gallops/murmurs, absence of angina Abdomen: tenderness with guarding, moderate abdominal distension, Grade 2 ascites Genitourinary: WNL Extremities: 2+ pitting edema Neuro: AO x 2; unsteady gait/balance, negative asterixis Psych: Mood: "anxious"; wants to feel better

Clinical Laboratory Report

Test Name	10/19/25	08/20/25	Range
Sodium (Na⁺)	132		136-145 mEq/L
Potassium (K⁺)	4.9	3.7	3.5-5 mEq/L
Chloride (Cl^-)	104		98-106 mEq/L
Bicarbonate (HCO₃^-)	26		23-28 mEq/L
Urea nitrogen (BUN)	32		8-20 mg/dL
Creatinine	1.2	1.0	0.5-1.3 mg/dL
Glucose	95		70-115 mg/dL
Hemoglobin A1c	5.6		5.3-7.5 %
Calcium,Total	8.5		8.6-10.2 mg/dL
Phosphate	3.3		3-4.5 mg/dL
Magnesium	1.9		1.6-2.6 mEq/L
Protein, total	4.8		5.5-9 g/dL
Albumin	2.4		3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	45	51	10-40 units/L
Aminotransferase,alanine (ALT)	39	41	10-40 units/L
Lactic dehydrogenase (LDH)	245		80-225 units/L
Alkaline phosphatase	125		30-120 units/L
Bilirubin, Total	4.1	3.7	0.3-1 mg/dL
Leukocytes (WBC)	18.1		4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.9		3.8-5.1 x10⁸/mcL
Hemoglobin, Male	12.3		14-18 g/dL
Hematocrit, Male	37.8		42-50 %
Mean corpuscular hemoglobin (MCH)	30		27-33 picogram
Mean corpuscular volume (MCV)	84		76-100 mcm³
Platelets	165		150-450 x10³/mcL
International normalized ratio (INR)	1.3		0.8-1.2
Prothrombin time (PT)	17		9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	27		25-35 sec

Additional Labs:

Other Labs	Today	2 Months Ago
Ammonia (mmol/L)	26	27
BNP (pg/mL)	76	685
Ethanol (mg/dL)	0	0
Phenytoin (mcg/mL)	15.5

Diagnostic Test	Result	Date
Ejection fraction (%)	30	5 months ago
FEV₁/FVC (%)	85	8 months ago

Cultures:

Paracentesis (today)

A total of 2.5 liters were removed
Appearance: cloudy
Serum-to-ascites albumin gradient (SA-AG): 15 g/L
Cell count: RBC <1000 mcg/L, polymorphonuclear leukocytes (PMNs) 475 cells/mm3, WBC many
Gram stain/culture: pending
Pain decreased to from 8/10 to 4/10 following paracentesis

Imaging Studies:

Chest X-ray: No acute abnormalities
EKG: Sinus pattern; no ischemic changes
Abdominal US: presence of ascitic fluid, no other abnormalities
CT chest/head: mild ascites, otherwise unremarkable with no neuro abnormalities

Vital Sign	10/19/25 08:40	08/20/25 09:10
Height (cm)	180	180
Weight (kg)	75	73
Body Temperature (°C)	39	37
Blood Pressure (mmHg)	124 / 83	122/85
Heart Rate (bpm)	90	88
Respiratory Rate (bpm)	16	16
Oxygen Saturation (%)	98	99

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

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?

USE	START DATE	STOP DATE	NOTES

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

DRUG	DOSE	FREQ & TIME	PRN?
			PRN nausea
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-4) or fever (>37°C)
USE	START DATE	STOP DATE	NOTES

Medication
History

SP has prescriptions from his cardiologist (Dr. Hooper) and his primary care physician (Dr. Dice).
Adherence/dosing issue: He is adherent to all his medications except for not taking his isosorbide mononitrate for the last month secondary to headache that he gets after use.
States he doesn’t and has never had angina type pain.
He states that he typically uses his albuterol inhaler only once a week and isn’t awaken at night with symptoms.
SB states that he missed his evening doses of medications prior to admission.

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

Patient Name: Putnam, Simon Date of Birth: 2/24/1990 Room#: 634	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Albuterol Sulfate 108 mcg/act oral inhaler	1-2 puffs PO QID	yes, SOB
Serevent Diskus 50 mcg/act oral inhaler	1 puff PO BID	no
Phenytoin 200 mg capsule	2 PO QPM	no
Enalapril 10 mg tablet	1 PO BID	no
Metoprolol tartrate 100 mg tablet	1 PO BID	no
Furosemide 40 mg tablet	1 PO QAM	no
Isosorbide mononitrate 30 mg ER tablet	1 PO QAM	no
Potassium chloride 20 mEq ER tablet	2 PO QAM	no
Sildenafil 50 mg tablet	1 PO PRN	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Vancomycin 1,000 mg IV pharmacy to dose Rate: 250 mL/hr
Salmeterol Diskus 1 puff (50 mcg) INH QD	09:56
Phenytoin 400 mg PO QD
Enalapril 10 mg PO BID	09:28
Metoprolol tartrate 100 mg PO BID	09:30
Furosemide 40 mg PO QD	09:47
Potassium chloride 40 mEq PO QD	09:10
Isosorbide mononitrate 30 mg PO QD	09:48
Enoxaparin 40 mg SC QD	08:10
Albuterol Sulfate MDI 2 puffs (216 mcg) INH QID PRN PRN SOB
Ondansetron 4 mg IV q4Hr PRN PRN nausea
Acetaminophen 500 mg PO q6Hr PRN PRN pain (1-4) or fever (>37°C)

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: Putnam, Simon

Date of Birth: 2/24/1990

Room: 634

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	180 cm
Actual Body Weight (ABW)	75 kg
Ideal Body Weight (IBW)	75.3 kg
ABW % of IBW	100 %
Adjusted Body Weight (AjBW)	75.2 kg
Body Surface Area (BSA)	1.94 m²
Body Mass Index (BMI)	23.1 kg/m²