View Patient Profiles

Reilly, Sophia

MRN: 173201

Room: 807

DOB: 3/16/1958

Age: 67

Gender: Female

Allergies: Levofloxacin (hives)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Medical ICU (MICU)
Scenario	Culture results and sensitivities finalize, SR’s septic shock has resolved, and she is extubated on day 4 of admission. She remains a little drowsy, but passed a swallow evaluation and is tolerating a renal restricted diet well. On day 5 of admission, her AKI is resolving. The medical team recognizes a developing thrombocytopenia and is concerned for possible heparin-induced thrombocytopenia (HIT). The medical team calculates a 4Ts score of 5 and orders both the HIT PF4 antibody test and serotonin release assay, which both later come back positive. The medical team then asks you, as the MICU clinical pharmacist, for further management recommendations and any additional recommendations you have for this patient’s care.
Admission note taken on 10/19/25
CC	Confusion, chills, lower back pain, and unable to get out of bed for two days
HPI	SR presents to the emergency department with her husband on 8/4/2017. Her husband states that she is confused and hasn’t been able to get out of bed for two days. He states SR reported chills and lower back pain earlier in the week, but that she has a history of chronic low back pain from a work-related injury. He is unsure if she checked her temperature at home. The physician is concerned for sepsis and that SR is unable to adequately protect her airway. He orders a complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis, urine culture, blood cultures, intravenous (IV) fluids, and empiric antibiotics. Her mental status continues to be poor with limited response to the medical team. The decision is made to perform rapid sequence intubation. Her blood pressure has improved, but still remains low after adequate fluid resuscitation so a norepinephrine infusion is initiated. SR is transferred to the medical intensive care unit (MICU) once stabilized in the emergency department. She is diagnosed with septic shock secondary to pyelonephritis and acute kidney injury (AKI).
PMH	Hypertension Hyperlipidemia Chronic lower back pain Morbid obesity Tobacco abuse
Social History	Alcohol intake: Occasional drinker (1-2 drinks per month) Tobacco: 47 pack year history, smokes 1 pack per day, 1st cigarette 2 hours after waking Illicit drugs: None Employment: Works as a secretary at an elementary school Married for 40 years	Family History	Father died of myocardial infarction at age 65 Mother still alive with history of hypothyroidism, type 2 diabetes, hypertension, and hyperlipidemia
Vaccine History	Influenza – received last season Tdap – received last dose 4 years ago Varicella – history of varicella infection as a child RZV – received last dose 7 years ago PPSV23 – received last dose 2 years ago	Surgical History	None
Physical Exam	Obtained 4 days ago: General: Obese woman in moderate distress HEENT: Conjunctiva clear; mucosal membranes appear pale and dry; no palpable lymphadenopathy Pulmonary: Acyanotic; faint expiratory wheeze bilaterally; no rhonchi/ crackles Cardiovascular: Negative JVD; tachycardic without murmurs/rubs/gallops Abdomen: Left flank tenderness to palpation with guarding; normal bowel sounds Genitourinary: WNL Extremities: No pitting edema Neuro: Confused, lethargic, oriented to person; cranial nerves 2-12 grossly intact; strength 4/5 x 4

Clinical Laboratory Report

Test Name	10/19/25	10/15/25	Range
Sodium (Na⁺)	138	139	136-145 mEq/L
Potassium (K⁺)	4.0	4.9	3.5-5 mEq/L
Chloride (Cl^-)	105	104	98-106 mEq/L
Bicarbonate (HCO₃^-)	25	30	23-28 mEq/L
Urea nitrogen (BUN)	40	80	8-20 mg/dL
Creatinine	2.6	3.4	0.5-1.3 mg/dL
Glucose	116	95	70-115 mg/dL
Hemoglobin A1c		5.4	5.3-7.5 %
Calcium,Total	8.6	8.5	8.6-10.2 mg/dL
Phosphate	3.7	5.3	3-4.5 mg/dL
Magnesium	1.9	2.1	1.6-2.6 mEq/L
Protein, total	5.5	5.5	5.5-9 g/dL
Albumin	3.3	3.4	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	18	14	10-40 units/L
Aminotransferase,alanine (ALT)	24	22	10-40 units/L
Lactic dehydrogenase (LDH)	124	123	80-225 units/L
Alkaline phosphatase	55	56	30-120 units/L
Bilirubin, Total	1.0	1.0	0.3-1 mg/dL
Leukocytes (WBC)	11.3	18.1	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.8	4.8	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	10.1	10.2	12-16 g/dL
Hematocrit, Female	31.3	31.2	37-47 %
Mean corpuscular hemoglobin (MCH)	29	29	27-33 picogram
Mean corpuscular volume (MCV)	84	84	76-100 mcm³
Platelets	88	240	150-450 x10³/mcL
International normalized ratio (INR)	1.04	1.01	0.8-1.2
Prothrombin time (PT)	11.4	11.1	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	26	26	25-35 sec

Additional Labs:

Other Labs	Today	4 Days Ago	6 Months Ago
HIT PF4 Antibody Assay	2.215
HIT PF4 Antibody Interpretation	Positive
Serotonin Release Assay	Positive
Lactate (mmol/L)	1.1	3.5
BUN (mg/dL)	40	80	12
SCr (mg/dL)	2.6	3.4	0.83

Fasting Lipids	6 Months Ago
TC (mg/dL)	180
TG (mg/dL)	110
HDL-C (mg/dL)	56
LDL-C (mg/dL)	98
Non-HDL-C (mg/dL)	124

Urinalysis	Result (4 days ago)
Specific Gravity	1.023
Color	Dark yellow
Clarity	Hazy
Leukocyte Esterase	Positive
Nitrite	Positive
Protein	Trace
Glucose	Negative
Ketone	Negative
Blood	Small
WBC	> 182
WBC Casts	Present
RBC	12
Squam Epithel	< 1
Bacteria	Many
Mucus	Rare

Cultures:

Date	Specimen	Result	Susceptibilities
4 Days Ago	Blood culture # 1	Stain: Gram negative bacilli Culture: Escherichia coli	Amikacin – Susceptible Ampicillin – Resistant Cefazolin – Resistant Ceftriaxone – Susceptible Cefepime – Susceptible Gentamicin – Susceptible Levofloxacin – Susceptible Piperacillin + Tazobactam – Susceptible Tobramycin – Susceptible
	Blood culture # 2	Stain: Gram negative bacilli Culture: Escherichia coli	See above isolate
	Urine culture	> 100,000 CFU/mL Escherichia coli	Ampicillin – Resistant Cefazolin – Resistant Ceftriaxone – Susceptible Cefepime – Susceptible Ciprofloxacin – Susceptible Levofloxacin – Susceptible Nitrofurantoin – Susceptible Piperacillin + Tazobactam – Susceptible Tobramycin – Susceptible TMP-SMX – Susceptible
2 Days Ago	Blood culture #1	No growth at 48 hrs
2 Days Ago	Blood culture #2	No growth at 48 hrs

Imaging Studies:

Test	Result	Date
Upper and lower extremity ultrasounds	negative for thrombosis	today
Chest X-ray	Endotracheal tube tip is appropriately positioned above the carina. Cardiomediastinal silhouette within normal limits. No overt pulmonary edema or focal consolidations.	4 days ago
EKG	Sinus rhythm	4 days ago

Vital Sign	10/19/25 08:36	10/15/25 07:17
Height (cm)	163	163
Weight (kg)	109	109
Body Temperature (°C)	37.2	39.1
Blood Pressure (mmHg)	121 / 76	85/50
Heart Rate (bpm)	99	120
Respiratory Rate (bpm)	12	12
Oxygen Saturation (%)	98	88

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

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?
			PRN for central line care
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN mild/moderate pain (1-4)
USE	START DATE	STOP DATE	NOTES

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

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			2 mcg/min, increase by 2 mcg/min q10Min to maintain MAP > 65 mmHg

DRUG	DOSE	FREQ & TIME	PRN?

RATE
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN severe pain (5-10)
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

SR has prescriptions from her primary care physician (Dr. Carter), and there are no adherence issues to report.
Per her husband’s report and based on her prescription refill history, she takes acetaminophen and oxycodone approximately 1-2 times per day.

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

Patient Name: Reilly, Sophia Date of Birth: 3/16/1958 Room#: 807	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Lisinopril 20 mg tablet	1 PO QD	no
Simvastatin 40 mg tablet	1 PO HS	no
Gabapentin 300 mg capsule	2 PO TID	no
Acetaminophen 325 mg tablet	2 PO QID	yes, mild pain
Oxycodone 5 mg tablet	1 PO QID	yes, severe pain
MiraLax powder	17 g PO QD	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Piperacillin/tazobactam 2.25 g IV q6Hr Rate: 100 mL/hr	00:14 05:50 12:52 17:28
Heparin 7,500 mg SC q8Hr	08:33 14:33 20:22
Chlorhexidine 0.12% Sol. swab with 5 mL PO q12Hr	07:51 19:43
Famotidine 20 mg PO QD	09:18
Simvastatin 40 mg PO HS
Gabapentin 600 mg PO q8Hr	08:38 13:27 20:57
Polyethylene glycol 17 g PO QD	09:16
Heparin 500 units IV QD PRN PRN for central line care Rate: injection	07:42
Acetaminophen 650 mg PO q6Hr PRN PRN mild/moderate pain (1-4)	8:12 18:48
Oxycodone 5 mg PO q6Hr PRN PRN severe pain (5-10)	10:48
Norepinephrine 8 mg IV continuous Rate: see notes
Sodium Chloride 0.9% 3,000 mL over 1 hour IV Stat x1 dose Rate: 3,000 mL/Hr
Hydromorphone 0.5 mg IV q4Hr PRN PRN severe pain (5-10) Rate: injection

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: Reilly, Sophia

Date of Birth: 3/16/1958

Room: 807

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	163 cm
Actual Body Weight (ABW)	109 kg
Ideal Body Weight (IBW)	54.7 kg
ABW % of IBW	199 %
Adjusted Body Weight (AjBW)	76.4 kg
Body Surface Area (BSA)	2.22 m²
Body Mass Index (BMI)	41 kg/m²