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Jefferson, Siya

MRN: 222417

Room: 447

DOB: 5/27/1952

Age: 73

Gender: Female

Allergies: PCN (hives), Codeine (nausea & vomiting), Eggs (hives & throat closure)

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	You are on rounds with the Internal Medicine team outside the patient’s room.
Admission note taken on 10/19/25
CC	chest discomfort, dizziness, weakness/feeling faint & rapid heart rate
HPI	Patient was admitted to the hospital last night for acute GI bleed secondary to chronic GERD & NSAID ingestion. She is feeling better today, more alert & full of strength. SJ began experiencing chest discomfort, dizziness, weakness/feeling faint & rapid heart rate, which promoted her visit to the ER.
PMH	Hypertension x 15 years Osteoarthritis x 15 years (bilat. hands & knees) Hyperlipidemia x 9 years Gastroesophageal Reflux Disease x 9 years Diverticulosis x 9 years S/P TIA (6 years ago) S/P Total abdominal hysterectomy (18 years ago) S/P Cholesystectomy (18 years ago)
Social History	Tobacco: smokes 1 ppd x 42 years EtOH: 1-2 glasses of red wine or beer 2x/month Caffeine: Diet soda 3-4 cans/day Occupation: Administrative assistant for local insurance company Status: Widow x 7 yr.; lives alone Children: 3 daughters & 2 sons. Two children, son & daughter, reside locally others scattered across USA. Physical Activity: No regular exercise routine. Tries to maintain an active lifestyle, but somewhat hindered by OA. SJ reports that she tries to walk extra when out shopping, ex. while at grocery store and malls; occasionally will walk around the neighborhood with friends, however fearful to walk alone. Diet: Attempts made towards a low salt & cholesterol diet. SJ has previously visited with dieticians. Admitted to some indiscretions; enjoys fried foods, snack foods & desserts.	Family History	Father: deceased at 68 yo secondary to MI; also had OA Mother: deceased at 33 yo due to complications during childbirth Sister: alive 70 yo with OA & dyslipidemia Sister: alive 69 yo with cataracts, diverticulosis, HTN & S/P MI (3 years ago) Brother: alive 67 yo with GERD & OA Brother: deceased at 3 yo secondary to epilepsy/convulsions
Vaccine History	None on file	Surgical History	None on file
Physical Exam	Gen: Pleasant African American woman in mild distress reporting to ER with CC of complaints of chest discomfort, dizziness, weakness/feeling faint & rapid heart rate. During the last week she has been experiencing abdominal cramping & noticed a change in bowel movements: more loose than usual (increase from daily stool to 2-3/day), color change from medium to very dark brown & stickier in consistency. Denied observation of blood in stool, commode or on paper. She denied any recent changes in diet or other acute illnesses. HEENT: NCAT; PERRLA; appreciate beginnings of cataract bilaterally; oral mucosa is somewhat dry in appearance, (-) ulceration, appreciate partial dentures on top Skin: Unremarkable; warm & dry to touch Neck: No JVD or thyromegaly; bruit appreciated on left, none right Heart: Regular rhythm with rapid VR Lungs: CTA Abdomen: No organomegaly; +BS; mild guarding & tender to deep palpation, no rebounding; well healed surgical scar GU: (+) guiac; remainder of exam deferred Extremities: No C/C/E; pulses 2+ bilaterally; slight tenderness but no swelling in OA affected joints; (+) crepitus (knees only)

Clinical Laboratory Report

Test Name	10/19/25	04/22/25	Range
Sodium (Na⁺)	130	135	136-145 mEq/L
Potassium (K⁺)	5.0	4.0	3.5-5 mEq/L
Chloride (Cl^-)	95	99	98-106 mEq/L
Bicarbonate (HCO₃^-)	27	25	23-28 mEq/L
Urea nitrogen (BUN)	28	12	8-20 mg/dL
Creatinine	1.7	1.2	0.5-1.3 mg/dL
Glucose	105	86	70-115 mg/dL
Hemoglobin A1c	6.3	6.4	5.3-7.5 %
Calcium,Total	9.2	9.2	8.6-10.2 mg/dL
Phosphate	4.2	4.0	3-4.5 mg/dL
Magnesium	1.9	2.2	1.6-2.6 mEq/L
Protein, total	7.4	7.6	5.5-9 g/dL
Albumin	3.8	4.2	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	29	27	10-40 units/L
Aminotransferase,alanine (ALT)	30	32	10-40 units/L
Lactic dehydrogenase (LDH)	90	87	80-225 units/L
Alkaline phosphatase	66	69	30-120 units/L
Bilirubin, Total	0.8	0.7	0.3-1 mg/dL
Leukocytes (WBC)	6.5	5.2	4.5-11 x10³/mcL
Red blood cells (RBC), Female	3.6	5.4	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	9	13.5	12-16 g/dL
Hematocrit, Female	30	38	37-47 %
Mean corpuscular hemoglobin (MCH)	27	31	27-33 picogram
Mean corpuscular volume (MCV)	90	92	76-100 mcm³
Platelets	225	200	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.0	0.8-1.2
Prothrombin time (PT)	10.4	9.6	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	27	25	25-35 sec

Additional Labs:

Ancillary Labs	Today	6 Months Ago
Reticulocyte count (%)	3.5	1
TSH (mIU/L)	3.8	3.7
H. pylori IgG	positive

Fasting Lipids	Today	6 Months Ago
Total Cholesterol (mg/dL)	275	221
Triglycerides (mg/dL)	345	150
HDL-C (mg/dL)	55	50
LDL-C (mg/dL)	151	141

Urinalysis	Today	6 Months Ago
Glucose	neg	neg
Ketones	neg	neg
Specific Gravity	1.02	1.02
pH	6.2	5.5
Bacteria	neg	neg
WBC	neg	neg
RBC	neg	neg
Protein	neg	neg
Leuk Est	neg	neg
Nitrite	neg	neg

Cultures:

None

Imaging Studies:

	Results (today)
ECG	Sinus tachycardia; VR = 112 bpm
Endoscopy with biopsy	Grade 2 esophagitis, no Barrett's epithelium; note 6 mm antral ulcer. Biopsy shows histologic presence of H Pylori, findings verified by (+) urease
Hemmocult	2/3 positive
Barium	confirm presence of bleeding 6 mm antral ulcer
Colonoscopy	diverticuli noted, no inflammation, ulceration or bleeding appreciated

Vital Sign	10/19/25 07:49	04/22/25 07:28
Height (cm)	157	157
Weight (kg)	76	76.5
Body Temperature (°C)	37.2	37.1
Blood Pressure (mmHg)	100 / 64	148/78
Heart Rate (bpm)	112	82
Respiratory Rate (bpm)	22	20
Oxygen Saturation (%)	98	99

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-5)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (6-10)
USE	START DATE	STOP DATE	NOTES

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

Medication
History

Medication list confirmed with patient and community pharmacy records.
Prior to admission SJ noted good tolerance of all medications.
SJ admitted to missing evening doses of BP & lipid medications if falls asleep on couch (1-2x/week).
Admitted to increasing need for Pepcid AC & Maalox over the past several weeks, despite no apparent change in diet.
During this time her use of Metamucil decreased as stools became more loose & changed appearance (see PE).

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

Patient Name: Jefferson, Siya Date of Birth: 5/27/1952 Room#: 447	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Enalapril 10 mg tablet	1 PO BID	no
Triamterene/HCTZ 37.5 / 25 mg tablet	1 PO QD	no
Simvastatin 20 mg tablet	1 PO HS	no
Aspirin 81 mg tablet	1 PO QD	no
Oxaprozin 600 mg tablet	1 PO QD	no
Famotidine 20 mg tablet	1 PO QD	yes, stomach upset
Maalox oral suspension	15 mL PO PRN	yes, stomach upset
Metamucil powder	1 tbsp PO QPM	no
Generic multivitamins/ minerals tablet	1 PO QD	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Dextrose 5% & Sodium Chloride 0.45% 60 mL/hr IV continuous infusion	9:29
Acetaminophen 650 mg PO q6Hr PRN PRN pain (1-5)	6:23
Oxycodone/APAP 5 mg/325 mg PO q6Hr PRN PRN pain (6-10)
Calcium Carb/Mag Hydroxide 400 mg/135 mg/5 mL PO 15 mL q4Hr PRN PRN stomach upset	7:32

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: Jefferson, Siya

Date of Birth: 5/27/1952

Room: 447

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	157 cm
Actual Body Weight (ABW)	76 kg
Ideal Body Weight (IBW)	50.1 kg
ABW % of IBW	152 %
Adjusted Body Weight (AjBW)	60.5 kg
Body Surface Area (BSA)	1.82 m²
Body Mass Index (BMI)	30.8 kg/m²