View Patient Profiles

Shanahan, Erin

MRN: 260114

Room: Exam #6

DOB: 4/19/1959

Age: 66

Gender: Female

Allergies: penicillin (hives), lovastatin (abdominal pain)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Outpatient Family Medicine Clinic
Scenario	You are rounding as part of the family medicine team. Patient presents to the family medicine clinic today for follow-up of a recent hospitalization for a left hip fracture.
Admission note taken on 10/19/25
CC	Hip pain and depression
HPI	ES presents to the family medicine clinic today for follow-up of a recent hospitalization for a left hip fracture. Her fracture occurred when she fell while walking her dog 6 weeks ago. She has had intermittent pain when ambulating (4 out of 10) in her left hip since then and has been feeling hopeless, extremely tired without being able to sleep, irritable, unwilling to participate in her normally pleasurable activities with friends and family (i.e., knitting group, women luncheons, writing), and has less interest in eating. She has not had thoughts of suicide and is able to perform activities of daily living well with walker. Just prior to her hip fracture, she was very active in several women's groups, writing a children's book, and volunteered at the local hospital.
PMH	Tobacco use x 46 years Mild-persistent asthma x 21 years Menopause x 15 years Major depression x 14 years Dyslipidemia x 6 years
Social History	Tobacco: 0.5 ppd x 46 years; recently quit - since hospitalization ETOH: occasional Illicit Drugs: none Caffeine: 3 cups coffee daily Occupation: retired; computer analyst Status: divorced Children: 2 daughters, 1 son; 1 grandchild Physical Activity: walked dog 3 miles daily and rode bicycle 30 minutes three times weekly until fracture occurred Diet: low sodium; eats out twice weekly	Family History	Father: MI at age 52, deceased - colon cancer at age 84 Mother: osteoporosis at age 75; deceased - pneumonia at age 87 Sister: age 68; alive, hypertension, osteoarthritis Brother 1: age 61; alive, hypertension, dyslipidemia Brother 2: deceased - MI at age 56
Vaccine History	None on file	Surgical History	Appendectomy (56 years ago) Open Reduction Internal Fixation - left hip (6 weeks ago)
Physical Exam	General: Healthy female appearing to be older than stated age and using a walker. SKIN: overall dry but intact HEENT: PERRLA, neck supple, thyroid palpated with no mass noted BREASTS: normal, patient performs self-breast examinations LUNGS: clear bilaterally with no wheezing, no rhonchi, no rales CARDIOVASCULAR: normal rate, rhythm, no gallops or murmurs noted ABDOMEN: normal GENITOURINARY: patient deferred RECTAL: patient deferred EXTREMITIES: no pitting edema, skin intact with no ulcerations, left hip ROM limited - 20°hip flexion with some pain (as expected with healing fracture) upon internal and external rotation, feet have appropriate sensation and blood flow NEUROLOGICAL: cranial nerves II - XII intact, deep tendon reflexes normal

Clinical Laboratory Report

Test Name	10/19/25	08/25/24	Range
Sodium (Na⁺)	137	144	136-145 mEq/L
Potassium (K⁺)	3.8	4.0	3.5-5 mEq/L
Chloride (Cl^-)	98	98	98-106 mEq/L
Bicarbonate (HCO₃^-)	26	24	23-28 mEq/L
Urea nitrogen (BUN)	15	12	8-20 mg/dL
Creatinine	0.9	0.8	0.5-1.3 mg/dL
Glucose	96	76	70-115 mg/dL
Hemoglobin A1c	5.4	5.0	5.3-7.5 %
Calcium,Total	9.3	9.1	8.6-10.2 mg/dL
Phosphate	4.1	4.3	3-4.5 mg/dL
Magnesium	1.9	2.0	1.6-2.6 mEq/L
Protein, total	6.4	6.6	5.5-9 g/dL
Albumin	3.9	4.2	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	28	22	10-40 units/L
Aminotransferase,alanine (ALT)	26	25	10-40 units/L
Lactic dehydrogenase (LDH)	88	92	80-225 units/L
Alkaline phosphatase	51	49	30-120 units/L
Bilirubin, Total	0.8	0.7	0.3-1 mg/dL
Leukocytes (WBC)	5.1	5.0	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.7	4.6	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	14.2	14.4	12-16 g/dL
Hematocrit, Female	44	45	37-47 %
Mean corpuscular hemoglobin (MCH)	28	30	27-33 picogram
Mean corpuscular volume (MCV)	89	87	76-100 mcm³
Platelets	324	322	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1.1	0.8-1.2
Prothrombin time (PT)	10.2	10.5	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	27.3	27.5	25-35 sec

Additional Labs:

Fasting	6 Months Ago	14 Months Ago	21 Months Ago
Total Cholesterol (mg/dL)	230	240	280
Triglycerides (mg/dL)	140	160	200
HDL-C (mg/dL)	49	52	58
LDL-C (mg/dL)	153	156	182

Other Tests	Today	6 Months Ago	21 Months Ago
Thyroid Stimulating Hormone		1.8	1.9
Hamilton Depression Scale (HAM-D)	20		7

Cultures:

None

Imaging Studies:

X-ray (6 weeks ago): Positive left hip (proximal femur) fracture

Central Bone Densitometry (DXA)	Today
T Score: Left Hip	-2.8
T Score: Lumbar Spine	-2.5

Vital Sign	10/19/25 09:36	08/25/24 07:27
Height (cm)	180	180
Weight (kg)	66	68
Body Temperature (°C)	37	37.2
Blood Pressure (mmHg)	138 / 86	118/84
Heart Rate (bpm)	75	70
Respiratory Rate (bpm)	16	18
Oxygen Saturation (%)	99	98

Current Orders

Medication
History

Patient is very compliant with medications and has minimal side effects, but had intolerance to lovastatin prior to switch to atorvastatin.
She stopped taking fluoxetine for 5 years because depressive symptoms improved. Restarted fluoxetine 20 mg daily 7 years ago while going through divorce with husband and decreased to 10 mg 5 years ago since doing well.
Patient was given oxycodone/acetaminophen PRN for pain while in the hospital after hip fracture. She has been taking acetaminophen only since discharge.
Medications have controlled asthma well for over 2 years as evidenced by albuterol use less than twice per month and vasomotor symptoms have been absent for the past 8 years with hormone therapy.

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

Patient Name: Shanahan, Erin Date of Birth: 4/19/1959 Room#: Exam #6	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
ProAir HFA 90 mcg/act oral inhaler	2 puffs PO Q4-6H	yes, SOB
Qvar RediHaler 40 mcg/act tablet	2 puffs PO BID	no
Premarin 0.625 mg tablet	1 PO QD	no
Medroxy-progesterone 2.5 mg tablet	1 PO QD	no
Fluoxetine 10 mg capsule	1 PO QD	no
Acetaminophen 500 mg caplet	1-2 PO TID	no
Flovent HFA 44 mcg/act oral inhaler	2 puffs PO BID	no
Atorvastatin 10 mg tablet	1 PO QD	no
Fish Oil 1,000 mg capsule	2 PO BID	no
Multivitamin w/ minerals tablet	1 PO QD	no
Nicotine 7 mg/day patch	1 TOP QD	no	has used for past 6 weeks
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication

10/19/25

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: Shanahan, Erin

Date of Birth: 4/19/1959

Room: Exam #6

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	180 cm
Actual Body Weight (ABW)	66 kg
Ideal Body Weight (IBW)	70.8 kg
ABW % of IBW	93 %
Adjusted Body Weight (AjBW)	68.9 kg
Body Surface Area (BSA)	1.82 m²
Body Mass Index (BMI)	20.4 kg/m²