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Robinson, Baron

MRN: 285914

Room: 106

DOB: 4/5/1955

Age: 70

Gender: Male

Allergies: Penicillin (rash)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Neurology ICU
Scenario	The Neurology ICU team has consulted the pharmacist for recommendations regarding sepsis/antimicrobial therapy as well as any other suggestions regarding this critically ill patient.
Admission note taken on 10/18/25
CC	mental status changes afer seizure
HPI	BR presented to the ED 7 days ago with mental status changes after a fall. EEG showed that he had a grand mal seizure. He was emergently intubated for airway protection and placed on a ventilator. A chest X-ray was performed to confirm endotracheal tube placement and did not have signs of pneumonia. He was transferred to the Neurology ICU and diagnosed with a subarachnoid hemorrhage (SAH). Yesterday (hospital day #6) BR’s nurse noted that he had thick, copious secretions. Today (hospital day #7) BR spiked a fever to 39°C and has new leukocytosis. A chest X-ray reveals an infiltrate in the left lower lobe, and the team diagnoses him with pneumonia. His blood pressure drops precipitously and does not respond to fluid resuscitation with 4 L of normal saline and he was started on norepinephrine at 4 mcg/min.
PMH	CAD s/p MI (4 yr. ago) Hypertension Hyperlipidemia Chronic Renal Insufficiency DVT 2 months ago Depression
Social History	Tobacco: Denies ETOH: Occasional Illicit Drugs: Past history of occasional marijuana, last used >20 years ago Caffeine: Occasional Occupation: Retired Astronaut Status: Widowed Children: None Physical Activity: Moderate Diet: Nothing notable	Family History	Unknown
Vaccine History	Unknown	Surgical History	Unknown
Physical Exam	General: Elderly, obese man who is sedated on a ventilator Skin: Cool extremities with 2+ edema in lower extremities HEENT: PERRLA; pink conjuctiva Chest: decreased breath sounds and crackles on left side CV: tachycardic, +S1S2, no bruits Abd: Soft, non-distended; no masses or obvious tenderness Neuro: Limited by sedation; deep tendon reflexes normal; tested cranial nerves normal

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	10/13/25	Range
Sodium (Na⁺)	140	140	140	136-145 mEq/L
Potassium (K⁺)	4.2	4.2	3.9	3.5-5 mEq/L
Chloride (Cl^-)	100	100	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	24	21	23-28 mEq/L
Urea nitrogen (BUN)	45	42	27	8-20 mg/dL
Creatinine	2.6	2.3	1.5	0.5-1.3 mg/dL
Glucose	194	172	168	70-115 mg/dL
Hemoglobin A1c			9.2	5.3-7.5 %
Calcium,Total	9.6	9.9	9.4	8.6-10.2 mg/dL
Phosphate	3.6	3.5	3.4	3-4.5 mg/dL
Magnesium	1.9	1.9	2.1	1.6-2.6 mEq/L
Protein, total	5.7	5.7	5.9	5.5-9 g/dL
Albumin	2.9	2.8	2.9	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	54	34	34	10-40 units/L
Aminotransferase,alanine (ALT)	41	37	37	10-40 units/L
Lactic dehydrogenase (LDH)	178	176	182	80-225 units/L
Alkaline phosphatase	83	80	79	30-120 units/L
Bilirubin, Total	1.1	1.1	1.0	0.3-1 mg/dL
Leukocytes (WBC)	18.9	14.5	7.8	4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.5	3.5	3.6	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	10.9	11.5	11.4	14-18 g/dL
Hematocrit, Male	32.1	33.4	34.2	42-50 %
Mean corpuscular hemoglobin (MCH)	30	30	31	27-33 picogram
Mean corpuscular volume (MCV)	84	86	86	76-100 mcm³
Platelets	168	186	286	150-450 x10³/mcL
International normalized ratio (INR)	1.2	1.2	5.2	0.8-1.2
Prothrombin time (PT)	12	11.9	36	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	32	32	31	25-35 sec

Additional Labs:

Urinalysis	Result (HD#1)
Appearance	Clear, yellow
Specific gravity	1.017
Blood	Trace
Ketones	Trace
Leukocyte esterase	Trace
Nitrites	Negative
Protein	4+
Glucose	Trace
Yeast	2+
WBCs	0-4 per high powered field
RBCs	4-10 per high powered field

Cultures:

Results (HD#1)

Blood culture: 2/2 no growth
Urine culture: <10,000 GNRs

Imaging Studies:

EEG (HD#1)

showed seizure activity that has resolved

X-ray (HD#7)

Chest: Left lower lobe consolidation, Radiologist interpretation: probable pneumonia

Lower extremity Doppler (HD#7)

negative for DVT in both LEs

Procedures

Intubated and placed on ventilator upon admission (HD#1)
Externalized ventricular drain (ventriculostomy) placed (HD#1)
Nasogastric tube placed for tube feeds and medications and an IVC filter was placed (HD#5)

Vital Sign	10/19/25 08:43	22:39	16:59	10/18/25 07:36	10/13/25 08:12
Height (cm)	180			180	180
Weight (kg)	110			111	114
Body Temperature (°C)	38.4	37.4	38.6	37.8	37.2
Blood Pressure (mmHg)	84 / 44	84/43	83/43	81/43	93/61
Heart Rate (bpm)	120	123	118	122	111
Respiratory Rate (bpm)	24 (on ventilator)	24	24	23	22
Oxygen Saturation (%)	95	96	94	94	98

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?

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?
			PRN yes
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			BG 150-199: 1 unit, BG 200-249: 3 units, BG 250-299: 5 units, BG 300-349: 7 units, BG Over 350: 8 units

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

Medication
History

Compliance is unknown.

Home Medication List: verified by pharmacy on admit (10/18/25)

Patient Name: Robinson, Baron Date of Birth: 4/5/1955 Room#: 106	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	LAST DOSE (date/time)	ADVERSE EFFECTS	ADHERENCE	NOTES	MED REC ACTION
Amlodipine 5 mg tablet	1 PO QD	no	unknown 10/17/25	unknown	unknown	from pharmacy records (CVS #342)
Lisinopril 5 mg tablet	1 PO QD	no	unknown 10/17/25	unknown	unknown	from pharmacy records (CVS #342)
Warfarin 2.5 mg tablet	1 PO QD	no	unknown 10/17/25	unknown	unknown	from pharmacy records (CVS #342)
Simvastatin 20 mg tablet	1 PO QD	no	unknown 10/17/25	unknown	unknown	from pharmacy records (CVS #342)
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25
Propofol IV continuous Rate: 20 mcg/kg/min	07:48	07:28 19:12
Simvastatin 20 mg NG QD		20:31
Lansoprazole (SoluTab) 30 mg PO QD	08:20	08:45
Phenytoin 100 mg NG TID	08:22 12:29	08:14 12:19 20:32
Fluoxetine 20 mg NG QD	08:20	08:42
0.9% Sodium Chloride (NS) IV continuous Rate: 100 mL/hr	07:47
Norepinephrine 4 mcg/min IV continuous Rate: 1 mL/min	07:17
Promote® with fiber 80 mL/hr NG continuous	08:40	08:35
Insulin (regular) sliding scale IV PRN PRN yes Rate: injection
Phytonadione 10 mg IV QD Rate: injection
Phenytoin 1,000 mg IV STAT x1 Rate: 300 mL/hr

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: Robinson, Baron

Date of Birth: 4/5/1955

Room: 106

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	180 cm
Actual Body Weight (ABW)	110 kg
Ideal Body Weight (IBW)	75.3 kg
ABW % of IBW	146 %
Adjusted Body Weight (AjBW)	89.2 kg
Body Surface Area (BSA)	2.35 m²
Body Mass Index (BMI)	34 kg/m²