View Patient Profiles

Cook, Savana

MRN: 292215

Room: 408

DOB: 12/17/1989

Age: 36

Gender: Female

Allergies: NKDA

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	Today, you are on rounds with the Internal Medicine team outside the patient’s room. Dr Graham, the attending physician, has diagnosed this patient with Pneumocystis jirovecii pneumonia and esophageal candidiasis. Dr Graham believes SC’s pneumonia is improving. SC will not be started on antiretroviral medications at this time. Nurse Jones steps out of the patient’s room and informs the team that the patient has become increasingly anxious overnight. Dr Graham would like recommendations from the pharmacist for SC.
Admission note taken on 10/18/25
CC	Cough and chills and panic-like agitation
HPI	SC presented to the emergency department yesterday with a cc of cough and chills and panic-like agitation. She was also experiencing moderate hand tremor, diaphoresis, nausea and itching with a sensation of bugs crawling on her skin. She has known HIV disease but is currently not on prophylaxis or antiretroviral therapy. Two weeks prior to admission she began to note the onset of a dry, nonproductive cough, intermittent chills, anorexia, and then progressive exertional dyspnea. She also complains of severe mouth and throat pain, as such she refuses to eat or drink. She was admitted her to the general medicine service, from the emergency department, for further inpatient management.
PMH	HIV diagnosed 3 years ago AIDS Hepatitis C Alcohol withdrawal related “seizures,” twice (3 and 1 year ago) Polysubstance abuse Gravida 4 Para 0
Social History	Tobacco: denies ETOH: drinks approximately twelve 12 oz cans of beer per day, she reports that she has not had any beer in the 12 hours before presenting to the emergency department due to severe mouth and throat pain and difficulty swallowing. Illicit Drugs: Past history of occasional marijuana, last used about 2 weeks ago; crack cocaine, last used about 1 month ago Caffeine: denies Occupation: unemployed Status: divorced/has boyfriend who is HIV negative (last HIV test 1 month ago). Children: None (states she can not afford her birth control) Physical Activity: denies Diet: Nothing notable	Family History	Unknown
Vaccine History	Unknown	Surgical History	None
Physical Exam	General: Thin female in acute distress with shortness of breath and obvious agitation Skin: Moist; no lesions, tumors or moles; no palmar erythema HEENT: Normocephalic; atraumatic; deferred remainder of exam due to agitation; sclerae are anicteric Chest: Tachypneic, labored breathing; decreased breath sounds in the right middle lung field CV: Regular rhythm; tachycardic; no murmurs, gallops, or rubs Abd: Soft, tender to palpation, moderately distended; (+) bowel sounds; liver span enlarged at 2 cm below right costal margin; no splenomegaly; no spider angiomata Ext: Moves all extremities; (+) tremor in both hands

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	Range
Sodium (Na⁺)	138	136	136-145 mEq/L
Potassium (K⁺)	3.6	3.5	3.5-5 mEq/L
Chloride (Cl^-)	104	103	98-106 mEq/L
Bicarbonate (HCO₃^-)	27	24	23-28 mEq/L
Urea nitrogen (BUN)	5	4	8-20 mg/dL
Creatinine	0.9	0.8	0.5-1.3 mg/dL
Glucose	109	143	70-115 mg/dL
Hemoglobin A1c		7.1	5.3-7.5 %
Calcium,Total	8.3	8.4	8.6-10.2 mg/dL
Phosphate	2.3	0.9	3-4.5 mg/dL
Magnesium	0.93	2.0	1.6-2.6 mEq/L
Protein, total	7.1	7.0	5.5-9 g/dL
Albumin	2.7	3.1	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	128	158	10-40 units/L
Aminotransferase,alanine (ALT)	124	113	10-40 units/L
Lactic dehydrogenase (LDH)	455	460	80-225 units/L
Alkaline phosphatase	206	205	30-120 units/L
Bilirubin, Total	0.4	0.5	0.3-1 mg/dL
Leukocytes (WBC)	3.0	3.4	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.1	4.2	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	10.4	10.0	12-16 g/dL
Hematocrit, Female	29.7	28.6	37-47 %
Mean corpuscular hemoglobin (MCH)	28	27	27-33 picogram
Mean corpuscular volume (MCV)	88	86	76-100 mcm³
Platelets	240	260	150-450 x10³/mcL
International normalized ratio (INR)	1.0	0.9	0.8-1.2
Prothrombin time (PT)	10.2	10.5	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29.6	29	25-35 sec

Additional Labs:

Immunology	Result (today)
Hep A	Reactive
Hep B Surface Ag	Nonreactive
Hep B Core Total Ab	Nonreactive
Hep C Virus Ab, Riba 3.0	Positive
HIV 1 RNA	3,531,673 copies/mL
CD4	2 cells/mm3
PPD	Pending

Urine Drug Screen	Result (today)
Amphetamines	Negative
Barbiturates	Negative
Benzodiazepines	Positive
Cocaine	Negative
Marijuana	Positive
Opiates	Negative

CBC	Result (yesterday)
Neut (%)	87
Lymph (%)	2
Mono (%)	3
Bands (%)	8
Eos (%)	0
Baso (%)	0

ABG	Result (yesterday)
pH	7.45
PaCO2 mmHg	35
PaO2 mmHg	65
HCO3 mmol/L	24

Other (yesterday)

β hCG negative
Blood alcohol (mg/dL) 200

Cultures:

Results (today)

Blood Culture X2 No Growth
AFB Smear X 3 No Growth
AFB Culture No Growth
Fungus Culture No Growth
Stool Culture No Growth
Sputum Gram Smear: <10 epithelial cell seen/LPF; <10 PMN/LPF, 1+ Gram Positive Cocci; 2+ Gram Positive Rods, 1+ Gram Negative Rods, 1+ Yeast
Pneumocystis DFA Stain 1+ Pneumocystis jirovecii

Imaging Studies:

Chest X-ray (taken in emergency department yesterday)

Reading: diffuse interstitial hilar infiltrates with ground glass appearance most prominent in the right mid lung field
Interpretation: consistent with Pneumocystis jirovecii pneumonia

Vital Sign	10/19/25 09:53	22:38	16:37	10/18/25 07:13
Height (cm)	163			163
Weight (kg)	54			54
Body Temperature (°C)	37.2	37.8	38.6	39
Blood Pressure (mmHg)	165 / 92	171/95	171/95	170/95
Heart Rate (bpm)	120	127	130	130
Respiratory Rate (bpm)	26	26	26	26
Oxygen Saturation (%)	92	85	85	84

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?

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?
			PRN yes, SOB
USE	START DATE	STOP DATE	NOTES

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

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, anxiety
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, nausea
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

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

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, pain (1-4)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN yes, pain (5-10)
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

Medication
History

Patient is non-adherent with medicine at home. She has a prescription for Yaz (drospirinone/ethinyl estradiol) at home but can not afford this medicine, and thus does not take it.

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

Patient Name: Cook, Savana Date of Birth: 12/17/1989 Room#: 408	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	MED REC REASON
Yaz 3 mg/0.02 mg tablet	1 PO QD	no			does not take	never picked up from pharmacy, can not afford
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25
Ceftriaxone 1 g IV QD Rate: 100 mL/hr	09:27
Azithromycin 500 mg PO QD	09:38
Trimethoprim/Sulfamethoxazole 160 mg/800 mg PO BID	08:58
Nystatin suspension 500,000 units PO TID	08:23 12:21
Enoxaparin 40 mg Subcut QD	08:54
Omeprazole 20 mg PO QD	09:10
Multivitamin 1 tab PO QD	09:24
Drospirenone/ethinyl estradiol 3 mg/0.02 mg PO QD	09:32
Ipratropium bromide 34 mcg (2 puffs) INH Q4H PRN PRN yes, SOB	09:58 14:47
Albuterol sulfate 216 mcg (2 puffs) INH Q4H PRN PRN yes, SOB	09:47 14:31 19:13
Lorazepam 1 mg PO QID PRN PRN yes, anxiety
Ondansetron 4 mg IV QID PRN PRN yes, nausea Rate: injection
Ondansetron 4 mg PO QID PRN PRN yes, nausea
Acetaminophen 650 mg PO Q4H PRN PRN yes, pain (1-4)
Hydrocodone/APAP 5 mg/325 mg PO Q4H PRN PRN yes, pain (5-10)
Lorazepam 1 mg IV STAT x1 Rate: injection	04:14
Lorazepam 1 mg PO STAT x1		22:26
Tuberculin PPD 0.1 mL ID STAT x1		22:47

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Lorazepam tablet	1 mg PO QID prn	For anxiety
Ceftriaxone injection	1 gram IV daily	Infuse over 30 min
Azithromycin tablet	500 mg PO daily
Trimethoprim/sulfamethoxazole injection	256/1280 mg IV q6h	Dose increased from original order. Change back to PO equivalent dose on discharge
Prednisone tablet	20 mg PO daily	For 10 more days
Nystatin suspension	500,000 units PO TID
Enoxaparin injection	40 units SC daily
Omeprazole capsule	20 mg PO daily	For stress ulcer prophylaxis
Multivitamin tablet	1 tablet PO daily	For vitamin supplement
Drospirenone/ethinyl estradiol tablet	3/0.02 mg PO daily	Formulary substitution
Ipratropium inhaler	34 mcg (2 puffs) by mouth q4h prn	For shortness of breath
Albuterol inhaler	216 mcg (2 puffs) PO q4h prn	For shortness of breath
Ondansetron tablet	4 mg PO QID prn	For nausea
Acetaminophen tablet	650 mg PO q4h prn	For pain
Hydrocodone/APAP tablet	5/325 mg PO q4h prn	For severe pain

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Yaz	1 tablet PO daily	For birth control

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: Cook, Savana

Date of Birth: 12/17/1989

Room: 408

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	163 cm
Actual Body Weight (ABW)	54 kg
Ideal Body Weight (IBW)	54.7 kg
ABW % of IBW	99 %
Adjusted Body Weight (AjBW)	54.4 kg
Body Surface Area (BSA)	1.56 m²
Body Mass Index (BMI)	20.3 kg/m²