| Pentz, Carolina |
| MRN: 303972 | Room: 324 | DOB: 05/06/1991 | Age: 34 | Gender: Female | Allergies: Aspirin (upset stomach) |
| Setting | Adult Medicine Unit | ||
| Scenario | Patient admitted to hospital due to increased pain and fatigue. | ||
| Admission note taken on 10/20/25 | |||
| CC | I feel tired all the time and am in pain all over. | ||
| HPI | Patient has increased fatigue resulting in difficulty performing her job and activities of daily living. She also has increased pain and has been taking OTC ibuprofen for arthralgias. She was diagnosed with drug-induced Lupus. | ||
| PMH |
|
||
| Social History |
|
Family History |
|
| Vaccine History |
|
Surgical History |
|
| Physical Exam |
|
||
| Test Name | 10/19/25 | Range |
| Sodium (Na+) | 142 | 136-145 mEq/L |
| Potassium (K+) | 4.9 | 3.5-5 mEq/L |
| Chloride (Cl-) | 105 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 25 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 30 | 8-20 mg/dL |
| Creatinine | 1.5 | 0.5-1.3 mg/dL |
| Glucose | 88 | 70-115 mg/dL |
| Hemoglobin A1c | 6.9 | 5.3-7.5 % |
| Calcium,Total | 9.1 | 8.6-10.2 mg/dL |
| Phosphate | 3.8 | 3-4.5 mg/dL |
| Magnesium | 1.9 | 1.6-2.6 mEq/L |
| Protein, total | 7.5 | 5.5-9 g/dL |
| Albumin | 4.9 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 15 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 13 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 90 | 80-225 units/L |
| Alkaline phosphatase | 69 | 30-120 units/L |
| Bilirubin, Total | 0.6 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 7.2 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Female | 4.1 | 4.3-5.7 x108/mcL |
| Hemoglobin, Female | 10 | 12-16 g/dL |
| Hematocrit, Female | 30 | 37-47 % |
| Mean corpuscular hemoglobin (MCH) | 28 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 82 | 76-100 mcm3 |
| Platelets | 250 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.0 | 0.8-1.2 |
| Prothrombin time (PT) | 9.7 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 31 | 25-35 sec |
| Additional Labs: | Uric Acid (today): 88 mg/dL |
| Cultures: | Blood cultures: not done. Urine Analysis (today): all results normal. |
| Imaging Studies: | None |
| ||||||||||||||||||
| Medication History |
|
| Patient Name: Pentz, Carolina Date of Birth: 05/06/1991 Room#: 324 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
|
| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
|||
|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
||||||||
| Medication | 10/19/25 |
| Sodium Chloride 0.9% 60 mL/hr IV continuous infusion | |
| Acetaminophen 1,000 mg PO q6Hr PRN PRN pain (1-3) | |
| Ketorolac 30 mg IV q6Hr PRN PRN pain (4-6) Rate: injection | |
| Hydromorphone 1 mg IV q4Hr PRN PRN pain (7-10) Rate: injection |
| Hospital Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Previous Home Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| 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 | |||||
| Patient Name: Pentz, Carolina | Date of Birth: 05/06/1991 | Room: 324 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |