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James, Martin

MRN: 304481

Room: 543

DOB: 05/06/1952

Age: 73

Gender: Male

Allergies: Bactrim (rash)

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	Patient is post-op following aortic and mitral valve replacement surgery.
Admission note taken on 10/17/25
CC	Heart failure
HPI	Patient was admitted to the hospital with symptoms of heart failure. He had surgery to replace the aortic and mitral valves. Three days post-op, purulent drainage was noted from the surgical site. Patient was diagnosed with bacteremia and mediastinitis and started on ceftazidime and gentamicin. SCr and BUN have increased over baseline and patient shows signs of volume overload. Patient has completed ceftazidime and needs a few more weeks of antibiotic therapy per ID. He now appears to have drug-induced renal failure from the gentamicin.
PMH	osteoarthritis hypertension atrial fibrillation
Social History	Retired coal miner Does not drink alcohol Does not use tobacco products Does not use illicit drugs	Family History	Mother - died of pneumonia at age 72 Father - died of diabetes at age 50
Vaccine History	Usual childhood vaccines Tdap 2 years ago Shingrix (2 doses) 6 years ago Flu last Fall COVID fully vaccinated and boosted	Surgical History	Not on file
Physical Exam	HEENT: PERRLA, EOMI. Patient wears glasses. Poor dentition. Neck: + JVD Lungs: basilar crackles, inspiratory wheezes Heart: S1 and S2 normal, no S3, irregular rhythm Abdomen: soft, nontender, + BS, - HSM Extremities: 2+ankle/sacral edema Neurological: A&O to person and place but not time

Clinical Laboratory Report

Test Name	10/19/25	10/18/25	10/17/25	Range
Sodium (Na⁺)	138	133	140	136-145 mEq/L
Potassium (K⁺)	3.9	3.8	3.8	3.5-5 mEq/L
Chloride (Cl^-)	104	101	101	98-106 mEq/L
Bicarbonate (HCO₃^-)	25	24	24	23-28 mEq/L
Urea nitrogen (BUN)	52	50	53	8-20 mg/dL
Creatinine	3.2	3.1	3.2	0.5-1.3 mg/dL
Glucose	130	128	133	70-115 mg/dL
Hemoglobin A1c			6.9	5.3-7.5 %
Calcium,Total	8.9	8.6	9	8.6-10.2 mg/dL
Phosphate	3.7	3.8	3.8	3-4.5 mg/dL
Magnesium	2.2	2.2	2.2	1.6-2.6 mEq/L
Protein, total	7.1	7.2	7	5.5-9 g/dL
Albumin	5.2	5.2	5.1	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	17	17	17	10-40 units/L
Aminotransferase,alanine (ALT)	23	22	22	10-40 units/L
Lactic dehydrogenase (LDH)	92	92	94	80-225 units/L
Alkaline phosphatase	67	67	64	30-120 units/L
Bilirubin, Total	0.5	0.5	0.5	0.3-1 mg/dL
Leukocytes (WBC)	9.9	10.1	9.9	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4	4	3.9	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	9.2	9	9	14-18 g/dL
Hematocrit, Male	28.5	28.8	29.1	42-50 %
Mean corpuscular hemoglobin (MCH)	32	31	32	27-33 picogram
Mean corpuscular volume (MCV)	80	82	77	76-100 mcm³
Platelets	263	265	265	150-450 x10³/mcL
International normalized ratio (INR)	0.9	0.9	0.9	0.8-1.2
Prothrombin time (PT)	9.1	9.4	8.9	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29	28	29	25-35 sec

Additional Labs:

Date	Intake	Output	Weight
3 days ago	3,200 mL	1,100 mL	77 kg
2 days ago	2,500 mL	1,050 mL	82 kg
yesterday	2,500 mL	1,250 mL	85 kg
today			87 kg

Cultures:

Blood cultures (x4): + Serratia marcescens

S to gentamicin
S to piperacillin/tazobactam
S to ceftazidime
S to levofloxacin
R to ampicillin

Repeat blood cultures came back negative today.

Imaging Studies:

None

Vital Sign	10/19/25 09:39	22:31	15:31	10/18/25 07:23	23:46	16:38	10/17/25 08:43	10/16/25 07:42
Height (cm)	178			178			178
Weight (kg)	87			85			82	77
Body Temperature (°C)	37.7	38.5	36.6	36.9	36.9	36.6	37.3
Blood Pressure (mmHg)	152 / 90	153/89	148/88	147/90	153/89	152/91	148/91	/
Heart Rate (bpm)	80	79	79	78	78	77	78
Respiratory Rate (bpm)	26	26	26	25	26	26	25
Oxygen Saturation (%)	98	97	96	98	99	98	97

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			Changed dose from 180 mg IV q24h 1 wk ago, and 240 mg IV q24h previously.

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			last dose received today; order discontinued

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			x2 days, discontinue tomorrow

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			check digoxin level

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-6)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (7-10)
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

Patient often confused on allergies.
According to PCP, patient has allergy to penicillin (rash 2 years ago) but no sulfa allergy - his father has this but he doesn’t.

Home Medication List: verified by pharmacy on admit (10/17/25)

Patient Name: James, Martin Date of Birth: 05/06/1952 Room#: 543	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Benazepril 40 mg tablet	1 PO QD	no
Digoxin 0.125 mg tablet	1 PO QD	no
Atorvastatin 40 mg tablet	1 PO QD	no
Senior Mens Multivitamin tablet	1 PO QD	no
Co-Q-10 100 mg capsule	1 PO QD	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25	10/18/25	10/17/25
Gentamicin 180 mg IV q48Hr Rate: 200 mL/hr			17:19
Ceftazidime 1,000 mg IV q12Hr Rate: 100 mL/hr	6:57 18:28	6:47 18:46	6:29 18:43
Lisinopril 40 mg PO q24Hr	8:30	8:25	8:33
Furosemide 80 mg PO q12Hr	8:42	8:41 20:41	8:34 20:40
Digoxin 0.125 mg PO q24Hr	8:40	8:26	8:24
Ibuprofen 400 mg PO q4Hr PRN PRN pain (1-6)
Hydromorphone 0.5 mg IV q4Hr PRN PRN pain (7-10) Rate: injection

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Gentamicin	180 mg q48Hr IV
Ceftazidime	1,000 mg q12Hr IV	switch to levofloxacin 500 mg PO q48Hr
Lisinopril	40 mg q24Hr PO	formulary substitution for benazepril
Furosemide	80 mg q12Hr PO
Digoxin	0.125 mg q24Hr PO
Hydromorphone	0.5 mg q4Hr IV PRN pain (7-10)
Ibuprofen	400 mg q4Hr IV PRN pain (1-6)	switch to APAP 650 mg q4h prn pain

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Benazepril	40 mg QD
Digoxin	0.125 mg QD
Atorvastatin	40 mg QD
Senior Mens Multivitamin	1 tablet QD
Co-Q-10	100 mg QD

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: James, Martin

Date of Birth: 05/06/1952

Room: 543

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	178 cm
Actual Body Weight (ABW)	87 kg
Ideal Body Weight (IBW)	73 kg
ABW % of IBW	119 %
Adjusted Body Weight (AjBW)	78.6 kg
Body Surface Area (BSA)	2.07 m²
Body Mass Index (BMI)	27.5 kg/m²