| Woods, John |
| MRN: 307223 | Room: 317 | DOB: 08/16/1957 | Age: 68 | Gender: Male | Allergies: NKDA |
| Setting | Inpatient Renal Unit | ||
| Scenario | Patient admitted to hospital from the dialysis center where he developed low blood pressure during dialysis. | ||
| Admission note taken on 10/19/25 | |||
| CC | Patient has felt more tired than usual lately and blood pressure dropped during dialysis. | ||
| HPI | Patient presented to the outpatient dialysis center and was brought to the hospital after developing low blood pressure during dialysis. He has been on dialysis for almost a year, using a left forearm AV fistula. His renal failure is thought to be due to hypertension. | ||
| PMH |
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam |
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| Test Name | 10/19/25 | Range |
| Sodium (Na+) | 142 | 136-145 mEq/L |
| Potassium (K+) | 5.3 | 3.5-5 mEq/L |
| Chloride (Cl-) | 110 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 24 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 80 | 8-20 mg/dL |
| Creatinine | 6.2 | 0.5-1.3 mg/dL |
| Glucose | 85 | 70-115 mg/dL |
| Hemoglobin A1c | 7.2 | 5.3-7.5 % |
| Calcium,Total | 8.6 | 8.6-10.2 mg/dL |
| Phosphate | 6.5 | 3-4.5 mg/dL |
| Magnesium | 2.3 | 1.6-2.6 mEq/L |
| Protein, total | 5.6 | 5.5-9 g/dL |
| Albumin | 3.0 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 25 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 19 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 90 | 80-225 units/L |
| Alkaline phosphatase | 112 | 30-120 units/L |
| Bilirubin, Total | 0.35 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 6.9 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 3.4 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 10.3 | 14-18 g/dL |
| Hematocrit, Male | 30 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 31 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 82 | 76-100 mcm3 |
| Platelets | 210 | 150-450 x103/mcL |
| International normalized ratio (INR) | 0.9 | 0.8-1.2 |
| Prothrombin time (PT) | 9.8 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 32 | 25-35 sec |
| Additional Labs: | None |
| Cultures: | None |
| Imaging Studies: | None |
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| Medication History |
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| Patient Name: Woods, John Date of Birth: 08/16/1957 Room#: 317 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
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| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
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|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
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| Medication | 10/19/25 |
| Sodium Chloride 0.9% IV continuous Rate: 75 mL/hr | 8:59 |
| Midodrine 5 mg PO x1 STAT | 10:21 |
| Sertraline 50 mg PO q24Hr | |
| Enoxaparin 40 mg SQ q24Hr | 9:23 |
| Famotidine 20 mg PO q12Hr | 7:53 17:21 |
| Ondansetron 4 mg PO q4Hr PRN PRN nausea | |
| Acetaminophen 650 mg PO q6Hr PRN PRN pain (1-2) or fever 37.2-38.5°C |
| 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: Woods, John | Date of Birth: 08/16/1957 | Room: 317 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |