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Patel, Haresh

MRN: 308614

Room: 421

DOB: 08/2/1941

Age: 84

Gender: Male

Allergies: penicillins and cephalosporins (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 was admitted today from Jayhawk Sunset Acres nursing home.
Admission note taken on 10/19/25
CC	Patient with fever, shortness of breath, and cough was brought to the ED.
HPI	Patient is an 84-year-old male who was brought to the ED from the nursing home today. When the nursing aid went to get him for breakfast, he was unable to get out of bed. Patient had been complaining of a cough for a few days and had used the guaifenesin w/codeine cough syrup on the nursing home standing order, as well as acetaminophen for fever of 100.7°F.
PMH	Patient had COVID in 2020 at the same time as his wife. She died and he was unable to live independently after that. He recovered but remains unable to complete activities of daily living on his own so remained at the nursing home where he was sent for rehab following hospital DC post-COVID. hypertension arthritis
Social History	Retired pharmacist Widowed—wife died 2 years ago from COVID and he was unable to live alone after that Has 2 children and 5 grandchildren who live out of state but visit occasionally Does not smoke, drink alcohol, or use illicit drugs Drinks coffee or hot tea with meals Exercises by walking down the hall and participates in chair aerobics at NH	Family History	Mother - died of cancer at age 87 Father - died of old age at 92 3 siblings all in reasonable health for their age
Vaccine History	Tdap 3 yr ago Shingrix (2 doses) 5 years ago Flu last fall COVID (Moderna) Jan/Feb 2021 & 2 boosters	Surgical History	Not on file
Physical Exam	HEENT: PERRLA, EOMI, mucus membranes moist. Patient wears glasses and bilat hearing aids. Neck: supple without lymphadenopathy Lungs: labored breathing, coarse rhonchi throughout lungs, decreased breath sounds bilat in lower lung fields Heart: Tachycardia, regular rhythm Abdomen: nontender, + bowel sounds Extremities: pulses 2+ throughout, normal appearance Neurological: Knows name, disoriented to place and time. Cranial nerves II-XII are grossly intact. Able to follow commands.

Clinical Laboratory Report

Test Name	10/19/25	Range
Sodium (Na⁺)	140	136-145 mEq/L
Potassium (K⁺)	4.2	3.5-5 mEq/L
Chloride (Cl^-)	97	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	23-28 mEq/L
Urea nitrogen (BUN)	20	8-20 mg/dL
Creatinine	1.1	0.5-1.3 mg/dL
Glucose	111	70-115 mg/dL
Hemoglobin A1c	7.4	5.3-7.5 %
Calcium,Total	8.6	8.6-10.2 mg/dL
Phosphate	4.4	3-4.5 mg/dL
Magnesium	2.3	1.6-2.6 mEq/L
Protein, total	6.6	5.5-9 g/dL
Albumin	3.8	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	14	10-40 units/L
Aminotransferase,alanine (ALT)	12	10-40 units/L
Lactic dehydrogenase (LDH)	88	80-225 units/L
Alkaline phosphatase	108	30-120 units/L
Bilirubin, Total	0.3	0.3-1 mg/dL
Leukocytes (WBC)	12.3	4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.9	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	11	14-18 g/dL
Hematocrit, Male	34.5	42-50 %
Mean corpuscular hemoglobin (MCH)	31	27-33 picogram
Mean corpuscular volume (MCV)	82	76-100 mcm³
Platelets	422	150-450 x10³/mcL
International normalized ratio (INR)	1.0	0.8-1.2
Prothrombin time (PT)	9.6	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	25-35 sec

Additional Labs:	None
Cultures:	Blood and sputum cultures sent to lab, final C&S results expected in 2-5 days. Sputum Gram stain on admission: > 25 WBC/hpf < 10 epithelial cells/hpf 2+ gram + cocci 3+ gram - rods Blood Gram stain: negative for bacteria
Imaging Studies:	None

Vital Sign	10/19/25 09:16
Height (cm)	175
Weight (kg)	80
Body Temperature (°C)	39.1
Blood Pressure (mmHg)	146 / 91
Heart Rate (bpm)	126
Respiratory Rate (bpm)	32
Oxygen Saturation (%)	84

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

RATE
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			change to PO tomorrow

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			tapering schedule

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			GI prophylaxis

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
			DVT prophylaxis

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-2) or fever 37.2-38.5
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (4-6) or fever > 38.6
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

Not on file

Home Medication List: verified by pharmacy on admit (10/19/25)

Patient Name: Patel, Haresh Date of Birth: 08/2/1941 Room#: 421	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Felodipine 10 mg tablet	1 PO QD	no	for HTN
Albuterol 90 mcg/act inhaler	2 puffs PO q6Hr	yes, SOB post-COVID
Meloxicam 7.5 mg tablet	1 PO QD	no	for arthritis
Milk of Magnesia 400 mg/5 mL suspension	30 mL PO QD	yes, constipation
Senior adult multivitamin/mineral tablet	1 PO QD	no
Loratadine 10 mg tablet	1 PO QD	yes, allergies
Melatonin 3 mg tablet	1 PO HS	yes, sleep
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Sodium Chloride 0.9% IV continuous Rate: 55 mL/hr	8:36
Levofloxacin 750 mg IV q24Hr Rate: 100 mL/hr	8:33
Methylprednisolone sod succ 125 mg IV q6Hr Rate: push over 5 min	6:47 12:34 18:51
Pantoprazole 20 mg PO q24Hr	7:14
Albuterol/ipratropium 2.5/0.5 mg per 3 mL NEB q4Hr WA	6:40 10:25 14:26 18:19
Enoxaparin 40 mg SQ q24Hr	9:13
Acetaminophen 650 mg PO q6Hr PRN PRN pain (1-2) or fever 37.2-38.5
Ibuprofen 400 mg PO q6Hr PRN PRN pain (4-6) or fever > 38.6	09:34
Morphine 1 mg IV q6Hr PRN PRN pain (7-10) Rate: injection

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Sodium Chloride 0.9%	continuous infusion, 60 mL/hr
Levofloxacin	750 mg PO q24h
Methylprednisolone	125 mg IV daily	tapered dose—last dose on day of discharge
Pantoprazole	20 mg IV q24h	for GI prophylaxis in hospital
Acetaminophen	650 mg PO q6h prn	for fever or pain (changed instructions for NH)
Ibuprofen	400 mg PO q6h prn	For fever or moderate pain
Morphine	1 mg IV q6h prn	for severe pain
Albuterol/ ipratropium neb sol	2.5/0.5 mg in 3 ml via neb q4h while awake	change back to albuterol inhaler from NH
Enoxaparin	40 mg SQ daily	for DVT prophylaxis

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Felodipine	10 mg PO daily	for HTN
Albuterol inhaler	2 puffs PO q6h prn	for SOB post-COVID
Meloxicam	10 mg PO daily	for arthritis
Milk of Magnesia	30 mL PO daily prn	for constipation
Senior adult multivitamin/mineral	1 tablet PO daily
Loratadine	10 mg PO daily prn	for allergies
Melatonin	3 mg PO daily at HS prn	for sleep

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: Patel, Haresh

Date of Birth: 08/2/1941

Room: 421

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	175 cm
Actual Body Weight (ABW)	80 kg
Ideal Body Weight (IBW)	70.7 kg
ABW % of IBW	113 %
Adjusted Body Weight (AjBW)	74.4 kg
Body Surface Area (BSA)	1.97 m²
Body Mass Index (BMI)	26.1 kg/m²