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Thompson, Jane

MRN: 309254

Room: 432

DOB: 08/12/1970

Age: 55

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	Patient was admitted yesterday from the ED with community-acquired pneumonia.
Admission note taken on 12/15/25
CC	Patient with fever, shortness of breath, and cough came to the ED.
HPI	Patient is a 55 year old woman with a 3 day history of worsening SOB, productive cough, fevers, chills, and right-sided pain. Patient states that her shortness of breath began about a week ago after delivering mail on a really hot, humid day. Since she didn’t get better, she went to an Urgent Care Clinic a few days later. They diagnosed her with a respiratory tract infection and prescribed Levofloxacin 750 mg PO daily x 5 days. She couldn’t afford to fill the prescription so has just been taking OTC acetaminophen and cough/cold medicine, but her symptoms keep getting worse. She started coughing up stuff a few days ago and has been feeling feverish with chills, but has not taken her temperature.
PMH	Hypertension x 15 years Diabetes Mellitus (type 2) x 10 years Asthma x 2 years
Social History	6th grade school teacher Married, one adult son (22 y/o) Alcohol use, 1-2 glasses of wine/week Denies tobacco/illicit drug use	Family History	Unknown, patient was adopted as a baby and did not know birth family
Vaccine History	Not on file	Surgical History	Gall bladder removed at age 26
Physical Exam	HEENT: PERRLA, EOMI, dry mucus membranes. Neck: No JVD; full range of motion, no neck stiffness, no masses or thyromegaly, no cervical lymphadenopathy Lungs: Tachypneic, labored breathing, coarse rhonchi throughout right lung fields; decreased breath sounds in right middle and right lower lung fields Heart: Tachycardic with regular rate and rhythm; no MRG Abdomen: NTND; + bowel sounds Extremities: No CCE; 5/5 grip strength, 2+ pulses bilat. Neurological: A&O x3; CN II-XII intact

Clinical Laboratory Report

Test Name	12/16/25	12/15/25	Range
Sodium (Na⁺)	141	139	136-145 mEq/L
Potassium (K⁺)	4.3	4.3	3.5-5 mEq/L
Chloride (Cl^-)	102	98	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	24	23-28 mEq/L
Urea nitrogen (BUN)	42	40	8-20 mg/dL
Creatinine	1.4	1.4	0.5-1.3 mg/dL
Glucose	295	297	70-115 mg/dL
Hemoglobin A1c		8.3	5.3-7.5 %
Calcium,Total	9.1	8.8	8.6-10.2 mg/dL
Phosphate	4.1	4	3-4.5 mg/dL
Magnesium	2.1	2.2	1.6-2.6 mEq/L
Protein, total	6.5	6.4	5.5-9 g/dL
Albumin	3.8	3.8	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	13	12	10-40 units/L
Aminotransferase,alanine (ALT)	10	10	10-40 units/L
Lactic dehydrogenase (LDH)	90	90	80-225 units/L
Alkaline phosphatase	115	113	30-120 units/L
Bilirubin, Total	0.4	0.4	0.3-1 mg/dL
Leukocytes (WBC)	23.1	22.6	4.5-11 x10³/mcL
Red blood cells (RBC), Female	3.8	3.8	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	12.1	12.1	12-16 g/dL
Hematocrit, Female	35	34.7	37-47 %
Mean corpuscular hemoglobin (MCH)	30	30	27-33 picogram
Mean corpuscular volume (MCV)	83	83	76-100 mcm³
Platelets	220	217	150-450 x10³/mcL
International normalized ratio (INR)	1.1	1.1	0.8-1.2
Prothrombin time (PT)	9.8	9.6	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	30	29	25-35 sec

Additional Labs:

None

Cultures:

Blood culture results expected in 3 more days—negative so far
Sputum culture today is + for Streptococcus pneumonia.

S to azithromycin (MIC < 1 mcg/ml)
S to penicillin (MIC < 2 mcg/ml)
S to ceftriaxone (MIC < 1 mcg/ml)
S to levofloxacin (MIC < 0.5 mcg/ml)
S to vancomycin (MIC < 1 mcg/ml)

Sputum Gram stain on admission:

> 25 WBC/hpf
< 10 epithelial cells/hpf
Many gram + cocci in pairs

Streptococcus pneumoniae urine antigen—positive
Legionella pneumophila urine antigen—negative

Imaging Studies:

Chest X-ray on admission shows right middle and lower lobe consolidated airspace disease, likely pneumonia. Left lung is clear. Heart size is normal.
CT on admission shows no axillary, mediastinal, or hilar lymphadenopathy. Heart size is normal. There is consolidation of the RLL and lateral segment of the middle lobe, with air bronchograms. No significant pleural effusions. Left lung is clear.

Vital Sign	12/16/25 09:49	22:16	15:25	12/15/25 09:16
Height (cm)	178			178
Weight (kg)	84			85
Body Temperature (°C)	37.3	39.9	39.1	39.5
Blood Pressure (mmHg)	129 / 80	151/85	158/84	155/85
Heart Rate (bpm)	82	127	127	127
Respiratory Rate (bpm)	20	31	32	32
Oxygen Saturation (%)	98	86	85	87

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

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

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

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN chest congestion
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN fever > 38.6
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-4) or fever < 38.6
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN shortness of breath
USE	START DATE	STOP DATE	NOTES

Medication
History

Not on file

Home Medication List: verified by pharmacy on admit (12/15/25)

Patient Name: Thompson, Jane Date of Birth: 08/12/1970 Room#: 432	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Benazepril 10 mg tablet	1 PO QD	no
HCTZ 25 mg tablet	1 PO QD	no
Vitamin C 500 mg tablet	1 PO QD	no
Acetaminophen 325 mg tablet	2 PO Q6H	yes, fever/ pain	has taken routinely for past 3 days
Generic 12 hr cough/cold medicine (guaifenesin, phenylephrine, acetaminophen, dextromethorphan) capsule	1 PO Q12H	yes, cough/ cold	has taken routinely for past 3 days
Zinc 50 mg caplet	1 PO QD	yes, cough/ cold	has taken routinely for past 3 days
Elderberry lozenges	1 PO PRN	yes, cough	has taken routinely for past 3 days
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	12/16/25	12/15/25
Sodium Chloride 0.9% IV continuous Rate: 60 mL/hr	8:59	8:46
Ceftriaxone 1 g IV q24Hr Rate: 100 mL/hr	9:58	9:34
Azithromycin 500 mg IV q24Hr Rate: 250 mL/hr	10:16	10:29
Methylprednisolone sod succ 125 mg IV q6Hr Rate: push over 5 min	3:56 9:58 15:19	3:44 9:14 15:31 21:33
Benazepril 20 mg PO q24Hr	9:20	9:55
Fluticasone/salmeterol Diskus 100 mcg/50 mcg/puff PO q8Hr	9:53 14:53	9:47 14:30 21:38
Guaifenesin 200 mg/10 mL PO q4Hr PRN PRN chest congestion
Ibuprofen 400 mg PO q6Hr PRN PRN fever > 38.6	08:29
Acetaminophen 650 mg PO q6Hr PRN PRN pain (1-4) or fever < 38.6
Albuterol/ipratropium 2.5/0.5 mg per 3 mL NEB q4Hr PRN PRN shortness of breath	8:23 14:17	8:58 14:44 19:53 23:53

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
Ceftriaxone	1 gram IV q24h
Azithromycin	500 mg IV q24h	change to 250 mg PO daily x5 more days
Lisinopril	10 mg PO q24h
Fluticasone/salmeterol Diskus	100 mcg/50 mcg/puff PO TID
Ibuprofen	400 mg PO q6h prn mild pain (1-4)
Acetaminophen	650 mg PO q6h prn fever
Guaifenesin	200 mg/10 mL PO q4h prn chest congestion

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Benazepril	10 mg PO daily
HCTZ	25 mg PO daily
12 hr couth/cold med (guaifenesin, phenylephrine, acetaminophen, dextromethorphan)	1 tablet PO BID	counsel not to use products with phenylephrine which can increase her blood pressure
Acetaminophen	650 mg PO q6h prn fever/ pain
Vitamin C	500 mg PO daily	may resume if symptoms return
Zinc	50 mg PO daily	may resume if symptoms return
Elderberry lozenges	1 lozenge PO prn cough	may resume if symptoms return

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: Thompson, Jane

Date of Birth: 08/12/1970

Room: 432

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	178 cm
Actual Body Weight (ABW)	84 kg
Ideal Body Weight (IBW)	68.5 kg
ABW % of IBW	123 %
Adjusted Body Weight (AjBW)	74.7 kg
Body Surface Area (BSA)	2.04 m²
Body Mass Index (BMI)	26.5 kg/m²