View Patient Profiles

Shin, Jay

MRN: 311065

Room: 509

DOB: 4/7/1980

Age: 45

Gender: Male

Allergies: Not on file

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	A patient presents to the ED for blurry vision and chest tightness. Patient is diagnosed as being in a hypertensive crisis. The attending physician has asked that you meet with the patient to conduct a medication reconciliation.
Admission note taken on 10/19/25
CC	"I’m having trouble seeing and my chest feels tight."
HPI	JS is a 45yoAM who was admitted to the ED with a chief complaint of blurry vision and chest tightness due to feeling anxious. He describes “blurry vision” that has been happening off and on for the last few days. The chest tightness started yesterday and is mild, occurring when he would walk his dog outside and resolving with rest.
PMH	Not on file
Social History	Accountant Married for 20 years, 4 children Alcohol – infrequent (once or twice a month) Tobacco – 1 pack/day for 15 years	Family History	Father deceased (age 60 from 2nd heart attack) – HTN Mother deceased (age 65 from stroke) – HTN Sister in good health
Vaccine History	Not on file	Surgical History	None
Physical Exam	ROS: JS complains of vision trouble as mentioned above; no hearing problems. He complains of chest discomfort as mentioned above but denies palpitations and dizziness. He admits to becoming short of breath more easily in the last few weeks and has felt a loss of energy over this same time period, although he never has been very active. He denies nausea, vomiting, or abdominal pain. He denies any swelling in his extremities or weight gain. He denies any mental status changes. General: Moderate distress Skin: Normal tone and temperature, good turgor HEENT: PERRLA; EOMI; no hemorrhages, exudates, or papilledema Neck: Neck supple, no JVD, no bruits, no thyromegaly, or lymphadenopathy Chest: CTA bilaterally CV: RRR, no MRG, normal S1 and S2; no S3 or S4 Abd: Soft, NT/ND, no guarding, (+) BS, no abdominal bruits appreciated, liver span about 12 cm Ext: Normal ROM, no CCE, pulses 2+ radial; 1+ to 2+ in the rest of her upper and lower extremities Neuro: A & O × 3, CN II–XII intact, motor/sensory normal

Clinical Laboratory Report

Test Name	10/19/25	Range
Sodium (Na⁺)	140	136-145 mEq/L
Potassium (K⁺)	4.9	3.5-5 mEq/L
Chloride (Cl^-)	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	28	23-28 mEq/L
Urea nitrogen (BUN)	30	8-20 mg/dL
Creatinine	1.5	0.5-1.3 mg/dL
Glucose	109	70-115 mg/dL
Hemoglobin A1c	6.7	5.3-7.5 %
Calcium,Total	9.1	8.6-10.2 mg/dL
Phosphate	3.9	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)	27	10-40 units/L
Aminotransferase,alanine (ALT)	45	10-40 units/L
Lactic dehydrogenase (LDH)	89	80-225 units/L
Alkaline phosphatase	103	30-120 units/L
Bilirubin, Total	0.5	0.3-1 mg/dL
Leukocytes (WBC)	6.6	4.5-11 x10³/mcL
Red blood cells (RBC), Male	3.9	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	13.2	14-18 g/dL
Hematocrit, Male	43	42-50 %
Mean corpuscular hemoglobin (MCH)	31	27-33 picogram
Mean corpuscular volume (MCV)	85	76-100 mcm³
Platelets	222	150-450 x10³/mcL
International normalized ratio (INR)	1.1	0.8-1.2
Prothrombin time (PT)	9.7	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	30	25-35 sec

Additional Labs:

Lipid Panel (today)

TC (mg/dL) 284
HDL (mg/dL) 37
LDL (mg/dL) 191
TG (mg/dL) 280

Urinalysis (UA)

Specific Gravity, Urine: 1.016
pH, Urine: 5.8
Other: Negative for blood or protein

Other (today)

Troponin-I: Normal

Cultures:

None

Imaging Studies:

None

Vital Sign	10/19/25 07:35
Height (cm)	165
Weight (kg)	80
Body Temperature (°C)	37
Blood Pressure (mmHg)	199 / 132
Heart Rate (bpm)	74
Respiratory Rate (bpm)	24
Oxygen Saturation (%)	98

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			to start tomorrow

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

DRUG	DOSE	FREQ & TIME	PRN?
			PRN if SBP > 160
USE	START DATE	STOP DATE	NOTES
			Pharmacy to calculate dose and prepare.

Medication
History

Community Pharmacy Records: None, has not used a pharmacy in 6 months.

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

Patient Name: Shin, Jay Date of Birth: 4/7/1980 Room#: 509	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Lisinopril/HCTZ 20/12.5 mg tablet	1 PO QD	no
Atorvastatin 20 mg tablet	1 PO QD	no
Pseudoephedrine 120 mg ER tablet	1 PO BID	yes, congestion
Prilosec OTC 20 mg capsule	1 PO QD	yes, GERD






			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Pantoprazole 40 mg PO QD	08:21
Lorazepam 1 mg IV Stat, then q 30-60 min PRN PRN PRN anxiety	06:20 08:41
Labetalol 0.6 mg/kg IV Push q 10 min PRN PRN if SBP > 160

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Labetalol 0.6 mg/kg	IV push q 10 min PRN if SBP > 160	for hypertensive urgency
Pantoprazole	40 mg PO QD	for GERD prophylaxis
Lorazepam	1 mg IV p30-60 min PRN	for anxiety due to hypertensive urgency

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent
Atorvastatin	20 mg PO QD	for cholesterol
Lisinopril/HCTZ	20/12.5 mg PO QD	for hypertension
Pseudoephedrine	120 mg ER PO BID PRN congestion	discontinue due to elevating BP
Prilosec OTC	20 mg PO QD PRN GERD

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: Shin, Jay

Date of Birth: 4/7/1980

Room: 509

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	165 cm
Actual Body Weight (ABW)	80 kg
Ideal Body Weight (IBW)	61.5 kg
ABW % of IBW	130 %
Adjusted Body Weight (AjBW)	68.9 kg
Body Surface Area (BSA)	1.91 m²
Body Mass Index (BMI)	29.4 kg/m²