View Patient Profiles

Chavez, Jesus

MRN: 312849

Room: 338

DOB: 1/5/1958

Age: 67

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 presented to the ED complaining of a sore and swollen foot.
Admission note taken on 10/19/25
CC	"My big toe is swollen, painful and I cannot put on my shoe."
HPI	JC is a 67yo Hispanic male experiencing significant pain in the right big toe. Five days ago, he stepped on a piece of metal and later noticed redness and soreness in the area, which increased over the next several days. Pain is described as an 8 out of 10. There was a purulent foul-swelling drainage expressed from the toe wound.
PMH	Not on file
Social History	Garbage collector Married, one adult daughter (42 y/o) Alcohol use, 4 - 5 12oz beers/day x multiple years Denies tobacco/illicit drug use	Family History	Father is deceased (56 y/o) secondary to MI, type 2 DM, HTN Mother is deceased (41 y/o) secondary to breast cancer
Vaccine History	Not on file	Surgical History	None
Physical Exam	General: NAD, alert, A&O x3 Skin: Warm, coarse, and very dry HEENT: PERRLA, EOMI; funduscopic exam is normal with absence of hemorrhages or exudates. Neck: Neck is supple; normal thyroid; no JVD, no LAD Chest: CTA bilaterally, no wheezes, crackles or rhonchi CV: RRR, no MRG, normal S1 and S2; no S3 or S4 Abd: (+) BS, no guarding, no hepatosplenomegaly or masses felt Ext: 2+ edema with markedly diminished sensation of the right foot. Cellulitis with abscess on right toe; erythema and warm. Pedal pulses present but diminished. Normal range of motion. Poor nail care with some fungus and overgrown toenails.

Clinical Laboratory Report

Test Name	10/19/25	Range
Sodium (Na⁺)	133	136-145 mEq/L
Potassium (K⁺)	5.9	3.5-5 mEq/L
Chloride (Cl^-)	98	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	23-28 mEq/L
Urea nitrogen (BUN)	21	8-20 mg/dL
Creatinine	1.1	0.5-1.3 mg/dL
Glucose	121	70-115 mg/dL
Hemoglobin A1c	6.3	5.3-7.5 %
Calcium,Total	8.2	8.6-10.2 mg/dL
Phosphate	4.3	3-4.5 mg/dL
Magnesium	2.2	1.6-2.6 mEq/L
Protein, total	6.3	5.5-9 g/dL
Albumin	3.6	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	14	10-40 units/L
Aminotransferase,alanine (ALT)	11	10-40 units/L
Lactic dehydrogenase (LDH)	91	80-225 units/L
Alkaline phosphatase	113	30-120 units/L
Bilirubin, Total	0.4	0.3-1 mg/dL
Leukocytes (WBC)	16.4	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.5	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	12.6	14-18 g/dL
Hematocrit, Male	37.8	42-50 %
Mean corpuscular hemoglobin (MCH)	31	27-33 picogram
Mean corpuscular volume (MCV)	82	76-100 mcm³
Platelets	390	150-450 x10³/mcL
International normalized ratio (INR)	1.0	0.8-1.2
Prothrombin time (PT)	9.9	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29	25-35 sec

Additional Labs:

CBC (today)

PMNs (%) 71
Bands (%) 8
Lymphs (%) 15
Monos (%) 6

Lipid Panel (today)

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

Cultures:

Staphylococcus aureus

Vancomycin – S (Susceptible)
Methicillin – R (Resistant)
TMP/SMX – S (Susceptible)
Doxycycline - S (Susceptible)

Imaging Studies:

None

Vital Sign	10/19/25 07:29
Height (cm)	178
Weight (kg)	60
Body Temperature (°C)	38.4
Blood Pressure (mmHg)	122 / 76
Heart Rate (bpm)	92
Respiratory Rate (bpm)	20
Oxygen Saturation (%)	99

Current Orders

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?

USE	START DATE	STOP DATE	NOTES

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

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

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (5-10)
USE	START DATE	STOP DATE	NOTES

Medication
History

Community Pharmacy Records

Rx Fill Date	Medication	Dose	SIG	Quantity	Day Supply
6 weeks ago	Benazepril	5 mg	1 po Q daily	90	90
6 weeks ago	Fexofenadine	60 mg	1 po twice daily	180	90
6 weeks ago	Citalopram	20 mg	1 po Q daily	90	90

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

Patient Name: Chavez, Jesus Date of Birth: 1/5/1958 Room#: 338	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Benazepril 5 mg tablet	1 PO QD	no
HCTZ 25 mg tablet	1 PO QD	no








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

Medication	10/19/25
Vancomycin 1 g IV BID	08:43
Aspirin 81 mg PO QD	08:23
Rosuvastatin 20 mg PO QD	08:44
Furosemide 20 mg IV QD PRN PRN for edema	08:37
Acetaminophen 1,000 mg PO q6Hr PRN PRN pain (1-4)
Hydrocodone/APAP 5/325 mg PO q6Hr PRN PRN pain (5-10)	08:27

Clinical Notes

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

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: Chavez, Jesus

Date of Birth: 1/5/1958

Room: 338

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	178 cm
Actual Body Weight (ABW)	60 kg
Ideal Body Weight (IBW)	73 kg
ABW % of IBW	82 %
Adjusted Body Weight (AjBW)	67.8 kg
Body Surface Area (BSA)	1.72 m²
Body Mass Index (BMI)	18.9 kg/m²