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Stone, Mitchel

MRN: 420798

Room: 805

DOB: 3/21/1939

Age: 86

Gender: Male

Allergies: Sulfamethoxazole/trimethoprim (hives)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Medical ICU (MICU)
Scenario	Mr. Stone is admitted directly to the medical ICU. His clinical status continues to worsen despite an IV fluid bolus and being placed on high flow nasal cannula prior to arrival. The team is preparing to intubate the patient and place an orogastric tube post intubation. Of note, Mr. Stone has limited line access consisting of two peripheral lines. Mr. Stone has pending orders to place a central line and an arterial line. While Mr. Stone is undergoing rapid sequence intubation, using hospitalized protocols for medication selection and dosing, the intern asks you to review Mr. Stone’s case and make recommendations regarding his ongoing acute hospital problems, as well as any additional areas of optimization you may find regarding his past medical history.
Admission note taken on 10/19/25
CC	“I am here to check-in for my hernia repair.”
HPI	Mr. Stone was transferred from Saint’s Community Hospital to Regional Academic Medical Center intensive care unit due to acute decompensation. Mr. Stone presented to Saint’s Community Hospital 3 days ago for an elective inguinal hernia repair. During Mr. Stone’s hernia repair, he became hypotensive requiring fluid administration, vasopressor therapy for 6 hours, and subsequent admission for observation. After being hemodynamically stable and having an unremarkable observation period, Mr. Stone was to be discharged today. See Clinical Notes for summary. Over the past 12 hours Mr. Stone has become increasingly short of breath and has notable sputum production. Of note, Mr. Stone was admitted to Saint’s Community Hospital two months ago for a COPD exacerbation. Saint’s Community Hospital is not affiliated with Regional Academic Medical Center, therefore details regarding his hospitalizations are limited to the transfer summary information that arrived with Mr. Stone.
PMH	COPD (mMRC 1, CAT 8 from clinic visit 2 months ago) Hypertension Type 2 diabetes Depression Inguinal hernia
Social History	Alcohol: Social drinker Tobacco: Active smoker, smokes ½ pack per day for 40 years Illicit drugs: None Employment: Retired construction worker Marital status: Married, one child	Family History	Father died of colon cancer (75 years old) Mother died of a stroke (67 years old)
Vaccine History	Received all childhood and adolescent vaccines up to age 18 Tdap (2 years ago) Zostavax (20 years ago)	Surgical History	None
Physical Exam	ROS: Positive, for productive cough General: Ill appearing overweight male in respiratory distress, using accessory muscles to breath HEENT: PERRLA Chest: Breath sounds diminished at the bases, positive rales and rhonchi bilaterally Cardiovascular: Tachycardic, normal sinus rhythm Abdomen: Positive bowel sounds Genitourinary: WNL Extremities: Cool to touch Neuro: AO x 3 Psych: Normal

Clinical Laboratory Report

Test Name	10/19/25	08/20/25	Range
Sodium (Na⁺)	138	140	136-145 mEq/L
Potassium (K⁺)	4.3	4.1	3.5-5 mEq/L
Chloride (Cl^-)	120	100	98-106 mEq/L
Bicarbonate (HCO₃^-)	28	15	23-28 mEq/L
Urea nitrogen (BUN)	18	12	8-20 mg/dL
Creatinine	2.3	1.1	0.5-1.3 mg/dL
Glucose	250	185	70-115 mg/dL
Hemoglobin A1c	12	11	5.3-7.5 %
Calcium,Total	8.7		8.6-10.2 mg/dL
Phosphate	2.4		3-4.5 mg/dL
Magnesium	2.4		1.6-2.6 mEq/L
Protein, total	6.2		5.5-9 g/dL
Albumin	4.5		3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	48		10-40 units/L
Aminotransferase,alanine (ALT)	37		10-40 units/L
Lactic dehydrogenase (LDH)			80-225 units/L
Alkaline phosphatase			30-120 units/L
Bilirubin, Total	1.1		0.3-1 mg/dL
Leukocytes (WBC)	18.5	6.1	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.4		3.8-5.1 x10⁸/mcL
Hemoglobin, Male	12.7	13.8	14-18 g/dL
Hematocrit, Male	38	41	42-50 %
Mean corpuscular hemoglobin (MCH)			27-33 picogram
Mean corpuscular volume (MCV)			76-100 mcm³
Platelets	250	320	150-450 x10³/mcL
International normalized ratio (INR)	1.1		0.8-1.2
Prothrombin time (PT)	11.4		9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	34		25-35 sec

Additional Labs:

Other Labs	Date	Result
Lactate (mmol/L)	Today (05:00)	3.2
Lactate (mmol/L)	Today (09:00)	4

Arterial Blood Gas (Today, 09:00)	Result
pH	7.2
PaCO₂ (mmHg)	50
HCO₃^- (mEq/L)	20
PaO₂ (mmHg)	65
SaO₂ (%)	80

Urinalysis (Today, 05:00)	Result
Specific Gravity	1.026
Color	Yellow
Leukocyte Esterase	Negative
Nitrite	Negative
Protein	100 mg/dL
Glucose	Negative
Ketone	Negative
Hemoglobin	Negative
pH	5.0
WBC per high-power field	2

Cultures:

Microbiology	Date	Result
Saint’s Community Hospital Expectorated sputum culture	Today	Gram stain: Many squamous epithelial cells seen Many Neutrophils seen Few Gram Positive Cocci in clusters seen Culture: Final results pending
Blood cultures x2	Today	Pending
SARS-CoV-2 PCR Cellex qSARS-CoV-2 IgG/IgM Rapid Test	Today	PCR: Not Detected IgG: Negative IgM: Negative
MRSA Nasal PCR	Today	Pending
Viral PCR Panel	Today	Pending

Imaging Studies:

Test	Date	Result
Chest X-ray Impression	Today	1. Pulmonary vascular congestion with small effusions 2. Left lower lobe consolidation, consistent with pneumonia

Vital Sign	10/19/25 07:43	08/20/25 08:57
Height (cm)	177.8	177.8
Weight (kg)	95.5	95
Body Temperature (°C)	38.4	37
Blood Pressure (mmHg)	70 / 40	128/85
Heart Rate (bpm)	100	84
Respiratory Rate (bpm)	25	14
Oxygen Saturation (%)	80	97

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			formulary substitution for lisinopril

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
			< 151 mg/dL give none; 151-200 mg/dL give 1 unit; 201-250 mg/dL give 2 units; 251-300 mg/dL give 3 units; 301-350 mg/dL give 4 units; 351-400 mg/dL give 5 units.

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?

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN SOB/wheezing
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN hypoglycemia
CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

Mr. Stone states that he has a pill organizer to manage his medications. He claims to never miss doses since starting to use the organizer.
Mr. Stone does admit that he was never good at managing his diabetes. He states he “just never understood why he needed to watch his sugars.”
The admitting physician verbally confirmed with Mr. Stone that he is no longer taking metformin.

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

Patient Name: Stone, Mitchel Date of Birth: 3/21/1939 Room#: 805	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	MED REC ACTION
Albuterol Sulfate 108 mcg/puff HFA inhaler	2 puffs PO Q4H	yes, SOB
Bupropion XL 150 mg tablet	1 PO QD	no
Escitalopram 20 mg tablet	1 PO QD	no
Famotidine 20 mg tablet	1 PO QD	no
Lisinopril 20 mg tablet	1 PO QD	no
Metformin 1,000 mg tablet	1 PO BID	no
Pantoprazole 40 mg DR tablet	1 PO QD	no
Prednisone 10 mg tablet	1 PO QD	no
Sitagliptin 100 mg tablet	1 PO QD	no
			Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/19/25
Bupropion XL 150 mg PO QD	9:23
Enalapril 5 mg PO QD	9:15
Escitalopram 20 mg PO QD	9:52
Famotidine 20 mg PO QD	9:51
Insulin, lispro 100 unit/mL SLIDING SCALE SC Q4H	8:10 12:31 16:58
Metformin 1,000 mg PO BID	9:59
Pantoprazole DR 40 mg PO QD	9:37
Prednisone 10 mg PO QD	9:55
Sitagliptin 100 mg PO QD	9:46
Albuterol Sulfate 108 mcg/puff 2 puffs PO Q4H PRN PRN SOB/wheezing
Dextrose 50% 25 g IV Q 30 MIN PRN PRN hypoglycemia Rate: 500 mg/kg/hr

Clinical Notes

TODAY at 8:45 am
-----------------
General Surgery Note - Saint’s Community Hospital

24 Hour events:
New sputum production that is purulent, green, and thick in nature. 
Worsening respiratory status is of concern. Now requiring oxygen, which is new from baseline. Notably hypotensive as well.

Current Vitals:
HR: 105 bpm
RR: 20 breaths/min
O2 Saturation: 87% on 4L NC
BP: 80/50 mmHg
Temp: 38.2°C

Current Medications:
3,000 mL IV bolus 0.9% sodium chloride (completed 8:30am)
Acetaminophen 500 mg PO every 4 hours PRN mild pain
Albuterol HFA 90 mcg/actuation 2 puffs every 4 hours shortness of breath, wheezing
Oxycodone 5 mg PO every 4 hours PRN moderate pain
Prednisone 10 mg PO daily

Assessment/Plan:
- Hypotensive this morning. Received fluid bolus. Appeared to have minimal to no impact on blood pressure.
- Worsening respiratory status. Titrate oxygen as needed. Sputum culture sent. No blood cultures sent at this time. Intubation may be imminent. Will prepare patient for transfer to Regional Academic Medical Center for higher level of care.
- Hernia repair appears to be healing well. No abdominal pain, nausea, vomiting, or diarrhea. Follow up with outpatient clinic in 2 weeks. Weight lifting restrictions should be followed for the next 7 days.

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: Stone, Mitchel

Date of Birth: 3/21/1939

Room: 805

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	177.8 cm
Actual Body Weight (ABW)	95.5 kg
Ideal Body Weight (IBW)	73 kg
ABW % of IBW	131 %
Adjusted Body Weight (AjBW)	82 kg
Body Surface Area (BSA)	2.17 m²
Body Mass Index (BMI)	30.2 kg/m²