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Jaramillo, Juan
MRN: 422321 Room: T48 DOB: 5/11/1956 Age: 69 Gender: Male Allergies: Cefdinir (rash), Lisinopril (cough)
 Admit Notes
 Clinical Notes
 Vitals
 Labs, Cultures, Imaging
 Clinical Calculators
 MAR
 Current Orders
 Home Med List
 Med Reconciliation
 Discharge Planning
Setting Telemetry
Scenario JJ is being admitted to the telemetry floor on the Internal Medicine Team for NSTEMI cardiac workup and comorbidity management. The cardiology consult team will be taking JJ for percutaneous coronary intervention (PCI) tomorrow morning at 0600. As a member of the Internal Medicine team please address pharmacotherapy recommendations, including all home medications, you may have to optimize this patient’s care in the hospital and at discharge.

Note: the patient arrived to the Emergency Department today at 7:45 AM
Admission note taken on 10/19/25
CC “My chest feels really tight.”
HPI JJ is a 69-year-old Hispanic male (preferred language Spanish) sent to the Emergency Department from a scheduled heart failure clinic visit for new chest pain and discomfort. He describes the chest pain as tightness, consistent in nature, and started after breakfast this morning. In the emergency department he is complaining of 9/10 chest pain to his nurse. The pain did not change after administration of GI Cocktail (magnesium hydroxide, viscous lidocaine 2%) or lorazepam but decreased to 3/10 after sublingual nitroglycerin. He endorses ongoing cocaine use, mostly on the weekends and last used last weekend. He reports that since his last heart failure admission six months ago, he has been feeling fine apart from not sleeping well until the chest pain developed.
PMH
  • Heart Failure with Preserved Ejection Fraction (HFpEF), diagnosed 1 year ago
    • hospitalized 4 times in the past 12 months (last was 6 months ago)
  • Hypertension, diagnosed 4 years ago
  • Insomnia
  • Cocaine Use Disorder
Social
History
  • Alcohol: 3 drinks/week, socially
  • Tobacco: never
  • Cocaine Use Disorder: “smokes crack” on the weekends, socially
 Family
History
  • Father - Unknown
  • Mother - Died of natural causes at 82
  • Daughter - Alive, type 2 diabetes after pregnancy
Vaccine
History
  • Received all recommended childhood and adolescent immunizations through age 18
  • Influenza: last season
  • COVID 19: Moderna 2 dose primary series at age 66
  • Varicella: History of infection as child
  • HZV: Zostavax, 1 dose at age 65
  • Tdap: 2 years ago
  • Pneumococcal: PCV13 1 dose at age 65, PPSV23 1 dose at age 66
 Surgical
History
  • None
Physical Exam
  • ROS: Positive for chest pain per HPI. Denies shortness of breath, cough, GERD. Chest pain is not reproducible. No aggravating or relieving factors.
  • General: Overweight male appearing uncomfortable
  • HEENT: Conjunctiva clear, moist mucosal membranes, no lymphadenopathy
  • Pulmonary: No rhonchi or crackles
  • Cardiovascular: Negative JVD, tachycardia without murmurs/rubs/gallops
  • Abdomen: Normal bowel sounds
  • Genitourinary: WNL
  • Extremities: WNL
  • Neuro: AO x3
  • Lines/Drains/Airways
    • 18 gauge Left Antecubital IV Catheter
    • 20 gauge Right Wrist IV Catheter
Clinical Laboratory Report
 
Test Name 10/19/2504/22/25 Range
Sodium (Na+) 135138 136-145 mEq/L
Potassium (K+) 2.84.1 3.5-5 mEq/L
Chloride (Cl-) 10399 98-106 mEq/L
Bicarbonate (HCO3-) 2426 23-28 mEq/L
Urea nitrogen (BUN) 1211 8-20 mg/dL
Creatinine 0.650.55 0.5-1.3 mg/dL
Glucose 190118 70-115 mg/dL
Hemoglobin A1c 8.7 5.3-7.5 %
Calcium,Total 9.9 8.6-10.2 mg/dL
Phosphate 3.6 3-4.5 mg/dL
Magnesium 1.2 1.6-2.6 mEq/L
Protein, total 5.5-9 g/dL
Albumin 4.7 3.5-5.5 g/dL
Aminotransferase,aspartate (AST) 26 10-40 units/L
Aminotransferase,alanine (ALT) 29 10-40 units/L
Lactic dehydrogenase (LDH) 80-225 units/L
Alkaline phosphatase 30-120 units/L
Bilirubin, Total 0.5 0.3-1 mg/dL
Leukocytes (WBC) 5.26.7 4.5-11 x103/mcL
Red blood cells (RBC), Male3.8-5.1 x108/mcL
Hemoglobin, Male13.71414-18 g/dL
Hematocrit, Male424442-50 %
Mean corpuscular hemoglobin (MCH) 27-33 picogram
Mean corpuscular volume (MCV) 76-100 mcm3
Platelets 188171 150-450 x103/mcL
International normalized ratio (INR) 1.1 0.8-1.2
Prothrombin time (PT) 12.7 9.5-11.3 sec
Partial thromboplastin time,activated (aPTT) 27.6 25-35 sec

 
 
Additional Labs:
Other Labs Today 6 Months Ago
Troponin (High Sensitivity) (ng/L) 800
TSH (uIU/mL) 2.17 2.21
T4 (Free) (ng/mL) 0.99 0.91
BNP (pg/mL) 73 247
COVID-19 Rapid Negative Negative


Fasting Lipid Panel (6 months ago) Result
Total cholesterol (mg/dL) 144
LDL-C (mg/dL) 95
HDL (mg/dL) 45
Triglycerides (mg/dL) 99
Urinalysis (Today) Result
Color Colorless
Glucose Positive
RBC Negative
Ketone Negative
Leukocyte esterase Negative
Nitrite Negative
Urine pH 6.5
Specific gravity 1.004
Protein +1
Epithelial cells per high-power field 0
WBC per high-power field <1
Amphetamine Screen Negative
Barbiturate Screen Negative
Benzodiazepine Screen Negative
Cannabinoid Screen Negative
Cocaine Screen Positive
Methadone Screen Negative
Opiate Screen Negative
Cultures:
  • None
Imaging Studies:
ECG 12-Lead Measurements (Today)
Ventricular Rate (BPM): 105
Atrial Rate (BPM): 105
QRS Duration (mS): 86
Q-T Interval (mS): 366
QTC Interval (mS): 457
Interpretation: Normal sinus rhythm with new left bundle branch block in leads V1 and V6. No ST elevation identified.


Other Diagnostic Tests Type Today 6 Months Ago
Transthoracic ECHO 2D Left Ventricular Ejection Fraction 50-55%
X-Rays Chest No acute abnormalities. Air space opacification suggestive of pulmonary edema, correlate clinically.
Vital Sign 10/19/25
08:46
Height (cm) 180.3
Weight (kg) 120
Body Temperature (°C) 37.2
Blood Pressure (mmHg) 155 / 90
Heart Rate (bpm) 105
Respiratory Rate (bpm) 24
Oxygen Saturation (%) 97
Current Orders
 
USE
START DATE
STOP DATE
NOTES

 

 

USE
START DATE
STOP DATE
NOTES

 

 

CONC
VOL
SOLN
RATE

USE
START DATE
STOP DATE
NOTES

 

 

USE
START DATE
STOP DATE
NOTES

 

 

Medication
History
  • JJ reports his daughter places his medications in a pillbox every week and he rarely misses doses.
  • Receives prescription bottles with Spanish directions on the labels.
  • Fill history confirmed with Kroger pharmacy and daughter confirms she fills the pillbox every Sunday after attending church.

 
Home Medication List: verified by pharmacy on admit (10/19/25)
 
Patient Name: Jaramillo, Juan
Date of Birth: 5/11/1956
Room#: T48		 Allergies:
 Immunization History:
Community Rx Info:
 
Rx Insurance: 		Social History:
Additional Notes:
DRUG
STRENGTH
DF
STRENGTH
ROUTE
FREQ
PRN?
LAST
DOSE
(date/time)
ADVERSE
EFFECTS
ADHERENCE
NOTES
MED REC
ACTION
MED REC
REASON
Action Key:
C = Continue, D = Discontinue*, H = Hold*, M = Modify*
*must provide reason

                    
Medication 10/19/25
Iohexol Solution  350 mg iodine/mL  intra-catheter  once  PRN
PRN heart catheterization
GI Cocktail  30 mL  PO  once8:52
Lorazepam  1 mg  IV  once
Rate: 2 mg/min		8:52
8:31
Nitroglycerin  0.4 mg  SL  once8:25
Aspirin Chewable Tablet  325 mg  PO  once8:19
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: Jaramillo, Juan Date of Birth: 5/11/1956 Room: T48

 
Medication (name/strength) Dose Route Frequency Notes

 
          
Height 180.3 cm
Actual Body Weight (ABW) 120 kg
Ideal Body Weight (IBW) 75.3 kg
ABW % of IBW 159 %
Adjusted Body Weight (AjBW) 93.2 kg
Body Surface Area (BSA) 2.45 m2
Body Mass Index (BMI) 36.9 kg/m2

Creatinine Clearance (Cockcroft-Gault Equation):
182 mL/min

 
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