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Ceptic Online - View Patient Profiles

Kamara, Amir
MRN: 423899 Room: 108 DOB: 6/27/1953 Age: 72 Gender: Male Allergies: NKDA
 Admit Notes
 Clinical Notes
 Vitals
 Labs, Cultures, Imaging
 Clinical Calculators
 MAR
 Current Orders
 Home Med List
 Med Reconciliation
 Discharge Planning
Setting Neurology ICU
Scenario Please see clinical note. As the critical care pharmacist, please address pharmacotherapy recommendations, including all home medications, you may have to optimize this patient’s care in the hospital and at discharge. Please note the following insulin infusion protocol.

Hospital regular human insulin infusion initiation protocol
Blood glucose (mg/dL) Initial insulin infusion rate (units/hour)
<150 0.5
150-179 1
180-240 2
241-300 3
301-360 4
>360 5
*Titrate per nursing protocol
Admission note taken on 10/19/25
CC “My dad has not been himself since earlier today.”
HPI Mr. Kamara is a 72 y/o male brought in by his daughter due to altered mental status for the past several hours. Daughter states that the patient was able to perform his normal daily activities until this morning. Patient had a stroke several years ago and this episode reminds her of how he appeared then. She reports that patient is on a blood thinner for atrial fibrillation. Additionally, patient recently saw a gastroenterologist and was started on three new medications that he was supposed to take for a couple weeks for a stomach ulcer.
PMH
  • Hypertension (diagnosed 20 years ago)
  • Diabetes mellitus, Type II (diagnosed 15 years ago)
  • Atrial fibrillation (diagnosed 8 years ago)
  • Cardioembolic cerebral vascular accident (diagnosed 8 years ago)
  • Heart failure with reduced ejection fraction (diagnosed 5 years ago)
  • Osteoarthritis (diagnosed 4 years ago)
  • Chronic kidney disease (diagnosed 2 years ago)
  • Peptic ulcer disease (diagnosed 5 days ago; esophagogastroduodenoscopy identified non-bleeding gastric ulcer, H. pylori confirmed via gastric biopsy)
Social
History
  • Tobacco: never smoker
  • Alcohol: drinks 1 to 2 drinks occasionally
  • Illicit drug use: never
  • Occupation: Mechanic (retired)
 Family
History
  • Father - Diabetes mellitus (Type II), hypertension
  • Mother - Hypertension, end-stage kidney disease
Vaccine
History
  • Tetanus: Tdap (1 years ago)
  • COVID-19: Doses up to date per recent guidelines
  • Influenza: last season
 Surgical
History
  • Esophagogastroduodenoscopy (5 days ago)
  • Patent foramen ovale closure (8 years ago)
Physical Exam
  • ROS: Unable to be obtained as patient is not alert to person, place, or time
  • General: no acute distress
  • Head: normocephalic, without obvious abnormality, atraumatic
  • Eyes: pupils equal, round, and reactive to light, diplopia, conjunctiva clear
  • Neck: supple, symmetrical
  • Skin: skin color, texture, turgor normal
  • Lungs: clear to auscultation bilaterally, symmetric excursion
  • CV: irregularly irregular rhythm, rate 150s
  • Abdomen: soft, non-tender non-distended; positive bowel sounds
  • Extremities: left-sided weakness warm and well-perfused, no cyanosis, clubbing, or edema
  • Neuro: withdraws to pain, slurred speech, left-sided facial droop, ataxia oriented only to self, NIH Stroke Scale score of 15
Clinical Laboratory Report
 
Test Name 10/19/2512/23/24 Range
Sodium (Na+) 142140 136-145 mEq/L
Potassium (K+) 4.73.8 3.5-5 mEq/L
Chloride (Cl-) 10298 98-106 mEq/L
Bicarbonate (HCO3-) 2223 23-28 mEq/L
Urea nitrogen (BUN) 2420 8-20 mg/dL
Creatinine 2.01.8 0.5-1.3 mg/dL
Glucose 33898 70-115 mg/dL
Hemoglobin A1c 7.86.6 5.3-7.5 %
Calcium,Total 8.18.5 8.6-10.2 mg/dL
Phosphate 4.5 3-4.5 mg/dL
Magnesium 2.0 1.6-2.6 mEq/L
Protein, total 5.5-9 g/dL
Albumin 3.2 3.5-5.5 g/dL
Aminotransferase,aspartate (AST) 36 10-40 units/L
Aminotransferase,alanine (ALT) 48 10-40 units/L
Lactic dehydrogenase (LDH) 80-225 units/L
Alkaline phosphatase 30-120 units/L
Bilirubin, Total 0.4 0.3-1 mg/dL
Leukocytes (WBC) 8.29.1 4.5-11 x103/mcL
Red blood cells (RBC), Male3.8-5.1 x108/mcL
Hemoglobin, Male11.311.814-18 g/dL
Hematocrit, Male424442-50 %
Mean corpuscular hemoglobin (MCH) 27-33 picogram
Mean corpuscular volume (MCV) 76-100 mcm3
Platelets 212220 150-450 x103/mcL
International normalized ratio (INR) 8.72.6 0.8-1.2
Prothrombin time (PT) 9.5-11.3 sec
Partial thromboplastin time,activated (aPTT) 25-35 sec

 
 
Additional Labs:


Other Labs (Today) Results
Troponin HS (pg/mL) 18.9
BNP (pg/mL) 79
Urine albumin-to-creatinine ratio (mg/g) 52


Fasting Lipid Panel (Today) Result
Total cholesterol (mg/dL) 192
LDL-C (mg/dL) 114
HDL (mg/dL) 40
Triglycerides (mg/dL) 107
Recent Warfarin Dosing and INR
Date Warfarin Dose INR
5 days ago held (procedure date) 1.2
10 days ago placed on hold for procedure -
2 months ago 5 mg daily 2.9
6 months ago 5 mg daily 2.7
10 months ago 5 mg daily 2.6
Cultures:
  • None
Imaging Studies:
  • CT head without contrast (today): intracerebral hemorrhage of the right hemisphere
  • ECG (today): irregularly irregular rhythm, absent P waves, rapid ventricular rate
  • transthoracic echocardiogram (10 months ago): left ventricular ejection fraction = 30-35%
Vital Sign 10/19/25
08:29
Height (cm) 188
Weight (kg) 94.5
Body Temperature (°C) 37.2
Blood Pressure (mmHg) 195 / 108
Heart Rate (bpm) 153
Respiratory Rate (bpm) 22
Oxygen Saturation (%) 96
Current Orders
 
Medication
History
  • Daughter brought all of patient’s medications with him to the ED. Reports patient is adherent to his medications and takes them every day.
  • She states that he has been on the same dose of warfarin for years. His daughter mentioned that the patient was told to hold his warfarin for several days prior to his endoscopy; he restarted it in the evening the day that he had his procedure.
  • Additionally, she states that he usually takes ibuprofen a couple times per day for arthritis pain in his knee.

 
Home Medication List: verified by pharmacy on admit (10/19/25)
 
Patient Name: Kamara, Amir
Date of Birth: 6/27/1953
Room#: 108		 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
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: Kamara, Amir Date of Birth: 6/27/1953 Room: 108

 
Medication (name/strength) Dose Route Frequency Notes

 
          
Height 188 cm
Actual Body Weight (ABW) 94.5 kg
Ideal Body Weight (IBW) 82.2 kg
ABW % of IBW 115 %
Adjusted Body Weight (AjBW) 87.1 kg
Body Surface Area (BSA) 2.22 m2
Body Mass Index (BMI) 26.7 kg/m2

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

 
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