View Patient Profiles

Dunlap, Jaden

MRN: 424433

Room: 624

DOB: 12/25/1949

Age: 77

Gender: Male

Allergies: Penicillin (rash), Lisinopril (cough), Ciprofloxacin (rash)

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	Please see clinical note. Jaden Dunlap is transferred from an outside freestanding ED to a medicine ward at your hospital for a higher level of care. The internal medicine care team has ordered a regular diet during the hospital stay. As a member of the patient’s care team, please address pharmacotherapy recommendations with respect to treatment of his influenza and presumed bacterial pneumonia as well as his other disease states to optimize this patient’s care in the hospital and at discharge.
Admission note taken on 01/31/26
CC	“I am short of breath and just don’t feel well.”
HPI	Mr. Dunlap is a 77 y.o. male who presented to an outside freestanding emergency department (ED) yesterday evening for shortness of breath, weakness, muscle aches, chills, productive cough, nausea, and lack of appetite since yesterday. He has only been able to keep down small amounts of water, tea, and electrolyte drinks. Mr. Dunlap reports he was exposed to family members who were recently diagnosed with influenza. He has not been hospitalized or received any antibiotics within the last 6 months. Mr. Dunlap was transferred to the hospital for continued management after being diagnosed with influenza A and suspected concomitant bacterial pneumonia. First doses of antimicrobials were initiated at the outside ED including oseltamivir 75 mg PO, vancomycin 1750 mg IV, and cefepime 1 gram IV, which were tolerated without any issues.
PMH	Type 2 diabetes mellitus – diagnosed 4 years ago Diabetic peripheral neuropathy – diagnosed 9 years ago Chronic obstructive pulmonary disease, GOLD stage 2, group E – diagnosed 8 years ago Stage 5 chronic kidney disease on peritoneal dialysis (9-hour dwell time every night) – diagnosed 6 years ago Chronic coronary disease – diagnosed 4 years ago Non-ST segment elevation myocardial infarction with placement of two drug-eluting stents – diagnosed 10 months ago
Social History	Tobacco: former smoker (quit 10 years ago) Alcohol: drinks socially (3-4 beers on the weekends) Lives at home with wife Occupation: retired music teacher	Family History	Father - type 2 diabetes mellitus, hypertension, hyperlipidemia, myocardial infarction at age 70. Passed away at age 81 from heart disease. Mother - asthma, hypertension, chronic kidney disease. Passed away at age 83 from pneumonia. Sisters (2) - one sister with hypertension & hyperlipidemia, second sister with asthma & hypertension. Both sisters are still living.
Vaccine History	Influenza (inactivated): last season COVID-19 (Moderna vaccine): up to date per most recent guidelines Pneumococcal: PPSV23 (14 years ago), PCV13 (13 years ago) Zostavax (live attenuated zoster vaccine): 14 years ago Tdap: 5 years ago Hepatitis B series: 3-dose series completed 5 years ago	Surgical History	Drug-eluting stents x2 (10 months ago) Peritoneal dialysis access (6 years ago)
Physical Exam	ROS (source: patient) Constitutional: feeling fatigued and weak, febrile HEENT: unremarkable Respiratory: positive for productive cough, shortness of breath CV: positive for chest pain with coughing, no edema GI: positive for nausea, loss of appetite x24 hours GU: no dysuria, urgency, or frequency MSK: positive for muscle aches Skin: normal appearance PE General: well-developed and well nourished, no acute distress, alert and oriented, appears stated age Head: normocephalic and atraumatic without any obvious abnormalities Eyes: pupils equal, round, and reactive to light and accommodation, extraocular muscles are intact, conjunctivae are clear Neck: supple, symmetrical, no adenopathy Neuro: alert and oriented to person, place, time and event, cranial nerves are intact, motor function and sensation of all four extremities intact bilaterally, gait is normal, Glasgow Coma Scale score 15 Lungs: crackles, rales, and decreased breath sounds bilaterally on auscultation, no signs of respiratory distress CV: normal rate and rhythm, no murmurs, rubs, or gallops Abdomen: soft, non-tender without distention, bowel sounds present, peritoneal dialysis catheter normal appearing Skin: warm, dry and intact, no rashes, lesions, or petechiae Extremities: atraumatic without obvious abnormalities, muscle strength 4/5 bilaterally, capillary refill normal, pulses detected

Clinical Laboratory Report

Test Name	02/01/26	01/31/26	Range
Sodium (Na⁺)	132	131	136-145 mEq/L
Potassium (K⁺)	4.5	4.7	3.5-5 mEq/L
Chloride (Cl^-)	97	95	98-106 mEq/L
Bicarbonate (HCO₃^-)	30	31	23-28 mEq/L
Urea nitrogen (BUN)	68	64	8-20 mg/dL
Creatinine	13.7	12.9	0.5-1.3 mg/dL
Glucose	387	405	70-115 mg/dL
Hemoglobin A1c		9.1	5.3-7.5 %
Calcium,Total	8.7	8.6	8.6-10.2 mg/dL
Phosphate	4	4.1	3-4.5 mg/dL
Magnesium	1.9	1.8	1.6-2.6 mEq/L
Protein, total	5.5	5.6	5.5-9 g/dL
Albumin	3.2	3.3	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	23	21	10-40 units/L
Aminotransferase,alanine (ALT)	16	14	10-40 units/L
Lactic dehydrogenase (LDH)	111	112	80-225 units/L
Alkaline phosphatase	60	61	30-120 units/L
Bilirubin, Total	0.7	0.6	0.3-1 mg/dL
Leukocytes (WBC)	15.3	15.1	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.1	4.1	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	10.4	10.5	14-18 g/dL
Hematocrit, Male	28.3	29	42-50 %
Mean corpuscular hemoglobin (MCH)	30	31	27-33 picogram
Mean corpuscular volume (MCV)	82	82	76-100 mcm³
Platelets	168	165	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1.1	0.8-1.2
Prothrombin time (PT)	11	11.1	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	33	33	25-35 sec

Additional Labs:

Other Labs (today)	Results
Troponin HS (pg/mL)	<20
BNP (pg/mL)	<100
Procalcitonin (ng/mL)	0.87
Lactic Acid (mg/dL)	1.8

CBC (today)	Result
Neutrophils (%)	87
Segs (%)	83
Bands (%)	10
Eosinophils (cells/microliter)	335

Arterial Blood Gas
(on room air, yesterday)

pH	7.31
pCO₂ (mmHg)	52
pO₂ (mmHg)	71
HCO₃ (mEq/L)	29
SaO₂ (%)	83
Hgb (mg/dL)	10.3
FiO₂ (%)	21

Fasting Lipid Panel (3 months ago)	Result
Total cholesterol (mg/dL)	126
LDL-C (mg/dL)	68
HDL (mg/dL)	35
Triglycerides (mg/dL)	114

Cultures:

Cultures (today)	Result
MRSA (nares)	Negative
Influenza A/B	Positive for influenza A
RSV	Negative
COVID-19	Negative
Blood cultures (2 sets)	Results pending
Sputum culture	Results pending

Imaging Studies:

Chest X-ray (yesterday): New right lower lobe (RLL) opacity
ECG (today): NSR, rate 88, QTc 415, no ST segment or T wave abnormalities

Vital Sign	02/01/26 09:44	22:29	16:49	01/31/26 09:46
Height (cm)	170			170
Weight (kg)	80			80
Body Temperature (°C)	39.5	38.3	39.5	39.1
Blood Pressure (mmHg)	111 / 60	108/62	107/62	110/62
Heart Rate (bpm)	89	84	84	85
Respiratory Rate (bpm)	20	20	21	21
Oxygen Saturation (%)	94 (3L of O₂)	92	91	92

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES
			PD dosing by level in 24 hours

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

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?

CONC	VOL	SOLN

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
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?
			PRN pain (1-4) or fever (>37.8°C)
USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

Mr. Dunlap reports he usually takes his medications as prescribed, rarely missing a dose.
However, he has not taken any insulin today or yesterday or checked his blood sugar (usually checks 3 times per day) due to not feeling well.

Home Medication List: verified by pharmacy on admit (01/31/26)

Patient Name: Dunlap, Jaden Date of Birth: 12/25/1949 Room#: 624	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	LAST DOSE (date/time)	MED REC ACTION
Albuterol 90 mcg/act MDI	2 puffs PO Q6H	SOB
Aspirin 81 mg tablet	1 PO QD	no
Atorvastatin 80 mg tablet	1 PO QD	no
Carvedilol 6.25 mg tablet	1 PO BID	no
Clopidogrel 75 mg tablet	1 PO QD	no
Dialyvite (renal multivitamin) tablet	1 PO QD	no
Insulin aspart 100 units/mL Pen	4 units Subcut TID w/meals	no
Insulin glargine 100 units/mL Vial	12 units Subcut QAM	no
Losartan 50 mg tablet	1 PO QD	no
Mometasone/ Formoterol 200 mcg/5 mcg MDI	2 puffs PO BID	no
Pregabalin 50 mg capsule	1 PO HS	no
Tiotropium 2.5 mcg Respimat	2 puffs PO QD	no
Acetaminophen 500 mg caplet	1 PO Q6H	pain or fever	2100 01/30/26
Dextromethorphan/ Guaifenesin 5 mg/100 mg/5 mL Syrup	10 mL PO Q6H	cough or congestion	1000 01/30/26
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	02/01/26	01/31/26
Vancomycin 1,000 mg IV Pharmacy to dose Rate: 133 mL/hr
Cefepime 1,000 mg IV Q24H Rate: 100 mL/hr		23:38
Oseltamivir 75 mg PO Q12H
Lactated Ringer’s Solution IV continuous, 100 mL/hr
Insulin aspart sliding scale SC ACHS
Heparin 5,000 units SC Q8H
Pregabalin 50 mg PO QHS
Aspirin 81 mg PO QD
Albuterol/Ipratropium 2.5 mg/0.5 mg NEB Q6H PRN PRN SOB
Acetaminophen 650 mg PO Q6H PRN PRN pain (1-4) or fever (>37.8°C)
Vancomycin 1,750 mg IV STAT x1 Rate: 175 mL/hr		23:13

Clinical Notes

Emergency Department Notes:
--------------------------
Assessment:

Patient is febrile with pneumonia, requiring supplemental oxygen on arrival but is in no acute distress. Labs were drawn at the outside ED yesterday evening and some repeated on admission to the hospital. Two sets of blood cultures and a sputum culture collected at the outside ED are pending, repeat blood cultures collected at the hospital are also pending. 

Respiratory viral tests were positive for Influenza A. No known recent hospitalizations, broad-spectrum IV antibiotics, or positive recent microbiology culture history. 

Patient has antimicrobial allergies/intolerances to penicillin (rash) and ciprofloxacin (rash). Patient is on peritoneal dialysis with a 9-hour dwell time every night. Two peripheral IV lines are present in the right and left antecubital fossae.

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: Dunlap, Jaden

Date of Birth: 12/25/1949

Room: 624

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	170 cm
Actual Body Weight (ABW)	80 kg
Ideal Body Weight (IBW)	66.1 kg
ABW % of IBW	121 %
Adjusted Body Weight (AjBW)	71.7 kg
Body Surface Area (BSA)	1.94 m²
Body Mass Index (BMI)	27.7 kg/m²