Medication Reconciliation (endless)

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Mauro Kaiser

MRN
101025

DOB
11/24/1965

Age
61

Gender
Male

Ethnicity
French

Height
182.9 cm

Weight
65.2 kg

Creatinine
1.8 mg/dL

Patient Name: Mauro Kaiser DOB: 11/24/1965 Room: 583	Allergies: no known drug allergies	Immunization History: influenza: current season (2026) covid-19: current season (2026) tetanus: Td (2020) pneumococcal: PCV20 (2018) shingles: Shingrix, 2 doses (2023)
Community Rx Info: Walgreens Rx Insurance: Express Scripts	Social History: Alcohol: none Nicotine: nicotine pouches (6 mg pouch 4 times per day) Caffeine: one 4 oz cup of dark brewed coffee every morning Rec Drugs: 3 THC gummies (100 mg) once a day

Complete Medication History Prior to Admission								Med Reconciliation
Medication Name	Strength	Route	Frequency	PRN?	Last Dose (date/time)	Adverse Effects	Adherence	Action	^*Reason for D,H,M
Ezetimibe	10 mg	PO	QD	no	02-01-2026 0730	none	never misses	C
Felodipine	10 mg	PO	QD	no	01-31-2026 0830	headache	miss 1 dose/month	M	formulary substitution to amlodipine 10 mg, same SIG
Ampicillin	500 mg	PO	Q6H, tx day 4 of 7	no	01-31-2026 1800	mild nausea	never misses	M	dose decrease to 500 mg Q8H for CrCl 30-50
Sudafed	30 mg	PO	Q6H	PRN sinus congestion	01-24-2026 2300	occasional agitation	uses 4 doses/month	H	non-daily OTC drug, resume on discharge
Nature Made Vitamin C	1,000 mg	PO	QD	no	02-01-2026 2300	none	miss 1 dose/week	H	non-formulary supplment, resume on discharge

Additional Notes: CrCl = 40 mL/min based on actual body weight of 65.2 kg (ABW/IBW = 84%)	Action Key: C = Continue ^*Must provide reason: D = Discontinue, H = Hold, M = Modify
Med history obtained by (sign and print):	Date: 02-01-2026

Patient Name: Mauro Kaiser DOB: 11/24/1965 Room: 583	Allergies: no known drug allergies	Immunization History: influenza: current season (2026) covid-19: current season (2026) tetanus: Td (2020) pneumococcal: PCV20 (2018) shingles: Shingrix, 2 doses (2023)
Community Rx Info: Walgreens Rx Insurance: Express Scripts	Social History: Alcohol: none Nicotine: nicotine pouches (6 mg pouch 4 times per day) Caffeine: one 4 oz cup of dark brewed coffee every morning Rec Drugs: 3 THC gummies (100 mg) once a day

Complete Medication History Prior to Admission								Med Reconciliation
Medication Name	Strength	Route	Frequency	PRN?	Last Dose (date/time)	Adverse Effects	Adherence	Action	^*Reason for D,H,M
Ezetimibe	10 mg	PO	QD	no	02-01-2026 0730	none	never misses
Felodipine	10 mg	PO	QD	no	01-31-2026 0830	headache	miss 1 dose/month
Ampicillin	500 mg	PO	Q6H, tx day 4 of 7	no	01-31-2026 1800	mild nausea	never misses
Sudafed	30 mg	PO	Q6H	PRN sinus congestion	01-24-2026 2300	occasional agitation	uses 4 doses/month
Nature Made Vitamin C	1,000 mg	PO	QD	no	02-01-2026 2300	none	miss 1 dose/week

Additional Notes:	Action Key: C = Continue ^*Must provide reason: D = Discontinue, H = Hold, M = Modify
Med history obtained by (sign and print):	Date: 02-01-2026