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John Doe12/28/1999

Chart Summary

Personal Information

John
Doe
12/28/1999
26 years old
Male
6 ft 0 in / 90 Kg
Full
Lisinopril, Morphine
English

Admission Details

245
Joe Bell, MD
2/26/2026
18 hours

Medical Status

Respiratory Failure
COPD, Pneumonia, Congestive Heart Failure

Vital Signs

1 hour ago
99.7 F
99 bpm
22
97%
120
80
500 mL
500 mL
Appears stable. Alert and Oriented. No complaints reported.
3 hours ago

Documentation

04/09/2026
0900
04/09/2026
1100
04/09/2026
1200
Vital Signs
Temperature98.998.4
Heart Rate88102
Blood Pressure112/92130/87
Respiratory Rate2026
SpO29892
Cardiac Assessment
Heart RhythmNSRSinus Tach
Heart AuscultationS1/S2 NormS1/S2 Norm
Pitting Edema+4 Pitting E+4 Pitting E
NotesReports no painMild chest discomfort
Pulse Rate88102

Lines, Drains, Airways (LDAs)

LDAs
Patient body — front view
View back
Lines
NameLocationStatusCategory
Peripheral IVRight ACActive Lines
PICC LineLeft Upper ArmDiscontinued Lines
Enter Name of LineEnter LocationEnter Status Lines
Drains
Airways
Other

Results

CBC (Complete Blood Count)
NameResultReference RangeStatusCategory
Hemoglobin12.212-16FinalNormal
Hematocrit42%40-55%FinalNormal
WBC12.55-10FinalABNORMAL
CMP (Comprehensive Metabolic Panel)
Lipid Panel
PT/INR
Troponin

Orders

Nursing
Notify Physician: Blood Pressure >160/90 or <90/60
Monitor Neurological Status every 1 hour
Diet
Lab
Imaging
Activity

Notes

CT Head w/o Contrast

CT Head Without Contrast

Radiology · CT Head Without Contrast

EXAM: CT head without intravenous contrast.

INDICATION: Altered mental status; evaluate for acute intracranial process.

TECHNIQUE: Contiguous axial images were obtained through the head without contrast. Coronal and sagittal reformations were generated.

COMPARISON: None available.

FINDINGS

  • No acute intracranial hemorrhage, mass, or mass effect.
  • No evidence of acute territorial infarction. Gray–white matter differentiation is preserved.
  • Ventricles and sulci are normal in size and configuration for age. No midline shift.
  • Basal cisterns are patent. No extra-axial fluid collection.
  • Visualized paranasal sinuses and mastoid air cells are clear.
  • The calvarium and skull base are intact, without acute fracture.

IMPRESSION

  • No acute intracranial abnormality.
  • No hemorrhage, mass, midline shift, or acute infarct.
History & Physical

Medication Administration Record (MAR)

0900
1000
1100
1200
1300
1400
1500
Aspirin 81mg PODose: 81 mgRoute: PO - OralFrequency: Once DailyRx
0900 Given
Dispense Location: Intulect Pharmacy  ·  Admin Instructions ▾

Norepinephrine (Levophed) (8mg/250mL)Dose: 8 mgRoute: IV InfusionFrequency: PRN for MAP <65Rx
0900 Started0905 Titrated
Administer STAT ⏱
Start at 5 mcg/min. Titrate 1-5 mcg/min every 5 minutes to maintain a MAP > 65 or a SBP > 90. Maximum Dose: 80 mcg/min.

Influenza VaccineDose: 1 mLRoute: IM - IntramuscularFrequency: OnceRx
1200 Due Now

Insulin Lispro (Humalog)Dose: 0-10 unitsRoute: SQ - SubcutaneousFrequency: ACHSRx
1100 Contraindicated
Medium strength insulin sliding scale: 151-200: 2 units · 201-250: 4 units · 251-300: 6 units

← Messaging: Joe Bell, MD

Message Transcript

You

Hi Dr. Bell, John is reporting worsened pain despite getting his Norco an hour ago

00:00
Joe Bell, MD

Okay, thanks for letting me know. I will take a look at his MAR in a minute and let you know what I can do

00:05
You

Sounds good. Thank you!

00:10
Joe Bell, MD

Looks like we can go up on the dose. I will put it in the orders here soon. Let me know if you have any questions.

00:12
Send a Message...

Change Patient Chart

John DoeCurrent
📅 12/28/1999
John Smith
📅 12/28/1997
Jane Doe
📅 12/28/1997
▲ John DoePatient
Send a message...
▾ Jane DoeSister
▾ Doctor Joe BellDoctor
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Academic EHR · Med-Surg UnitAllergy: Penicillin
MR
Rivera, Maria
67 F · MRN 004812 · Bed 4
Full code
SummaryMAROrdersNotesI&O
Furosemide 40 mg IV pushDaily · Loop diuretic
0900Given
Metoprolol tartrate 25 mg POHold if SBP < 100
0900Held
Potassium chloride 20 mEq PODaily · With food
1000Due
Enoxaparin 40 mg subcutDaily · DVT prophylaxis
2100Scheduled
Scan wristband to administer

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Trusted by nursing schools and health systems

90+institutions10,000+nursing students