Patient Chart
Mrs. G.E
63 yrs • Female • 66 kg • 158 cm
Diagnosis
Major depressive disorder, post-operative nausea
Past Medical History
- Major depressive disorder (on citalopram 2 years)
- Hypertension
- Recent cholecystectomy (2 days post-op)
Current Medications
- Citalopram 40 mg once daily
- Lisinopril 10 mg once daily
- Furosemide 20 mg once daily
New Prescription
Ondansetron 8 mg — IV, Every 8 hours as needed for nausea
Vitals
BP128/78 mmHgNormalBlood PressureReference90–120 / 60–80 mmHgActual128/78 mmHg
HR92 bpmNormalHeart RateReference60–100 bpmActual92 bpm
RR18/minNormalRespiratory RateReference12–20 breaths/minActual18/min
TEMP37.2°CNormalTemperatureReference36.1–37.2°CActual37.2°C
SPO296%NormalOxygen SaturationReference≥ 95%Actual96%
Labs
Serum Creatinine0.9 mg/dLNormalSerum CreatinineReference0.5–1.3 mg/dLActual0.9 mg/dL
Creatinine Clearance68 mL/minNormalCreatinine ClearanceReference≥ 50 mL/min (normal/mild impairment)Actual68 mL/min
eGFR72 mL/min/1.73m²NormaleGFRReference≥ 60 mL/min/1.73m²Actual72 mL/min/1.73m²
Liver FunctionWithin normal limitsNormalLiver FunctionReferenceWithin normal limitsActualWithin normal limits
Blood Glucose6.1 mmol/LNormalBlood GlucoseReference4.0–7.8 mmol/LActual6.1 mmol/L
Potassium3.2 mmol/L (low)LowPotassiumReference3.5–5.0 mmol/LActual3.2 mmol/L (low)
Allergies & Status
No known drug allergies (NKDA)
Not applicable
Clinical Notes
Post-operative day 2 following laparoscopic cholecystectomy, experiencing nausea. Ondansetron prescribed for symptom control. Potassium is low, likely related to furosemide and post-operative fluid shifts.
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