Name: ………………………………………………….….

……..
DOB: ………………………………. Gender:
…………….
MRN: …………………………….. NOG:
…………………
Adm. Date: …………………… Bed:

Resident Admission Note

DATE: Thursday, September 17, 2020 TIME: 3:36 PM

CHIEF COMPLAINT: pain
A case of 39 years old female patient KTH DM, breast ca triple negative with metastasis to the brain,
liver, kidney and lung presented for pain management. The patient failed multiple lines of
chemotherapy. She is status post pleurodesis on the right side because she experienced dyspnea
which was due to pleural effusion.

PMH : DM, breast ca triple negative with metastasis to the brain, liver, kidney and lung presented for
pain management

PSH: mastectomy, c-section

SH: smoker, drinks alcohol occasionally

Allergies: negative

Medications: Nexium (esomeprazole) 20mg BID

Prednisone 10mg 1 pill in the morning
Topamax (Topiramate) 50mg BID
Lyrica (pregabalin) 75mg BID
Keppra (Levetiracetam) 1000mg BID
Lioresal (Baclofen) 10mg 1 pill in the morning
Cipralex (Escitalopram) 10mg
Januvia (Sitagliptin) 100mg 1 pill in the morning
Triptizol (Amitriptyline) 75mg at night
Navelbine (Vinorelbine) 30mg 2pills once per week
Oxynorm (Oxycodone) 10mg
Panadol (Paracetamol) 500mg 2 tabs q6
Durogesic (Fentanyl) Patch 50 q72
Lidocaine Patch 12h on 12h off
MgB6

TEMPERATURE: RESPIRATION: PULSE: BP: HEIGHT: WEIGHT:

GENERAL APPEARANCE: conscious cooperative oriented, in pain

HHENT: pallor, No jaundice , no cyanosis
Lungs: Decreased air entry on the right side
ABDOMEN: soft, no tenderness
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MR F-10 Ed.7
 Name: ………………………………………………….….
……..
LL: no LLE
DOB: ………………………………. Gender:
…………….
MRN: …………………………….. NOG:
…………………
Resident Admission Note (Continued) Adm. Date: …………………… Bed:

DIAGNOSTIC TESTS:
Labs pending

IMPRESSION: A case of 39 years old female patient KTH DM, breast ca triple negative with metastasis to
the brain, liver, kidney and lung presented for pain management.
MANAGEMENT PLAN:
IV : 1L NSS Q 24 h
Nexium (esomeprazole) 20mg BID
Prednisone 10mg 1 pill in the morning
Topamax (Topiramate) 50mg BID
Lyrica (pregabalin) 75mg BID
Keppra (Levetiracetam) 1000mg BID
Lioresal (Baclofen) 10mg 1 pill in the morning
Cipralex (Escitalopram) 10mg QPM
Januvia (Sitagliptin) 100mg 1 pill in the morning
Triptizol (Amitriptyline) 75mg at night
Navelbine (Vinorelbine) 30mg 2pills once per week
Oxynorm (Oxycodone) 10mg
Panadol (Paracetamol) 500mg 2 tabs q6
Durogesic (Fentanyl) Patch 50 q72
Lidocaine Patch 12h on 12h off
MgB6
Ketamine 15 mg per hour

RESIDENT NAME & SIGNATURE: Mohamad Khalifeh, PGY1 DATE TIME:3:36 PM

9/17/2020
ATTENDING NAME & SIGNATURE: DATE TIME

Page 2 of 2
MR F-10 Ed.7