Clinical Worksheet
Date: 3/9/2021 Student Name:Jaleesa Taube Assigned vSim: Pharm: Danielle Young Bear
Initials: Diagnosis: Admit Dx: HCP: Dr. Isolation: standard IV Type: Critical Labs: Other Services:
D.Y.B Common Cold Samuel Fall Risk: none PTT 7.8
Age: 32 Length of Stay: Riverton low Location: Albumin 3.2
M/F: F 0 days Transfer: n/a Alkaline Phosphate 33.6
Code Status: Full Allergies: None Consults: Pain Clinic Fluid/Rate: n/a Consults Needed: Pain Clinic
code; CPR
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?: My patient is being seen for
chronic low back. Reported pain level 6 on 0-10 pain scale. Reported dull, achey, and occasional sharp upon movement. Chronic pain, “live with it, it’s last a while”. Pt.
reports, “medications help” pain levels. “Heavy lifting” makes pain worse.
Health History/Comorbities (that relate to this hospitalization): Admit Dx: Common Cold. c/o persistent cough and fatigue lasting greater than 2 weeks. Post common
cold. History of low back pain, occupational hazards: construction worker. Polypharmacy concerning Rx, OTC, and herbal supplements. Increased dose and longterm
use of acetaminophen both Rx and OTC.
Path to Discharge: Address polypharmacy. MD Orders for labs: liver function test and serum acetaminophen levels. Education on use of acetaminophen. Current Rx,
OTC, and herbal supplement useages. Educate when purchasing OTC medications finding meds without acetaminophen and consult a pharmacist before use. Consult
for management of chronic pain. d/c use of OTC cough medications.
Path to Death or Injury: Continue increased use of acetaminophen. Overdose can cause acute liver failure, require transplant, or death. Unamanged pain with
depression can cause increased mental instability and risk of suicide.
Date: 3/9/2021 Student Name:Jaleesa Taube Assigned vSim: Pharm: Danielle Young Bear
Initials: Diagnosis: Admit Dx: HCP: Dr. Isolation: standard IV Type: Critical Labs: Other Services:
D.Y.B Common Cold Samuel Fall Risk: none PTT 7.8
Age: 32 Length of Stay: Riverton low Location: Albumin 3.2
M/F: F 0 days Transfer: n/a Alkaline Phosphate 33.6
Code Status: Full Allergies: None Consults: Pain Clinic Fluid/Rate: n/a Consults Needed: Pain Clinic
code; CPR
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?: My patient is being seen for
chronic low back. Reported pain level 6 on 0-10 pain scale. Reported dull, achey, and occasional sharp upon movement. Chronic pain, “live with it, it’s last a while”. Pt.
reports, “medications help” pain levels. “Heavy lifting” makes pain worse.
Health History/Comorbities (that relate to this hospitalization): Admit Dx: Common Cold. c/o persistent cough and fatigue lasting greater than 2 weeks. Post common
cold. History of low back pain, occupational hazards: construction worker. Polypharmacy concerning Rx, OTC, and herbal supplements. Increased dose and longterm
use of acetaminophen both Rx and OTC.
Path to Discharge: Address polypharmacy. MD Orders for labs: liver function test and serum acetaminophen levels. Education on use of acetaminophen. Current Rx,
OTC, and herbal supplement useages. Educate when purchasing OTC medications finding meds without acetaminophen and consult a pharmacist before use. Consult
for management of chronic pain. d/c use of OTC cough medications.
Path to Death or Injury: Continue increased use of acetaminophen. Overdose can cause acute liver failure, require transplant, or death. Unamanged pain with
depression can cause increased mental instability and risk of suicide.
