Electronic Health Record (EHR)
Active Inpatient Ward 3 • Bed 204
Eleanor Vance
Blood Group: O+ MRN: #MED-8492034 Years Old • Female • Born Aug 14, 1992 • Admitted Oct 12, 2026
Patient Real-Time Vital Signs & Metrics (Last Recorded: 15 mins ago)
Chronological Clinical Care Events
Patient admitted through Emergency Wing presenting palpitations, mild dizziness, and exertional shortness of breath. Triaged by Dr. Anjali Shetty and scheduled for 24-hour Holter monitoring.
Coronary angiography revealed patent coronary arteries without hemodynamically significant stenosis. Preserved Left Ventricular Ejection Fraction (LVEF 60%). Discharged without complications after 24h.
Elective removal of gallbladder for symptomatic cholelithiasis. Uneventful post-operative recovery, discharged on POD 1.
Administered intramuscularly at Primary Health Clinic. No adverse reactions recorded.
Consultation SOAP Notes
Patient reports feeling much calmer today. Palpitation episodes subsided overnight following Metoprolol administration. Denies chest pain, orthopnea, or syncope. Slept for 7 hours uninterrupted.
BP: 120/80 mmHg, HR: 72 bpm regular rhythm. Lungs clear to auscultation bilaterally. No peripheral edema noted. Jugular venous pressure normal. EKG shows normal sinus rhythm.
Transient paroxysmal supraventricular tachycardia (PSVT), now well-controlled with beta-blocker therapy. Potassium levels need close re-testing following iv electrolyte repletion.
1. Maintain Metoprolol Succinate 25mg PO daily.
2. Repeat serum electrolytes at 16:00.
3. Plan for tentative hospital discharge tomorrow morning if stable.
Current Prescription Regimen
Open Full Rx Manager| Medication & Brand | Strength | Dosage & Frequency | Route | Prescribed Date | Refills Left | Status |
|---|---|---|---|---|---|---|
|
Metoprolol Succinate ER
Toprol XL • Beta Blocker
|
25 mg | 1 tablet once daily in morning | Oral (PO) | Oct 12, 2026 | 3 refills | Active |
|
Atorvastatin Calcium
Lipitor • Statin
|
10 mg | 1 tablet at bedtime | Oral (PO) | Jul 18, 2025 | 2 refills | Active |
|
Potassium Chloride ER
Klor-Con • Mineral Supplement
|
20 mEq | 1 tablet twice daily with meals | Oral (PO) | Oct 12, 2026 | 0 refills | Short-term (3d) |
|
Amoxicillin
Amoxil • Penicillin Class
|
500 mg | -- | -- | Sep 10, 2021 | 0 | Contraindicated (Allergic) |
Laboratory & Diagnostic Reports
Automated HL7 Lab Interconnect| Test Panel | Observed Value | Reference Range | Status | Reported By | Date | Report |
|---|---|---|---|---|---|---|
|
Complete Blood Count (CBC)
WBC: 6.8 K/uL, Hemoglobin: 13.8 g/dL
|
Normal | Standard Range | Normal | Central Lab | Oct 13, 2026 | |
|
Serum Potassium (K+)
Electrolyte Panel
|
5.2 mEq/L | 3.5 - 5.0 mEq/L | Slightly Elevated | Pathology Team | Oct 13, 2026 | |
|
Lipid Panel
Total Chol: 178 mg/dL, LDL: 94 mg/dL
|
Optimal | < 200 mg/dL | Normal | Biochem Dept | Oct 12, 2026 | |
|
12-Lead Electrocardiogram (ECG)
Sinus rhythm with regular PR interval (142 ms)
|
Sinus Rhythm | Normal Axis | Normal | Cardio Lab | Oct 12, 2026 |