Medication Reconciliation
Admission and discharge medication reconciliation record
4 medication discrepancies identified — withheld, discontinued, or pending review. Inform treating team.
Lakshmi Nair, 62F — UH-2026-0744 · ICU-2
8 medications
4 discrepancies
| Medication | Pre-Admission | Inpatient | Action | Notes |
|---|---|---|---|---|
| Aspirin 75 mg OD | ✓ | ✓ | Continue | Antiplatelet — continue perioperatively |
| Ticagrelor 90 mg BD | ✓ | ✓ | Withhold | Withheld 5 days pre-OT per surgical team instruction. Restart post-op day 1. |
| Metformin 1g BD | ✓ | — | Withhold | Withheld on admission — contrast CT planned; restart 48h after contrast if eGFR stable. |
| Ramipril 5 mg OD | ✓ | — | Discontinued | Discontinued — AKI on CKD background, K+ 5.4. Review at discharge. |
| Atorvastatin 40 mg ON | ✓ | ✓ | Continue | — |
| Noradrenaline 0.08 mcg/kg/min | — | ✓ | New | Started in ICU for haemodynamic support |
| Pantoprazole 40 mg OD | — | ✓ | New | GI prophylaxis on ICU admission |
| Warfarin 5 mg OD | ✓ | — | Pending Review | INR supratherapeutic on admission (3.4). Rheumatology to advise bridging plan. |