Medical Record For Ladel, A.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Dyspnea on exertion
Admitting Physician:
Johhanna Bach ER NP

Past Medical History

Allergies

None

Medical Problems

Chicken pox, Retinal detachment right eye

Surgical History

Spine surgery (2012), Tonsils removed as a child

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	201	70-100
BUN	11	5-20
Creatinine	0.9	0.5-1.5
Sodium	136	135-145
Potassium	3.8	3.5-5.0
Chloride	99	95-105
Calcium	9.2	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	9	4.8-10.8
RBC	4.7	4.7-6.1
HGB	8.8	12.6-17.4
HCT	32	37-51
Platelets	131	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	9.4	7.6-10.6
PTT	29	26-38
INR	1.2	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	79	76	78
Blood Pressure	158/90	152/88	150/78
Respiratory Rate	24	24	24
Pulse Ox	92% on Room Air	94% on 2L NC	94% on 2L NC
Temperature	99.1 F Oral	99.0 F Oral	99.0 F Oral
Pain	0/10	0/10	0/10

Provider Notes

Time	Provider	Notes
1100	Johhanna Bach ER NP	Patient admitted for SOB with activity. States when they walk more than to the bathroom and back they get very short of breath. Stated they have noticed their skin is paler than usual, hands and feet are cold, they have been getting dizzy at times and that has never happened before. Feels extra tired most of the day even after getting a good nights rest