Medical Record For Reynolds, Caroline


Caroline
DOB:
09/09/1965
MRN:
946221
Weight:
160lb or 73kg
Admitting Diagnosis:
Afib
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

Latex

Medical Problems

High Cholesterol

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 130 70-100
BUN 18 5-20
Creatinine 1.2 0.5-1.5
Sodium 131 135-145
Potassium 3.7 3.5-5.0
Chloride 99 95-105
Calcium 9.8 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 8.2 4.8-10.8
RBC 5.1 4.7-6.1
HGB 13.1 12.6-17.4
HCT 39 37-51
MCV 85 80-94
MCH 28 27-31
MCHC 35 33-37
Platelets 190 130-400
Segmented Neutrophils % 61 50-70
Neutrophils, bands 0 0-5
Lymphocytes % 26 20-40
Monocytes % 7 0-15
Eosinophils % 3 0-6
Basophils % 1 0-2
Reticulocytes 0 0-1

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 9.1 7.6-10.6
PTT 30 26-38

Cardiac Enzymes

Lab Result Tested Value Normal Value Range
Troponin <0.01 <0.01

Vital Signs

Time 2000 0000 0400
Heart Rate 88 90 85
Blood Pressure 129/71 120/85 121/87
Respiratory Rate 18 14 16
Pulse Ox 96% on RA 98% on RA 97% on RA
Temperature 98.6 Oral NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD 55 year old female presenting to ED with complaints of feeling chest palpitations for the past week and started feeling dizzier the past few days so went to get it checked out. EKG shows Afib,rate controlled. Pt denies history of Afib. Pt in Afib on tele with HR 88 currently (controlled). Admit to floor telemetry to monitor and consider treatment.