Patient Picture
Patient Information
Carson Mills
DOB:
01/17/1970
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
SBO, Anemia
Admitting Physician:
Johhanna Bach ER PA
Past Medical History
Allergies
Penicillin
Medical Problems
GERD, Asthma, Migraines, Anxiety, Mitral Valve Regurgitation
Surgical History
Right meniscus tear repair
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0800 | Mary Rolland, RN | Assumed care of patient, patient AAOx4, patient oriented to room, hospital policies, and surroundings. Patient describes coming to hospital due to vomiting blood and abdominal pain that comes and goes. Patient reports vomiting makes the pain go away. Abdominal distention noted on assessment. Abdominal Xray positive for small bowel obstruction per provider. H/H low, patient reports feeling tired and dizzy. Patient placed on fall precautions. Awaiting provider orders for transfusion of PRBCs and NG tube. Patient resting comfortably at this time, will continue to monitor. |
Vital Signs
| Time | 0800 |
|---|---|
| Heart Rate | 110 |
| Blood Pressure | 95/70 |
| Respiratory Rate | 20 |
| Pulse Ox | 97% on Room Air |
| Temperature | 98.6 F Oral |
| Pain | 9/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 86 | 70-100 |
| BUN | 22 | 5-20 |
| Creatinine | 1.9 | 0.5-1.5 |
| Sodium | 136 | 135-145 |
| Potassium | 3.5 | 3.5-5.0 |
| Chloride | 95 | 95-105 |
| Calcium | 10 | 9-11 |
Complete Blood Count with Diff
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 10.8 | 4.8-10.8 |
| RBC | 3.1 | 4.7-6.1 |
| HGB | 6.8 | 12.6-17.4 |
| HCT | 30 | 37-51 |
| Platelets | 350 | 130-400 |
Coagulation Studies
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 10.2 | 7.6-10.6 |
| PTT | 30 | 26-38 |
| INR | 1.0 | 0.8-1.2 |