Medical Record For Carson Mills

Patient Picture

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Patient Information

Carson Mills
160lb or 73kg
Admitting Diagnosis:
SBO, Anemia
Admitting Physician:
Johhanna Bach ER PA

Past Medical History



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


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