Medical Record For Perez, Eric



Joy
DOB:
2/14/2000
MRN:
689892
Weight:
160lb or 73kg
Admitting Diagnosis:
Schizophrenia
Admitting Physician:
Janel Stiller, MD

Past Medical History

Allergies

Penicillin

Medical Problems

Schizophrenia

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 80 70-100
BUN 11 5-20
Creatinine 1.2 0.5-1.5
Sodium 135 135-145
Potassium 3.9 3.5-5.0
Chloride 97 95-105
Calcium 9.5 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 6.8 4.8-10.8
RBC 5.5 4.7-6.1
HGB 13.6 12.6-17.4
HCT 44 37-51

Thyroid Studies

Lab Result Tested Value Normal Value Range
TSH 2.1 0.3-5.0
T3 2.4 2.0-4.4
T4 1.2 0.7-1.7

Vital Signs

Time 1300
Heart Rate 131
Blood Pressure 139/89
Respiratory Rate 24
Pulse Ox 98% on RA
Temperature 98.6 Oral
Pain 0

Provider Notes

Time Provider Notes
1300 Janel Stiller, MD Patient presents to the ER complaining that he "can't stop moving". When assessing patient, he is pacing in the room and appears agitated but redirectable and reasonable. Mother at the bedside with patient. States patient recently diagnosed with schizophrenia after having an acute psychotic episode 2 months ago when he was hospitalized and started on Haldol. Patient denies suicidal or homicidal ideation and states he has been taking his medications as ordered; Mom confirms. Denies auditory or visual hallucinations or delusions. Pt AAOx3 and appears well groomed and able to carry on conversation with appropriate affect.