Medical Record For York, Jackie



DOB:
12/25/1961
MRN:
8433220
Weight:
160lb or 73kg
Admitting Diagnosis:
Migraine
Admitting Physician:
Johanna Bach, PA

Past Medical History

Allergies

None

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 86 70-100
BUN 10 5-20
Creatinine 0.7 0.5-1.5
Sodium 134 135-145
Potassium 3.5 3.5-5.0
Chloride 99 95-105
Calcium 9.6 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 10.2 4.8-10.8
RBC 4.8 4.7-6.1
HGB 13 12.6-17.4
HCT 42 37-51

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 9.5 7.6-10.6
PTT 59 26-38
INR 0.9 0.8-1.2

Vital Signs

Time 0800 1200
Heart Rate 98 102
Blood Pressure 160/80 162/88
Respiratory Rate 18 18
Pulse Ox 98% on RA 98% on RA
Temperature 99.6 Oral 99.2 Oral
Pain 1/10 8/10

Provider Notes

Time Provider Notes
0730 Johanna Bach, PA Patient admitted with unilateral headache that will not go away despite use of alternating Tylenol and Motrin for 48 hours. Headache is over left eye and left forehead. States feels nauseous. No recent falls or head trauma, never felt this type of pain before. Extremely sensitive to light and smells. Has spent the last 48 hours in bed with an ice pack on the head and covers over the eyes.