Medical Record For Adams, J.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Orthostatic Hypotension; Fall
Admitting Physician:
Johhanna Bach ER PA

Past Medical History

Allergies

None

Medical Problems

Orthostatic hypotension, Rosacea

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	79	70-100
BUN	21	5-20
Creatinine	1.1	0.5-1.5
Sodium	141	135-145
Potassium	4.1	3.5-5.0
Chloride	99	95-105
Calcium	9.2	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	11.5	4.8-10.8
RBC	4.9	4.7-6.1
HGB	13.6	12.6-17.4
HCT	45	37-51
Platelets	154	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	9.2	7.6-10.6
PTT	59	26-38
INR	1	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	88	86	90
Blood Pressure	100/60	96/64	98/66
Respiratory Rate	18	20	20
Pulse Ox	95% on Room Air	96% on Room Air	95% on Room Air
Temperature	98.6 F Oral	98.2 F Oral	98.6 F Oral
Pain	0/10	0/10	0/10

Provider Notes

Time	Provider	Notes
1100	Johhanna Bach ER PA	Patient admitted for dizziness and lightheadedness when standing up too fast. Patient states "room felt like it was spinning and like they were going to faint" Was directed by PCP to wear compression stocking 12 hours on and 12 hours off at home. Patient states they don't like wearing them because they are too tight and ugly.