Medical Record For Bucks, J.

Past Medical History

Allergies

None

Medical Problems

Exercise induced asthma, Eczema, Bowel obstruction (2002)

Surgical History

Bowel surgery (2002), Nasal polyps removed

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	85	70-100
BUN	11	5-20
Creatinine	1.1	0.5-1.5
Sodium	139	135-145
Potassium	3.9	3.5-5.0
Chloride	100	95-105
Calcium	9.2	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	5.2	4.8-10.8
RBC	5.9	4.7-6.1
HGB	13.8	12.6-17.4
HCT	48	37-51
Platelets	228	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	8.2	7.6-10.6
PTT	29	26-38
INR	0.09	0.8-1.2
D-dimer	<0.50	<0.50

Cardiac Labs

Lab Result	Tested Value	Normal Value Range
BNP	<125	<125

Vital Signs

Time	0800
Heart Rate	92
Blood Pressure	128/68
Respiratory Rate	22
Pulse Ox	88% on Room Air
Temperature	98.6 F Oral
Pain	4/10

Provider Notes

Time	Provider	Notes
0900	Johhanna Bach ER NP	Patient admitted for wheezing, home inhaler not working. Recently started playing in an adult soccer league. Has had a history of excercise induce asthma. States there is a slight tightness of the chest and has had trouble sleeping due to the wheezing