Medical Record For Perry, J.

Past Medical History

Allergies

None

Medical Problems

Arthritis, Basal cell carcinoma (1999), Dementia

Surgical History

Right knee replacement (2008), Tonsilectomy

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	157	70-100
BUN	15	5-20
Creatinine	0.9	0.5-1.5
Sodium	143	135-145
Potassium	3.9	3.5-5.0
Chloride	101	95-105
Calcium	10	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	9	4.8-10.8
RBC	5.1	4.7-6.1
HGB	12.2	12.6-17.4
HCT	45	37-51
Platelets	362	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	10.2	7.6-10.6
PTT	61.1	26-38
INR	1.1	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	76	86	82
Blood Pressure	126/80	130/88	128/86
Respiratory Rate	18	20	20
Pulse Ox	99% on Room Air	99% on Room Air	99% on Room Air
Temperature	98.6 F Oral	98.2 F Oral	98.8 F Oral
Pain	0/10	0/10	0/10

Provider Notes

Time	Provider	Notes
1700	Johhanna Bach ER NP	Patient dx dementia 5 years ago. Has been living at home with family andbeing cared for with assistance of home health aids who assist with bathing and giving the family a break during the day. Patient has becomeincreasingly confused, incresed episodes of incontinence when usually can verbalize need for the bathroom, has become combative during meal times and medication administration. PCP recommended bringing patient to the ER to be evaluated for long term care placement