Patient Picture
Patient Information
Justine Jackson
DOB:
06/13/1980
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Appendicitis status post MVC
Admitting Physician:
Johhanna Bach ER PA
Past Medical History
Allergies
None
Medical Problems
Marijuana use
Surgical History
Fractured ankle with 4 screws placed, Tonsillectomy, Wisdom Teeth Extraction
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0800 | Mary Rolland, RN | Assumed care of patient, patient AAOx4, patient oriented to room, hospital policies, and surroundings. Admitted after a car accident for abdominal pain. Complains of pain in abdomen primarily in RLQ. Positive rebound tenderness noted. Patient with fever and chills. Vital signs stable except for temperature of 101.2 degrees F and elevated heart rate at 110. WBCs elevated. Provider notified that scans completed in ER and requested to come see patient. Patient kept NPO at this time. |
Vital Signs
| Time | 0800 |
|---|---|
| Heart Rate | 110 |
| Blood Pressure | 138/80 |
| Respiratory Rate | 22 |
| Pulse Ox | 98% on Room Air |
| Temperature | 101.2 F Oral |
| Pain | 10/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 86 | 70-100 |
| BUN | 18 | 5-20 |
| Creatinine | 0.8 | 0.5-1.5 |
| Sodium | 136 | 135-145 |
| Potassium | 3.5 | 3.5-5.0 |
| Chloride | 95 | 95-105 |
| Calcium | 10 | 9-11 |
Complete Blood Count with Diff
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 14.0 | 4.8-10.8 |
| RBC | 5.1 | 4.7-6.1 |
| HGB | 13.8 | 12.6-17.4 |
| HCT | 39 | 37-51 |
| Platelets | 300 | 130-400 |
Coagulation Studies
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 10.4 | 7.6-10.6 |
| PTT | 31 | 26-38 |
| INR | 1.1 | 0.8-1.2 |