Medical Record For Justine Jackson

Patient Picture

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Patient Information

Justine Jackson
160lb or 73kg
Admitting Diagnosis:
Appendicitis status post MVC
Admitting Physician:
Johhanna Bach ER PA

Past Medical History



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


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