Medical Record For Blair, L.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Chest pain, relief with home Nitroglycerin
Admitting Physician:
Johhanna Bach ER PA

Past Medical History

Allergies

None

Medical Problems

Angina, Anxiety, Eczema, Cystitis

Surgical History

Cardiac Catheterization

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	86	70-100
BUN	15	5-20
Creatinine	1.1	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	11	4.8-10.8
RBC	5.1	4.7-6.1
HGB	12.2	12.6-17.4
HCT	40	37-51
Platelets	399	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	102	99	110
Blood Pressure	110/72	98/70	106/78
Respiratory Rate	20	20	20
Pulse Ox	97% on Room Air	97% on Room Air	96% on Room Air
Temperature	98.4 F Oral	98.6 F Oral	98.2 F Oral
Pain	0/10	2/10	1/10

Provider Notes

Time	Provider	Notes
0715	Johhanna Bach ER PA	Patient came to the hospital because they took 3 doses of NTG at home with relief for chest pain. Has had this happen in the past. Patient states "chest pain scared me., I usually only have to take 1 pill to relieve the pain". Patient appears very anxious. States they are afraid the pain will come back
1130	Johhanna Bach ER PA	Consult psych, anxiety