Medical Record For Berks, M.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Loose productive cough, fever
Admitting Physician:
Johhanna Bach ER NP

Past Medical History

Allergies

Latex

Medical Problems

Plantar fascitis

Surgical History

Lipoma removed from lower back

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	143	70-100
BUN	3	5-20
Creatinine	1.7	0.5-1.5
Sodium	135	135-145
Potassium	3.6	3.5-5.0
Chloride	95	95-105
Calcium	9.1	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	20	4.8-10.8
RBC	4.8	4.7-6.1
HGB	12.4	12.6-17.4
HCT	37	37-51
Platelets	130	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	85	82	90
Blood Pressure	166/56	170/62	168/60
Respiratory Rate	18	22	20
Pulse Ox	92% on Room Air	96% on 2L NC	93% on Room Air
Temperature	100.8 F Oral	101.1 F Oral	100.9 F Oral

Provider Notes

Time	Provider	Notes
1100	Johhanna Bach ER NP	Patient admitted with loose productive cough and pleuritic chest pain. States has been watching his grandchild since day care is closed and child recently had a runny nose and cough. Stating cough is productive with white mucus, chest hurts from coughing so much. Has tried Sudafed adn vicks. Sleeping with a humidifuer all with no relief.