Medical Record For Montgomery, O.

Past Medical History

Allergies

None

Medical Problems

Smoker, COPD, Chronic Bronchitis

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	199	70-100
BUN	9	5-20
Creatinine	0.9	0.5-1.5
Sodium	140	135-145
Potassium	3.8	3.5-5.0
Chloride	99	95-105
Calcium	8.9	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	12	4.8-10.8
RBC	5.2	4.7-6.1
HGB	12.6	12.6-17.4
HCT	41	37-51
Platelets	224	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	10.2	7.6-10.6
PTT	31	26-38
INR	1.1	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	68	70	66
Blood Pressure	146/78	144/70	150/66
Respiratory Rate	22	24	24
Pulse Ox	88% on Room Air	90% on 2L NC	93% on 4L NC
Temperature	100.8 F Oral	101.1 F Oral	100.9 F Oral
Pain	0/10	0/10	0/10

Provider Notes

Time	Provider	Notes
1600	Johhanna Bach ER NP	Patient admitted for low pulse ox. States uses 3L oxygen at hime but recently has had to increase to 5L or 6L after walking to the bathroom. History of 2 pack a day smoker for 25 years. States still "sneaks a smoke" occasionally.
1800	Johhanna Bach ER NP	addendum - ABG's ph 7.36, PCO2 51, HCO3 26, PO2 63; respiratory acidosis