Medical Record For J. Porter

Nurse Report Video

Patient Information


Name
J. Porter
DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Nausea, Vomiting, Diarrhea x 3 Days
Admitting Physician:
Johhanna Bach ER PA

Past Medical History

Allergies

None

Medical Problems

None

Surgical History

None

Provider Notes

Time Provider Notes
0800 Mary Rolland, RN Patient presenting to ED triage with history of abdominal pain and cramping x 3 days located in the epigastric area of abdomen, patient describes as "sharp" and intermittant although getting worse x 3 days. Patient states pain started 3 days ago after dinner, lasted an hour and went away. Then 2 days ago the pain started after eating lunch and got worse throughout the day. Patient states pain 10/10 also woke them up in middle of night. Patient states fever of 101 yesterday with nausea, vomiting, and diarrhea x 3 days as well, denies any blood in vomit or stool. Patient reports they are currently taking the medication cephalexin to treat a UTI. Decreased skin turgor noted in assessment at triage. Patient AAOx3, labs sent, waiting for ED room.

Vital Signs

Time 0800
Heart Rate 110
Blood Pressure 95/70
Respiratory Rate 20
Pulse Ox 97% on Room Air
Temperature 101.4 F Oral
Pain 6/10

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 86 70-100
BUN 15 5-20
Creatinine 1.4 0.5-1.5
Sodium 134 135-145
Potassium 3.4 3.5-5.0
Chloride 94 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 30 26-38
INR 1.0 0.8-1.2