Medical Record For Sullivan, R.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Witnessed Seizure
Admitting Physician:
Johhanna Bach ER NP

Past Medical History

Allergies

None

Medical Problems

Seizures, Hypothyroidism, Broken left foot

Surgical History

Cholecystectomy

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	98	70-100
BUN	11	5-20
Creatinine	0.92	0.5-1.5
Sodium	145	135-145
Potassium	4.2	3.5-5.0
Chloride	101	95-105
Calcium	9.2	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	14.2	4.8-10.8
RBC	4.2	4.7-6.1
HGB	14.5	12.6-17.4
HCT	42	37-51
Platelets	352	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	9.9	7.6-10.6
PTT	58	26-38
INR	1.2	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	78	77	80
Blood Pressure	118/62	120/68	114/66
Respiratory Rate	18	20	18
Pulse Ox	99% on Room Air	97% on Room Air	98% on Room Air
Temperature	98.6 F Oral	98.2 F Oral	98.8 F Oral
Pain	0/10	0/10	0/10

Provider Notes

Time	Provider	Notes
0930	Johhanna Bach ER NP	Patient admitted for witnessed clonic seizure at home. Awating theraputic level of medication (dilantin). Has had a history of seizure disrder since childhood, has not has a seizure in over 10 years.