Medical Record For Yang, Suki

Past Medical History

Allergies

None

Medical Problems

High Cholesterol

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	90	70-100
BUN	16	5-20
Creatinine	1.4	0.5-1.5
Sodium	137	135-145
Potassium	4.1	3.5-5.0
Chloride	99	95-105
Calcium	10	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	7.8	4.8-10.8
RBC	5.3	4.7-6.1
HGB	13.2	12.6-17.4
HCT	44	37-51
MCV	87	80-94
MCH	30	27-31
MCHC	35	33-37
Platelets	255	130-400
Segmented Neutrophils %	60	50-70
Neutrophils, bands	0	0-5
Lymphocytes %	30	20-40
Monocytes %	6	0-15
Eosinophils %	0	0-6
Basophils %	0	0-2
Reticulocytes	0	0-1

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	8.1	7.6-10.6
PTT	28	26-38

Cardiac Enzymes

Lab Result	Tested Value	Normal Value Range
Troponin	0.6	<0.01

Vital Signs

Time	0400	0500	0800
Heart Rate	105	87	84
Blood Pressure	145/90	129/73	121/68
Respiratory Rate	22	18	16
Pulse Ox	97% on RA	98% on RA	98% on RA
Temperature	98.6 Oral	NOT RECORDED	NOT RECORDED

Provider Notes

Time	Provider	Notes
0400	James Rudolph, MD	Patient presents to ED with crushing chest pain x 2 hours, substernal with radiation to L jaw and down L arm. Pt denies numbness of left arm, AAOx3, no dizziness. Diaphoresis noted. Pt states only medical history is high cholesterol, managed with diet. EKG shows STEMI- heart alert activated and cath lab ready to receive patient.
0415	Terry Cloth, RN	Received patient to cath lab, AAOx3; per MD plan for cardiac cath with stent placement. Open heart team on call pending findings of cath.
0500	Destiny Martin, RN	Received patient from cath lab after stent placement x 2. Pt AAOx3, states no pain "just soreness" in R groin area (cath access site). New Medications prescribed by provider for 0800.