Medical Record For Camden, T.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Hx Atrial fibrillation, Feeling fluttering in chest with palpitations
Admitting Physician:
Johhanna Bach ER PA

Past Medical History

Allergies

None

Medical Problems

Atrial Fibrillation

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	88	70-100
BUN	10	5-20
Creatinine	0.77	0.5-1.5
Sodium	135	135-145
Potassium	5	3.5-5.0
Chloride	102	95-105
Calcium	8.6	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	7	4.8-10.8
RBC	5.2	4.7-6.1
HGB	12	12.6-17.4
HCT	41	37-51
Platelets	130	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	8.2	7.6-10.6
PTT	54	26-38
INR	1.4	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	99	102	97
Blood Pressure	112/58	116/72	110/66
Respiratory Rate	18	18	18
Pulse Ox	97% on Room Air	96% on Room Air	96% on Room Air
Temperature	98.0 F Oral	97.9 F Oral	98.5 F Oral
Pain	0/10	0/10	0/10

Provider Notes

Time	Provider	Notes
0830	Johhanna Bach ER PA	Patient admitted for a feeling of fluttering in the chest adn palpitations. Has a history of artial fibrillation, on anticoagulant at home, states is compliant with medications.
1100	Johhanna Bach ER PA	Consult dietician, patient needs dietary education (coumadin & vitamin K).