Medical Record For Miller, Veronica

Past Medical History

Allergies

None

Medical Problems

High Cholesterol

Surgical History

Hysterectomy
L Knee Replacement

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	130	70-100
BUN	18	5-20
Creatinine	1.2	0.5-1.5
Sodium	131	135-145
Potassium	3.7	3.5-5.0
Chloride	99	95-105
Calcium	9.8	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	8.2	4.8-10.8
RBC	5.1	4.7-6.1
HGB	13.1	12.6-17.4
HCT	39	37-51
MCV	85	80-94
MCH	28	27-31
MCHC	35	33-37
Platelets	190	130-400
Segmented Neutrophils %	61	50-70
Neutrophils, bands	0	0-5
Lymphocytes %	26	20-40
Monocytes %	7	0-15
Eosinophils %	3	0-6
Basophils %	1	0-2
Reticulocytes	0	0-1

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	9.1	7.6-10.6
PTT	30	26-38

Cardiac Enzymes

Lab Result	Tested Value	Normal Value Range
Troponin	0.7	<0.01

Vital Signs

Time	2000	0000	0400
Heart Rate	109	80	85
Blood Pressure	150/90	120/85	121/87
Respiratory Rate	22	14	16
Pulse Ox	98% on 2L NC	98% on RA	97% on RA
Temperature	98.6 Oral	NOT RECORDED	NOT RECORDED

Provider Notes

Time	Provider	Notes
2000	Wilson James, MD	65 yo female presenting to the ED with chest pain x 1 hour, getting worse. On arrival, pt diaphoretic with crushing chest pain radiating to back, complains also of heartburn x 1 hour. EKG shows STEMI. Heart Alert activated to open cath lab. Plan to admit to cardiac ICU post cath lab.
0000	Jen Carroll, RN	Assumed care of patient in cardiac ICU status post cath lab with stent placement. 18G IVR in RFA patent to NS flush with + blood return. Pt AAOx3 with GCS 15, denies pain but states "sore" after cath lab. Cath access site in L thigh without signs of bleeding, bruising or hematoma, neurovascular checks WNL in all extremities. Will continue to monitor.
0400	Jen Carroll, RN	Pt sleeping comfortably at this time, vital signs within normal limits, will continue to monitor. NSR on monitor.