Medical Record For Monroe, W.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Headache and High Blood Pressure
Admitting Physician:
Johhanna Bach ER NP

Past Medical History

Allergies

None

Medical Problems

High Blood Pressure, Tooth Abcess

Surgical History

Plantar warts removed b/l feet, Appendectomy 1980's

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	98	70-100
BUN	21	5-20
Creatinine	0.96	0.5-1.5
Sodium	138	135-145
Potassium	4.2	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	8.2	4.8-10.8
RBC	6	4.7-6.1
HGB	15	12.6-17.4
HCT	45	37-51
Platelets	156	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	11	7.6-10.6
PTT	62	26-38
INR	0.9	0.8-1.2

Vital Signs

Time	0800	1200	1600
Heart Rate	89	88	92
Blood Pressure	176/86	182/88	170/78
Respiratory Rate	18	20	18
Pulse Ox	99% on Room Air	99% on Room Air	99% on Room Air
Temperature	97.9 F Oral	98.6 F Oral	98.2 F Oral
Pain	6/10	7/10	4/10

Provider Notes

Time	Provider	Notes
1400	Johhanna Bach ER PA	Patient admitted with a headache for 2 days with no relief from Tylenol/Motrin. Pateint states they ran out of their blood pressure medication at home and haven't had a chance to go to the pharmacy to pcik uptheir refill, pharmacy does not deliver.
1830	Johhanna Bach ER PA	Need to consult social work/care management. Recently unemployed, no health insurance/perscription coverage.