Medical Record For Amy Jones
Patient Information
Amy Jones
DOB:
2/13/1957
Sex:
Female
Gender Idenity:
Female
MRN:
843201
Weight:
150 lbs or 68.04 kg
Admitting Diagnosis:
Diarrhea
Admitting Physician:
Michael Stark M.D.
Past Medical History
Allergies
No Known Drug Allergies/Tree Nuts(Hives)
Medical Problems
heart failure, hypertension, ovarian cyst
Surgical History
hysterectomy at age 50, wisdom teeth removal at age 20
Social History
widowed, retired. Denies tobacco, etoh, and substance use
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Michael Stark M.D. | AAOx3, in bed. Patient started having diarrhea 3 days ago with associated loss of appetite and nausea. Denies vomiting. Patient ate at a roadside diner while traveling about 5 days ago. Patient had a large salad with salmon. Patient felt queasy several hours after the meal and developed watery stools 2 days later. She thought the diarrhea would pass, but became worried today when they continue to have multiple episodes of liquid diarrhea and things have not improved. She also felt increasingly fatigued with palpitations. Monitor patient for dehydration. Evaluate for foodborne pathogen exposure. |
Vital Signs
| Time | 0800 | |
|---|---|---|
| Heart Rate | 126 bpm | |
| Blood Pressure | 92/58 mmHg | |
| Respiratory Rate | 18 breaths/min | |
| Temperature | 100.5 F | |
| Pulse Oximetry | 98% | |
| Oxygen in Liters | Room Air | |
| Pain | 6/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 75 | 70-99 mg/dL |
| BUN | 20 | 8-20 mg/dL |
| Creatinine | 1 | 0.44-1.03 mg/dL |
| Sodium | 138 | 136-144 mmol/L |
| Potassium | 3.8 | 3.5-5.1 mmol/L |
| Chloride | 101 | 101-111 mmol/L |
| Calcium | 7 | 8.9-10.3 mg/dL |
Comprehensive Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Albumin | 4.8 | 3.5-5.1 g/dL |
| Total Protein | 6.8 | 6.1-7.9 g/dL |
| Alkaline Phosphatase (ALP) | 46 | 38-126 U/L |
| Alanine Aminotransferase (ALT) | 44 | 14-54 U/L |
| Aspartate Aminotransferase (AST) | 36 | 15-41 U/L |
| Bilirubin | 0.9 | 0.3-1.2 mg/dL |
Complete Blood Count with Diff
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 13.4 | 4.0-11.0 THO/L |
| RBC | 4.3 | 3.80- 5.30 MIL/L |
| HGB | 12 | 13.5-17.5 g/dL |
| HCT | 40% | 36-48% |
| Platelets | 280 | 150-400 THO/uL |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Troponins | 0.02 | 0 -0.04 ng/mL |
| B-Natriuretic Peptide | 76 | < 100 pg/mL |
| Lactic Acid | 1 | < 2 mmol/L |
| Stool Culture | Pending | Negative |
| Urine Culture | Pending | Negative |