Patient Picture
Patient Information
DOB: 06/24/1953
Sex: F
Diagnosis: Cholecystitis
Proposed Surgical Procedure: Lap Cholecystectomy, possible open
Surgeon: Dr. Noah Blackwell
Medical History
Allergies: Codeine (nausea); Egg whites (rash)
Cardiovascular: NONE
Pulmonary: Asthma
Neurology/Neuromuscular: Osteoarthritis
GI/Endocrine: NONE
Hematology: NONE
GYN/GU: Kidney Disease
Anesthesia History: No anesthetic complications
Smoker: NONE
Alcohol: N/A
Ilicit Drugs: N/A
Comments on Positive Assessment/Conditions Not Listed:
Past Surgical History
Surgery: Cataract-Right eye
Year of Surgery: 2018
Facility: Pearlman Surgery Center
Complications: None
Surgery: Cataract-Left eye
Year of Surgery: 2017
Facility: Pearlman Surgery Center
Complications: None
Surgery: Left knee arthroscopy
Year of Surgery: 2012
Facility: Hahnemann Univ Hosp
Complications: Tooth was chipped
Family history: non-contributory
Admission Lab Test Results
Lab ID: 210045674
| Test | Normal Value Range | Test Result |
|---|---|---|
| WBC | 4-10 g/dL | 10 |
| Hemoglobin | 12.0-15.0 g/100ml | 12 |
| Hematocrit | 36-44% | 38.1% |
| MCV | 80-100 | 88 |
| MCHC% | 31-37 | 35 |
| Platelet Count | 100,000-450,000/mL | 211,000 |
| PT(Prothrombin Time) | 10-14 seconds | 14 seconds |
| PTT(Partial Thromboplastin Time) | 32-45 seconds | 39 seconds |
| INR | 0.8-1.2 | 1.0 |
Chemistry Test Results
| Test | Normal Value Range | Test Result |
|---|---|---|
| Sodium | 137-145 mEq/L | 139 |
| Potassium | 3.6-5.0 mEq/L | 4.5 |
| Chloride | 90-109 mEq/L | 102 |
| Bicarbonate (HCO3) | 22-30 mEq/L | 28 |
| Blood Urea Nitrogen (BUN) | 7-21 mg/dL | 32 |
| Creatinine | 0.5-1.4 mg/dL | 1.4 |
| Glucose | 65-110 mg/d | 92 |
Current Medications
| Medication | Dosage | Frequency |
|---|---|---|
| Advair diskus | 250/50 mg | Q12 hours |
| Celebrex | 100 mg | BID |