Patient Information

Past Medical History

Allergies

No Known Drug Allergies

Medical Problems

History of cocaine misuse, PTSD

Surgical History

Denies

Social History

Vapes, Drinks etoh daily, and smokes marijuana

Provider Notes

Time	Provider	Notes
0830	Michael Stark, M.D.	AAOx4, in bed. Patient reports onset of pain a few hours ago when they were relaxing on the couch and suddenly developed chest pain. Rates pain 10/10, sharp and throbbing, mid-sternum, no associated symptoms, nothing makes it better, and exertion makes it worse. Work up for chest pain, rule out myocardial infarction.

Vital Signs

Time	0800
Heart Rate	120 bpm
Blood Pressure	148/76 mmHg
Respiratory Rate	24 breaths/min
Temperature	98.5 F
Pulse Oximetry	96%
Oxygen in Liters	Room Air
Pain	8/10

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	82	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	4	3.5-5.1 mmol/L
Chloride	101	101-111 mmol/L
Calcium	9.2	8.9-10.3 mg/dL

Comprehensive Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Albumin	3.6	3.5-5.1 g/dL
Total Protein	6	6.1-7.9 g/dL
Alkaline Phosphatase (ALP)	108	38-126 U/L
Alanine Aminotransferase (ALT)	54	14-54 U/L
Aspartate Aminotransferase (AST)	40	15-41 U/L
Bilirubin	1	0.3-1.2 mg/dL

Complete Blood Count

Lab Result	Tested Value	Normal Value Range
WBC	7.5	4.0-11.0 THO/L
RBC	4.8	3.80- 5.30 MIL/L
HGB	14	12.5-15 g/dL
HCT	48%	36-48%
Platelets	284	150-400 THO/uL

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	11	11-13.5 seconds
PTT	28	25-35 seconds
INR	0.9	0.8-1.1

Additonal Labs

Lab Result	Tested Value	Normal Value Range
Troponins	0.04	0 -0.04 ng/mL
D-Dimer	0.5	< 0.50g/L