Medical Record For Joe Capistrano
Patient Information
Joe Capistrano
DOB:
4/26/1970
Sex:
Male
Gender Idenity:
MRN:
843201
Weight:
175 lbs or 79.38 kg
Admitting Diagnosis:
Heart Failure Exacerbation
Admitting Physician:
Michael Stark, M.D.
Past Medical History
Allergies
None
Medical Problems
Heart failure, hypertension, hyperlipidemia, myocardial infarction 3 months ago
Surgical History
Wisdom teeth removal at age 18. Cardiac angioplasty with stenting 5/2024.
Social History
Lives with spouse of 35 years. Has two adult children, both live out of state. Retired 1/2024, formerly worked as an accountant. Former smoker quit 20 years ago and has a 25-pack-year history. Drinks a glass of scotch almost nightly. Denies illicit drug use.
Immunizations
Up to date on all immunizations
Family History
Both parents deceased. Father died of myocardial infarction at age 58. Mother died of breast cancer at age 53. Sister, age 65 is alive with hypertension and hyperlipidemia.
Medications
aspirin 81mg by mouth once daily, metoprolol 50mg by mouth once daily, furosemide 40mg by mouth once daily, clopidogrel 75mg by mouth once daily.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Michael Stark, M.D. | Patient admitted for heart failure exacerbation. Patient presented to the emergency department overnight with complaints of shortness of breath, fatigue, and increased edema in lower extremities. The shortness of breath worsens when lying flat. They have been sleeping at home in a reclined position. Patient reports weight gain of greater than 10lbs over the past two days. Denies fevers/chills. Denies chest pain. Started diuresis in the ED, and the patient has been responding well. Continue with diuresis. Monitor I/Os closely. Awaiting chest x-ray results. |
Vital Signs
| Time | 0800 | |
|---|---|---|
| Heart Rate | 110 bpm | |
| Blood Pressure | 160/95 mmHg | |
| Respiratory Rate | 26 breaths/min | |
| Temperature | 98.2 F | |
| Pulse Oximetry | 90% | |
| Oxygen in Liters | On Room Air | |
| Pain | 5/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| BUN | 30 md/dL | 10-20 mg/dL |
| Creatinine | 1.4 mg/dL | 0.5-1.2 mg/dL |
| Glucose | 88 mg/dL | 65-100 mg/dL |
| Potassium | 5.0 mEq/L | 3.5-5.0 mEq/L |
| Sodium | 136 mEq/L | 135-143 mEq/L |
Complete Blood Count
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 5,500/uL | 5,000-10000/uL |
| RBC | 4.5 Million/uL | 4.2-5.4 million/uL |
| HGB | 13.4 g/dL | 12-16 g/dL |
| HCT | 38 % | 36-45% |
| Platelet Count | 345,000/uL | 150,000-400,000/uL |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| pH | 7.32 | 7.38-7.44 |
| PC02 | 55 mmHg | 35-45 mmHg |
| P02 | 60 mmHg | 80-100 mmHg |
| 02 sat | 95% | >95% |