Medical Record For Terry Mann
Patient Information
Terry Mann
DOB:
1/22/1977
Sex:
Male
Gender Idenity:
Male
MRN:
843201
Weight:
162 lbs or 73.48 kg
Admitting Diagnosis:
Chest Pain
Admitting Physician:
Penny Potts M.D.
Past Medical History
Allergies
No Known Drug Allergies
Medical Problems
hypertension, hyperlipidemia, diabetes
Surgical History
Right knee arthroplasty at age 18 secondary to hockey injury
Social History
Newly divorced. Smokes 1PPD, Drinks 2 glasses of bourbon 5 days out of the week.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Penny Potts M.D. | AAOx3, in bed. Patient was at company BBQ earlier and developed midsternal chest pain about 2 hours into the event. The pain became persistently worse. The patient left and picnic and presented to the ED. Patient reports this is the worst pain he has ever felt, and it had not gone away. The midsternal pain is 10/10, burning with associated nausea and retching, nonproductive. Nothing makes it better or worse. It stays in the midsternal. No referred pain. The patient admitted for chest pain work up and to rule out myocardial infarction. |
Vital Signs
| Time | 0800 | |
|---|---|---|
| Heart Rate | 86 bpm | |
| Blood Pressure | 130/84 mmHg | |
| Respiratory Rate | 22 breaths/min | |
| Temperature | 98.4 F | |
| Pulse Oximetry | 97% | |
| Oxygen in Liters | Room Air | |
| Pain | 7/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 110 | 70-99 mg/dL |
| BUN | 14 | 8-20 mg/dL |
| Creatinine | 0.9 | 0.44-1.03 mg/dL |
| Sodium | 140 | 136-144 mmol/L |
| Potassium | 4.5 | 3.5-5.1 mmol/L |
| Chloride | 101 | 101-111 mmol/L |
| Calcium | 10 | 8.9-10.3 mg/dL |
Comprehensive Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Albumin | 5.1 | 3.5-5.1 g/dL |
| Total Protein | 7.1 | 6.1-7.9 g/dL |
| Alkaline Phosphatase (ALP) | 58 | 38-126 U/L |
| Alanine Aminotransferase (ALT) | 44 | 14-54 U/L |
| Aspartate Aminotransferase (AST) | 32 | 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 | 6.5 | 4.0-11.0 THO/L |
| RBC | 4.3 | 3.80- 5.30 MIL/L |
| HGB | 15 | 13.5-17.5 g/dL |
| HCT | 48% | 41-53% |
| Platelets | 360 | 150-400 THO/uL |
Coagulation Studies
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 12.5 | 11 -13.5 seconds |
| PTT | 30 | 25-35 seconds |
| INR | 1 | 0.8-1.1 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Troponins | 0.04 | 0 -0.04 ng/mL |
| D-Dimer | 0.5 | < 0.50g/L |