Medical Record For Warren, E.

DOB:
12/25/1961
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
TIA (Transient Ischemic Attack)
Admitting Physician:
Johhanna Bach ER NP

Past Medical History

Allergies

None

Medical Problems

Diabetes, High cholesterol, Peripherial arterial disease

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	229	70-100
BUN	18	5-20
Creatinine	0.7	0.5-1.5
Sodium	138	135-145
Potassium	3.6	3.5-5.0
Chloride	100	95-105
Calcium	8.9	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	8.7	4.8-10.8
RBC	4.9	4.7-6.1
HGB	13.5	12.6-17.4
HCT	46	37-51
Platelets	227	130-400

Coagulation Studies

Lab Result	Tested Value	Normal Value Range
PT	11	7.6-10.6
PTT	62	26-38
INR	1	0.8-1.2

Vital Signs

Time	0800	1200
Heart Rate	102	98
Blood Pressure	176/86	172/88
Respiratory Rate	20	20
Pulse Ox	98% on Room Air	98% on Room Air
Temperature	98.9 F Oral	98.8 F Oral
Pain	0/10	0/10

Provider Notes

Time	Provider	Notes
2215	Johhanna Bach ER NP	Patient admtted for right sided weakness, blurred vision and slurred speech. Resolved int he emergency room. Needs 48 hours in hospital observation before can be discharged.