Patient Picture
Patient Information
DOB: 06/16/1963
Sex: F
Diagnosis: DJD Right Hip
Proposed Surgical Procedure: Right Total Hip Arthroplasty
Surgeon: Dr. Matthew Wesley
Medical History
Allergies: NKDA
Cardiovascular: Hypertension
Pulmonary: Smoking History
Neurology/Neuromuscular: Migraines
GI/Endocrine: GERD
Hematology: Cancer
GYN/GU: NONE
Anesthesia History: No anesthetic complications
Smoker: 1 pack per day x 20 years
Alcohol: N/A
Ilicit Drugs: N/A
Comments on Positive Assessment/Conditions Not Listed: Left breast cancer
Past Surgical History
Surgery: Sphenopalatine block
Year of Surgery: 2018
Facility: Hospital Univ Penn
Complications: None
Surgery: Left breast mastectomy
Year of Surgery: 2015
Facility: Thomas Jefferson Hosp
Complications: PONV
Family history: non-contributory
Admission Lab Test Results
Lab ID: 210045678
| Test | Normal Value Range | Test Result |
|---|---|---|
| WBC | 4-10 g/dL | 10 |
| Hemoglobin | 12.0-15.0 g/100ml | 13.6 gm/100ml |
| Hematocrit | 36-44% | 40.6 |
| MCV | 80-100 | 88 |
| MCHC% | 31-37 | 35 |
| Platelet Count | 100,000-450,000/mL | 140,000 |
| PT(Prothrombin Time) | 10-14 seconds | 14 seconds |
| PTT(Partial Thromboplastin Time) | 32-45 seconds | 41 seconds |
| INR | 0.8-1.2 | 1.1 |
Chemistry Test Results
| Test | Normal Value Range | Test Result |
|---|---|---|
| Sodium | 137-145 mEq/L | 140 |
| Potassium | 3.6-5.0 mEq/L | 4.1 |
| Chloride | 90-109 mEq/L | 104 |
| Bicarbonate (HCO3) | 22-30 mEq/L | 26 |
| Blood Urea Nitrogen (BUN) | 7-21 mg/dL | 16 |
| Creatinine | 0.5-1.4 mg/dL | 0.9 |
| Glucose | 65-110 mg/d | 109 |
Current Medications
| Medication | Dosage | Frequency |
|---|---|---|
| Hyzaar | 50/12.5 mg | QD |
| Prevacid | 15 mg | QD |
| Motrin | 600mg | TID |