Patient Picture
Patient Information
DOB: 01/04/1962
Sex: M
Diagnosis: Right shoulder rotator cuff tear
Proposed Surgical Procedure: Right shoulder arthroscopy
Surgeon: Dr David Castle
Medical History
Allergies: NKDA
Cardiovascular: NONE
Pulmonary: Asthma, Smoking History
Neurology/Neuromuscular: Other Anxiety NONE
GI/Endocrine: Diabetes Type 2
Hematology: NONE
GYN/GU: NONE
Anesthesia History: No anesthetic complications
Smoker: 1 pack per day x 14 years, quit 4 years ago
Alcohol: N/A
Ilicit Drugs: N/A
Comments on Positive Assessment/Conditions Not Listed:
Past Surgical History
Surgery: Left Knee Arthroscopy
Year of Surgery: 2016
Facility: York Hospital
Complications: None
Family history: non-contributory
Admission Lab Test Results
Lab ID: 210045669
| Test | Normal Value Range | Test Result |
|---|---|---|
| WBC | 4-10 g/dL | 5 |
| Hemoglobin | 12.0-15.0 g/100ml | 13 g/100ml |
| Hematocrit | 36-44% | 38% |
| MCV | 80-100 | 80 |
| MCHC% | 31-37 | 35 |
| Platelet Count | 100,000-450,000/mL | 130,000 |
| PT(Prothrombin Time) | 10-14 seconds | 13 seconds |
| PTT(Partial Thromboplastin Time) | 32-45 seconds | 40 seconds |
| INR | 0.8-1.2 | 1.2 |
Chemistry Test Results
| Test | Normal Value Range | Test Result |
|---|---|---|
| Sodium | 137-145 mEq/L | 138 |
| Potassium | 3.6-5.0 mEq/L | 3.8 |
| Chloride | 90-109 mEq/L | 94 |
| Bicarbonate (HCO3) | 22-30 mEq/L | 26 |
| Blood Urea Nitrogen (BUN) | 7-21 mg/dL | 15 |
| Creatinine | 0.5-1.4 mg/dL | 1.1 |
| Glucose | 65-110 mg/d | 73 |
Current Medications
| Medication | Dosage | Frequency |
|---|---|---|
| Spivera | 2 puffs | QD |
| Albuterol inhaler | 2 puffs | PRN |
| Ozempic | 1 mg | Weekly |
| Motrin | 600mg | PRN |