Name
Age
Height
Weight
Sex
Charlie Nowak
38
5 ft 8 in
140 lb
Female
VITALS
140/90 mm Hg
Blood Pressure
60 bpm
Heart Rate
12 bpm
Respiratory Rate
98.7 °F
Temperature ℉
98%
SpO2
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Appointment Notes
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Ears, nose and throat were normal, small amount of mucus in nasal cavities.
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Heart and lung sounds were normal.
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Urine sample taken and sent to the lab for testing. Urine was dark yellow color.
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There was a slight decrease in skin turgor upon physical exam.
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A mole on the left shoulder showed irregular borders and at least three distinct colors.
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Eye exam was normal; Visual acuity - 20/70 in right eye; 20/50 in left eye. Patient does not wear corrective lens.
Patient History
- Refer to your notes
Patient Health Conditions
-
n/a
Medications
- Ibuprofen (as needed for pain)
- Multivitamin (sporadic use)
Lab Result
-
Complete Blood Count Results:
Patient’s Measurement Normal Range (female) WBC count 5,005 cells/mcL 4,500 – 10,000 cells/mcL RBC count 5.5 million cells/mcL 4.2 – 5.4 million cells/mcL Hematocrit 44.1% 36.1 – 44.3% Hemoglobin 14.6 g/dL 12.1 – 15.1 g/dL Platelet count 355,650/dL 150,000 – 450,000/dL -
Basic Metabolic Panel:
Patient’s Measurement Normal Range Glucose 75 mg/dL 65 – 99 mg/dL BUN 10 mg/dL 6 – 24 mg/dL Creatinine 0.61 mg/dL 0.57 – 1.00 mg/dL BUN/Creatinine ratio 16 9 – 23 Sodium 146 mmol/L 134 – 144 mmol/L Potassium 5.2 mmol/L 3.5 – 5.2 mmol/L Chloride 108 mmol/L 96 – 106 mmol/L Carbon Dioxide, total 25 mmol/L 20 – 29 mmol/L Calcium 8.9 mg/dL 8.7 – 10.2 mg/dL Protein 6.6 g/dL 6.0 – 8.5 g/dL Albumin 4.3 g/dL 3.8 – 4.8 g/dL -
Cholesterol Panel:
- Total: 198 mg/dL
- LDL: 120 mg/dL
- HDL: 47 mg/dL
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Urinalysis:
- Urine showed a higher than normal specific gravity.
Medical Procedures
- Appendectomy at age 8.
Imaging Results
- No recent imaging results.
Plan of Care
-
n/a
Alerts
- No known food or drug allergies
Patient Reminders
- Schedule your flu shot
- Schedule annual skin cancer check