Blood Work Results

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for review of recent blood work results



Lab results:

CBC:

- Hb ‍ ‍normal

- WBC ‍ ‍normal

- Platelets ‍ ‍normal

Chemistry:

- Na ‍ ‍normal

- K ‍ ‍normal

- Cl ‍ ‍normal

- HCO3 ‍ ‍normal

- BUN ‍ ‍normal

- Creatinine ‍ ‍normal

- Glucose ‍ ‍normal

Liver function tests:

- ALT ‍ ‍normal

- ALP ‍ ‍normal

- Total bilirubin ‍ ‍normal

- Direct bilirubin ‍ ‍normal

- Albumin ‍ ‍normal

Lipid panel:

- Total Cholesterol ‍ ‍normal

- HDL ‍ ‍normal

- LDL ‍ ‍normal

- Triglycerides ‍ ‍normal

Others

- TSH ‍ ‍normal

- HbA1c ‍ ‍normal

- CRP ‍ ‍normal

- ESR ‍ ‍normal



Associated symptoms: *Try using right-click for negatives*

‍none

‍fatigue

‍weakness

‍fever, up to ‍°, over ‍ ‍hoursdays

‍unintentional weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths

‍joint pain

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍shortness of breath





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Normal blood work





PLAN:

Investigations:

- Additional blood work: ‍

- Repeat blood work: ‍

- ‍

Treatments:

- ‍

Further care:

- Referral to ‍

- Follow-up in ‍ ‍weeksmonthsyears