Patient Story (Day 1)

Thomas Jameson, 69, presented with acute right lower extremity pain and swelling that began two days prior to admission...

Orders (Day 1)

• IV Heparin drip (aPTT goal 60–80s)
• Transition to Warfarin once INR 2–3
• Labs: CBC, CMP, PT/INR, aPTT, D-dimer
• Activity: bed rest, bathroom privileges

Vital Signs (Day 1)

• BP: 144/90
• HR: 105 bpm (A-fib)
• RR: 18
• SpO2: 95% RA
• Temp: 37.5°C

Medical History

• Hypertension (5 years)
• Type 2 Diabetes Mellitus (15 years)
• Atrial Fibrillation (6 months)
• Hyperlipidemia
• No known drug allergies

Labs/Diagnostics (Day 1)

• PT: 12.2s, INR: 1.1, aPTT: 32s
• CBC: WBC 8k, RBC 4.5, Hgb 14.2, Platelets 230k
• D-dimer: Elevated

Documentation

For day 1, nursing notes, MAR, or embedded documentation system iFrame.