Mr. Thomas Jameson’s Chart
Medication Orders:
- Heparin Drip (weight-based), target aPTT 60–80
- Warfarin 5 mg PO daily (start bridging)
Bed rest with bathroom privileges, Telemetry, Vitals q4h
Current Vitals:
BP: 130/85 mmHg, HR: 100 (irreg), RR: 18, SpO2: 95% on RA, Temp: 37.5°C
BP: 130/85 mmHg, HR: 100 (irreg), RR: 18, SpO2: 95% on RA, Temp: 37.5°C
Lab Updates:
| Test | Value | Ref Range | Status |
|---|---|---|---|
| aPTT | 90 s | 60–80 s | High |
| INR | 5.2 | 2–3 | High |
| WBC | 8k | 4–10k | Normal |
Clinical Notes:
- Day 2: Mild gum bleeding, small forearm cut that bled steadily.
- Patient concerned about hemorrhage risk.
- Plan: Evaluate drip rate + Warfarin dose. Possibly hold if labs too high.
You Killed the Patient!
