Medical Record For Hart, Bart: Hospitalization Day 1

Bart
DOB:
05/07/1968
MRN:
991246
Weight:
160lb or 73kg
Admitting Diagnosis:
Shortness of Breath r/t COVID-19
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

Latex

Medical Problems

Type 2 Diabetes

Surgical History

None

Labs

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 11.2 4.8-10.8
RBC 4.9 4.7-6.1
HGB 15.1 12.6-17.4
HCT 39 37-51
MCV 83 80-94
MCH 29 27-31
MCHC 34 33-37
Platelets 190 130-400
Segmented Neutrophils % 61 50-70
Neutrophils, bands 0 0-5
Lymphocytes % 21 20-40
Monocytes % 7 0-15
Eosinophils % 3 0-6
Basophils % 1 0-2
Reticulocytes 0 0-1

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 9.1 7.6-10.6
PTT 31 26-38
D-dimer <0.50 <0.50

Vital Signs

Time 2000 0000 0400
Heart Rate 107 96 90
Blood Pressure 120/73 115/72 110/75
Respiratory Rate 20 22 27
Pulse Ox 97% on 2L NC 98% on 2L NC 98% on 2L NC
Temperature 102.6 Rectal NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD 52/M with history of DM2 presents with cough, fever, and SOB x 3 days, getting worse. Lungs clear to auscultation BIL, pt speaking in full sentences without difficulty but oxygen saturation dropped during ambulation. Admit for observation.