Medical Record For Carter, Clarence


Clarence
DOB:
12/07/1989
MRN:
98685
Weight:
170lb or 77kg
Admitting Diagnosis:
Anaphylaxis
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

Bee Venom

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 100 70-100
BUN 17 5-20
Creatinine 1.2 0.5-1.5
Sodium 137 135-145
Potassium 3.6 3.5-5.0
Chloride 96 95-105
Calcium 9.5 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 11.3 4.8-10.8
RBC 5.8 4.7-6.1
HGB 12.8 12.6-17.4
HCT 38 37-51
MCV 82 80-94
MCH 30 27-31
MCHC 35 33-37
Platelets 250 130-400
Segmented Neutrophils % 68 50-70
Neutrophils, bands 0 0-5
Lymphocytes % 22 20-40
Monocytes % 8 0-15
Eosinophils % 10 0-6
Basophils % 5 0-2
Reticulocytes 0 0-1

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 10 7.6-10.6
PTT 28 26-38

Vital Signs

Time 2000 0000 0400
Heart Rate 103 96 85
Blood Pressure 126/72 120/74 117/79
Respiratory Rate 22 20 18
Pulse Ox 97% on RA 98% on RA 98% on RA
Temperature 98.6 Oral NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD Pt reports bee sting at park, known allergy to bees, presents to the ED after administering EpiPen prehospital. Another EpiPen administered on arrival to ED. Admit for observation overnight.