Medical Record For Dickson, Darla


Darla
DOB:
05/09/1986
MRN:
991776
Weight:
140lb
Admitting Diagnosis:
Cellulitis vs DVT
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

None

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 90 70-100
BUN 18 5-20
Creatinine 1.2 0.5-1.5
Sodium 136 135-145
Potassium 3.7 3.5-5.0
Chloride 99 95-105
Calcium 9.8 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 9.1 4.8-10.8
RBC 5.1 4.7-6.1
HGB 13.1 12.6-17.4
HCT 39 37-51
MCV 85 80-94
MCH 28 27-31
MCHC 35 33-37
Platelets 190 130-400
Segmented Neutrophils % 55 50-70
Neutrophils, bands 1 0-5
Lymphocytes % 26 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 9.4 7.6-10.6
PTT 32 26-38
D-Dimer 8 <0.50

Vital Signs

Time 2000 0000 0400
Heart Rate 98 85 81
Blood Pressure 135/75 119/78 115/71
Respiratory Rate 20 18 16
Pulse Ox 96% on RA 98% on RA 97% on RA
Temperature 98.6 Oral NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD 34 yo female presenting to the ED with L leg pain and swelling and redness x 1 week. Recent travel including 8+hr flight. Pt has been taking hormonal oral birth control x 2 years. During assessment, L leg warm to touch and patient reports painful. 6Ps instact in BUE and BLE. Admit for ultrasound of leg and further lab tests and will treat according to results.