Patient Name: Carmichael, Harold

DOB: 4/17/50
MRN: 987573
Allergies: No Known Drug Allergies
Medical History: Diabetes Type 2, CVA

Time Provider Notes
0800 Mary Rolland, RN Assumed care of patient at 0700. Patient arrived to ED via ambulance from long term care at 0745. Long term care states they sent the patient due to periods of confusion. Patient has had diabetes x 12 years and had a stroke a year ago when he was then sent to live at long term care facility. Facility states patient is normally oriented but has been having periods of confusion recently. On arrival to ED patient GCS=14 (confused to place). Facility states patient baseline blood sugar has been steadily climbing the past 2 weeks with typical results between 160 and 200mg/dL and increasing urine output. Patient has been taking oral antidiabetic medications as ordered. Facility states patient does not exercise due to residual weakness from the stroke. Patient has frequent visitors at facility and keeps a dish of hard candies that family restocks. Patient with ulcer to left leg with redness and swelling and facility states they have an appointment with PCP to assess the ulcer this upcoming week. Patient resting comfortably at this time. POC Blood glucose = 721mg/dL. Dr. James ED attending made aware of critical result. 20G IVR inserted in RFA, labs drawn and held, awaiting orders from Dr. James.
Status Time Ordering Physician Order
Active- Completed 0830 Perry James, MD BMP, CBC, Coagulation labs once
Active- Completed 0830 Perry James, MD Hemoglobin A1c lab once
Active- Completed 0830 Perry James, MD Urinalysis

NONE

Time 0800
Heart Rate 110
Blood Pressure 105/75
Respiratory Rate 29
Pulse Ox 97% on Room Air
Temperature 101.6 F Oral
Pain NOT ASSESSED

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 726 70-100
Hemoglobin A1c 9.5% less than 5.7%
BUN 21 5-29
Creatinine 1.9 0.5-1.5
Sodium 146 135-145
Potassium 6.3 3.5-5.0
Chloride 105 95-105
Calcium 9.9 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 14.1 4.8-10.8
RBC 6.2 4.7-6.1
HGB 16.9 12.6-17.4
HCT 52 37-51
Platelets 350 130-400

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 10.2 7.6-10.6
PTT 30 26-38
INR 1.0 0.8-1.2

Urinalysis

Lab Result Tested Value
Color Dark yellow
pH 7.1
Specific Gravity 1.010
Glucose Positive
Blood Negative
Ketones Negative
Protein Negative

NONE

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