Medical Record For Grey, Jennifer

Past Medical History

Allergies

None

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	120	70-100
BUN	15	5-20
Creatinine	0.8	0.5-1.5
Sodium	136	135-145
Potassium	3.8	3.5-5.0
Chloride	98	95-105
Calcium	10	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	9.0	4.8-10.8
RBC	5.0	4.7-6.1
HGB	13.1	12.6-17.4
HCT	40	37-51
MCV	84	80-94
MCH	28	27-31
MCHC	35	33-37
Platelets	205	130-400
Segmented Neutrophils %	68	50-70
Neutrophils, bands	0	0-5
Lymphocytes %	22	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	10	7.6-10.6
PTT	28	26-38

Vital Signs

Time	2000	0000	0400
Heart Rate	119	128	138
Blood Pressure	120/54	130/89	140/95
Respiratory Rate	16	12	10
Pulse Ox	98% on RA	95% on RA	94% on RA
Temperature	99 Oral	99.5 Oral	98.0 Oral
ICP and Neuro Status	PERRLA 3mm brisk, GCS=15, ICP=15	PERRLA 5mm brisk, GCS=14, ICP=18	PERRLA 6mm sluggish, GCS=6, ICP=20

Provider Notes

Time	Provider	Notes
2000	Amy Linden, MD	23 yo female who was hiking and climbed up on some rocks to take look at the view. She slipped and hit her head on the rocks. She came into the ED via EMS with C-Collar in place. Alert and oriented. But CT revealed a large subdural hematoma. She was taken to the OR for evacuation and came to the ICU with a ventriculostomy in place. Admitted to the ICU for observation post op, subdural evacuation and ventriculostomy placement.
0000	Jen Carroll, RN	Dr. Kyle Jones MD from neurosurgery aware of clot in venticulostomy tubing, no further orders at this time. MD also aware of GCS and ICP change and again no orders. Request neurosurgery come to bedside to evaluate patient.
0400	Jen Carroll, RN	Called intensivist to bedside for change in patient condition. Neurosurgery stat paged by intensivist, now at bedside. Neurosurgery flushed clot out of line, ICP reading now 54.