Medical Record For Grey, Jennifer


Jennifer
DOB:
02/17/1997
MRN:
645210
Weight:
130lb or 59kg
Admitting Diagnosis:
Head injury
Admitting Physician:
Amy Linden, MD

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.