05/07/1968
MRN:
991246
Weight:
160lb or 73kg
Admitting Diagnosis:
Penetrating leg injury; Head injury
Admitting Physician:
Wilson James, MD
Latex
Type 2 Diabetes
None
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 260 | 70-100 |
| BUN | 26 | 5-20 |
| Creatinine | 2.9 | 0.5-1.5 |
| Sodium | 130 | 135-145 |
| Potassium | 3.4 | 3.5-5.0 |
| Chloride | 93 | 95-105 |
| Calcium | 9.1 | 9-11 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 7.2 | 4.8-10.8 |
| RBC | 4.1 | 4.7-6.1 |
| HGB | 8.1 | 12.6-17.4 |
| HCT | 30 | 37-51 |
| MCV | 80 | 80-94 |
| MCH | 25 | 27-31 |
| MCHC | 31 | 33-37 |
| Platelets | 120 | 130-400 |
| Segmented Neutrophils % | 61 | 50-70 |
| Neutrophils, bands | 0 | 0-5 |
| Lymphocytes % | 21 | 20-40 |
| Monocytes % | 7 | 0-15 |
| Eosinophils % | 3 | 0-6 |
| Basophils % | 1 | 0-2 |
| Reticulocytes | 0 | 0-1 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 13.1 | 7.6-10.6 |
| PTT | 45 | 26-38 |
| Time | 2000 | 0000 | 0400 |
|---|---|---|---|
| Heart Rate | 107 | 96 | 90 |
| Blood Pressure | 91/73 - MAP 79 | 95/72 - MAP 80 | 110/75 - MAP 87 |
| Respiratory Rate | 14 | 14 | 14 |
| Pulse Ox | 97% on 50% FiO2 via ventilator | 98% on 50% FiO2 via ventilator | 98% on 50% FiO2 via ventilator |
| Temperature | 98.6 Rectal | NOT RECORDED | NOT RECORDED |
| ICP | 18 | 22 | 22 |
| Time | Provider | Notes |
|---|---|---|
| 2000 | Wilson James, MD | Pt fell from ladder during storm, branch impaled L leg at thigh, +LOC. GCS of 15 on arrival. During ED treatment, tension pneumothorax noted with tracheal deviation to R, needle decompression to L chest and chest tube placed on L in ED. Battle sign and Raccoon eyes present on ED arrival. Pt in c-collar, to OR for surgical repair of L leg. Pt to ICU from OR, GCS of 15 after surgery. Yesterday in ICU, pt became very confused, was intubated and ventriculostomy placed. Pt went to CT scan head and c-spine, basilar skull fracture noted, c-spine cleared and c-collar removed. On Metformin at home for DM2. |
| 0000 | Jen Carroll, RN | Pt intubated with 8.0ETT, 23 at lip, CT on L with no evidence of air leak, to suction and tidaling, no drainage, no subq emphysema noted, dressing intact, no complications at site, CT supplies at bedside. Pt sedated per orders, vent settings A/C Volume, Rate 14, Tv 400, FiO2 50%, PEEP=3. Lungs CTA BIL. CVC and 20GIVR L hand both with blood return and no site complications, Aline visible above sheets, all connections tight, no site complications. Foley draining straw colored urine of adequate amounts. |
| 0400 | Jen Carroll, RN | Pt with elevated ICP after rolling, sustained, James MD aware, no further orders at this time. |