04/07/1984
MRN:
991777
Weight:
130lb or 59kg
Admitting Diagnosis:
Anemia
Admitting Physician:
Wilson James, MD
None
Uterine Fibroids
None
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 110 | 70-100 |
| BUN | 15 | 5-20 |
| Creatinine | 1.1 | 0.5-1.5 |
| Sodium | 137 | 135-145 |
| Potassium | 3.6 | 3.5-5.0 |
| Chloride | 98 | 95-105 |
| Calcium | 9.9 | 9-11 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 10.2 | 4.8-10.8 |
| RBC | 3.9 | 4.7-6.1 |
| HGB | 7.1 | 12.6-17.4 |
| HCT | 20 | 37-51 |
| MCV | 60 | 80-94 |
| MCH | 15 | 27-31 |
| MCHC | 20 | 33-37 |
| Platelets | 190 | 130-400 |
| Segmented Neutrophils % | 55 | 50-70 |
| Neutrophils, bands | 0 | 0-5 |
| Lymphocytes % | 26 | 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 | 9.1 | 7.6-10.6 |
| PTT | 30 | 26-38 |
| Time | 2000 | 0000 | 0400 |
|---|---|---|---|
| Heart Rate | 109 | 107 | 110 |
| Blood Pressure | 95/60 | 97/65 | 98/66 |
| Respiratory Rate | 28 | 29 | 27 |
| Pulse Ox | 96% on 2L NC | 95% on 2L NC | 96% on 2L NC |
| Temperature | 98.6 Oral | NOT RECORDED | NOT RECORDED |
| Time | Provider | Notes |
|---|---|---|
| 2000 | Wilson James, MD | 36 yo female presenting to the ED with shortness of breath and extreme fatigue x 1 month, getting worse. Pt also complains of heavy menstrual bleeding x 1 month. On arrival, pt speaking in full sentences without difficulty, lungs clear to auscultation bilaterally. Pt appears pale, denies any other bleeding. Chest xray shows no infiltrates, pelvic ultrasound shows enlarged uterine fibroids. 2 units of PRBCs ordered to treat anemia, plan to recheck CBC in 6 hours. |