Medical Record For Clark, Loretta

Past Medical History

Allergies

No Known Drug Allergies

Medical Problems

Hypertension

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	120	70-100
BUN	12	5-20
Creatinine	0.8	0.5-1.5
Sodium	130	135-145
Potassium	3.1	3.5-5.0
Chloride	91	95-105
Calcium	9.1	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	11.0	4.8-10.8
RBC	5.8	4.7-6.1
HGB	12.8	12.6-17.4
HCT	38	37-51
MCV	82	80-94
MCH	30	27-31
MCHC	35	33-37
Platelets	250	130-400
Segmented Neutrophils %	68	50-70
Neutrophils, bands	0	0-5
Lymphocytes %	22	20-40
Monocytes %	8	0-15
Eosinophils %	2	0-6
Basophils %	0	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	122	132	154
Blood Pressure	120/80	110/74	98/66
Respiratory Rate	20	22	24
Pulse Ox	98% on RA	94% on RA	88% on RA

Provider Notes

Time	Provider	Notes
2000	Wilson James, MD	Admit pt to burn unit s/p house fire. 40% BSA 2nd and 3rd degree burns. See orders in chart.