12/07/1989
MRN:
98684
Weight:
170lb or 77kg
Admitting Diagnosis:
Motorcycle crash, 36% BSA burns
Admitting Physician:
Wilson James, MD
Penicillin
None
None
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 120 | 70-100 |
| BUN | 18 | 5-20 |
| Creatinine | 1.4 | 0.5-1.5 |
| Sodium | 134 | 135-145 |
| Potassium | 3.4 | 3.5-5.0 |
| Chloride | 96 | 95-105 |
| Calcium | 9.5 | 9-11 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 6.3 | 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 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 10 | 7.6-10.6 |
| PTT | 28 | 26-38 |
| Time | 2000 | 0000 | 0400 |
|---|---|---|---|
| Heart Rate | 103 | 96 | 85 |
| Blood Pressure | 126/72 | 120/74 | 117/79 |
| Respiratory Rate | 22 | 20 | 18 |
| Pulse Ox | 97% on RA | 98% on RA | 98% on RA |
| Temperature | 98.6 Oral | NOT RECORDED | NOT RECORDED |
| Time | Provider | Notes |
|---|---|---|
| 2000 | Wilson James, MD | Admit pt to floor s/p motorcycle accident with 36% BSA burns to R arm, R leg, half of back, all 2nd degree partial thickness with blisters noted. Parkland formula ordered for resuscitation. Plan for dressing change in morning. |
| 0000 | Jen Carroll, RN | Pt with GCS=15, per Dr. James pt is cleared of trauma after CT scans of head and neck. Dr. James removed pt c-collar. Fluids infusing as ordered, urine output from foley WNL. Neurovascular status of all 4 extremities WNL BIL. |
| 0400 | Jen Carroll, RN | Pt resting comfortably after pain medication administered as ordered. Awaiting dressing change. Neurovascular checks WNL BIL all 4 extremities. |