Medical Record For Sommers, Miranda

Past Medical History

Allergies

No Known Drug Allergies

Medical Problems

High Cholesterol
Hypertension
TIA

Surgical History

Hysterectomy

Labs

Basic Metabolic Panel

Lab Result	Tested Value	Normal Value Range
Glucose	131	70-100
BUN	29	5-20
Creatinine	3.1	0.5-1.5
Sodium	141	135-145
Potassium	5.5	3.5-5.0
Chloride	96	95-105
Calcium	9.8	9-11

Complete Blood Count with Diff

Lab Result	Tested Value	Normal Value Range
WBC	19.5	4.8-10.8
RBC	5.8	4.7-6.1
HGB	10.9	12.6-17.4
HCT	32	37-51
MCV	82	80-94
MCH	30	27-31
MCHC	35	33-37
Platelets	145	130-400
Segmented Neutrophils %	85	50-70
Neutrophils, bands	7	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

Lactic Acid

Lab Result	Tested Value	Normal Value Range
Lactate	6	0-4

Vital Signs

Time	2000	0000	0400
Heart Rate	130	127	125
Blood Pressure	86/51	87/52	84/55
Respiratory Rate	24	25	22
Pulse Ox	97% on RA	95% on RA	96% on RA
Temperature	102.7 Rectal	NOT RECORDED	NOT RECORDED

Provider Notes

Time	Provider	Notes
2000	Wilson James, MD	Patient presented to emergency department from long term care with confusion x 3 days per staff. GCS=14, at baseline patient is normally AAOx3 per family. Admit to floor with diagnosis of urosepsis after workup in ED.
0000	Jen Carroll, RN	Pt with GCS=14, 20G IVR in RFA patent with blood return, fluids infusing per order without difficulty. Lungs CTA BIL, abd soft, nontender, nondistended, pt returned from CT head, now resting comfortably. Denies pain.
0400	Jen Carroll, RN	Dr. James made aware via telephone conversation pt still hypotensive after ordered fluids administered. Awaiting further orders.