Medical Record For Perkins, Pearl


Pearl
DOB:
01/07/1986
MRN:
778635
Weight:
140lb or 59kg
Admitting Diagnosis:
SOB
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

None

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 100 70-100
BUN 18 5-20
Creatinine 1.2 0.5-1.5
Sodium 136 135-145
Potassium 3.9 3.5-5.0
Chloride 99 95-105
Calcium 9.9 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 9.2 4.8-10.8
RBC 6.1 4.7-6.1
HGB 14.1 12.6-17.4
HCT 49 37-51
MCV 85 80-94
MCH 28 27-31
MCHC 35 33-37
Platelets 200 130-400
Segmented Neutrophils % 61 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

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 9.1 7.6-10.6
PTT 30 26-38
D-dimer 8 <0.50

Vital Signs

Time 2000 0000 0400
Heart Rate 135
Blood Pressure 90/60
Respiratory Rate 35
Pulse Ox 91% on 2L NC
Temperature 98.6 Oral

Provider Notes

Time Provider Notes
2000 Wilson James, MD 34 year old female presenting to ED with sudden onset extreme shortness of breath and anxiety x 1 hour. Pt tachypneic and unable to speak in full sentences.