Medical Record For Rumsfeld, Randall


Randall
DOB:
03/07/1950
MRN:
991789
Weight:
170lb
Admitting Diagnosis:
Hyperkalemia
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

Penicillin

Medical Problems

ESRD
Hypertension

Surgical History

R Knee Replacement

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 98 70-100
BUN 40 5-20
Creatinine 5.2 0.5-1.5
Sodium 133 135-145
Potassium 6.8 3.5-5.0
Chloride 94 95-105
Calcium 8.4 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 10.0 4.8-10.8
RBC 3.2 4.7-6.1
HGB 7.8 12.6-17.4
HCT 29 37-51
MCV 81 80-94
MCH 28 27-31
MCHC 34 33-37
Platelets 130 130-400
Segmented Neutrophils % 57 50-70
Neutrophils, bands 0 0-5
Lymphocytes % 25 20-40
Monocytes % 5 0-15
Eosinophils % 3 0-6
Basophils % 1 0-2
Reticulocytes 0 0-1

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 10.4 7.6-10.6
PTT 30 26-38
D-Dimer <0.50 <0.50

Liver Function Tests

Lab Result Tested Value Normal Value Range
AST 30 5-40
ALT 45 7-56

Vital Signs

Time 2000 0000 0400
Heart Rate 104 110 108
Blood Pressure 185/95 179/99 181/98
Respiratory Rate 30 28 29
Pulse Ox 94% on 2L NC 95% on 2L NC 93% on 2L NC
Temperature 98.6 Oral NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD 70 yo male presenting to the ED with shortness of breath today and "feels like fluttering in the chest". Pt missed dialysis yesterday because he was taking care of sick wife and could not leave. Lungs with crackles auscultated bilaterally. Pt reports he normally makes a scant amount of urine but hasn't made any urine over the past day. Pt reports feeling very tired and weak as well.