Medical Record For Clark, Roberta


Roberta
DOB:
05/14/1979
MRN:
987543
Weight:
161lb or 73kg
Admitting Diagnosis:
COVID+, ARDS
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

No Known Drug Allergies

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 120 70-100
BUN 25 5-20
Creatinine 2.7 0.5-1.5
Sodium 140 135-145
Potassium 5.2 3.5-5.0
Chloride 101 95-105
Calcium 9.1 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 18.0 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 140 139 141
Blood Pressure 145/90 89/52 75/50
Respiratory Rate 40 32 28
Pulse Ox 82% on 4LNC 84% on 100%FiO2 ventilator 85% on 100%FiO2 ventilator
Temperature 101.7 PR NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD Admit pt to floor + COVID, SOB and fever, on 4L NC at this time, plan to round on patient in a few hours to check status.
0000 Jen Carroll, RN Pt increasingly dyspneic, called Dr. James who came to bedside. Bedside CXR done showing whiteout. Dr. James intubated pt, 7.5ETT, 21cm at lip, vent settings A/C PC, RR12, FiO2 100%, Tv 300, PEEP 15. Lungs with crackles BIL, tube placement verified with repeat CXR, OG placed. Awaiting further orders.
0400 Jen Carroll, RN Foley placed as ordered, CVC and A-line placed by Dr. James. Dr. James called to report scant urine output and hypotension, awaiting further orders. Pt with fentanyl and versed infusing as ordered. Pt difficult to ventilate with high pressure alarm on ventilator, Dr. James aware, awaiting further orders. Lung sounds with crackles BIL.