Medical Record For Clark, Roberta

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.