Medical Record For Thomas, Tina


Caroline
DOB:
09/30/1984
MRN:
673899
Weight:
150lb
Admitting Diagnosis:
Penetrating Trauma
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

Latex

Medical Problems

None

Surgical History

None

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 100 70-100
BUN 17 5-20
Creatinine 1.1 0.5-1.5
Sodium 137 135-145
Potassium 3.8 3.5-5.0
Chloride 98 95-105
Calcium 9.9 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 7.2 4.8-10.8
RBC 5.5 4.7-6.1
HGB 13.3 12.6-17.4
HCT 39 37-51
MCV 85 80-94
MCH 28 27-31
MCHC 35 33-37
Platelets 190 130-400
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

Vital Signs

Time 2000 0000 0400
Heart Rate 120 90 85
Blood Pressure 95/61 120/85 121/87
Respiratory Rate 20 14 16
Pulse Ox 97% on RA 98% on RA 97% on RA
Temperature 98.6 Oral NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD 35 year old female impaled in R thigh by a tree branch while doing yard work. 6Ps intact in BLE and BUE. Pt denies hitting head or LOC, AAOx3, awaiting surgical consult for OR.