Medical Record For Jamie Baldwin
Patient Information
Jamie Baldwin
DOB:
12/18/2000
Sex:
Female
Gender Idenity:
MRN:
843201
Weight:
150 lbs or 68.04 kg
Admitting Diagnosis:
Sickle cell disease with crisis
Admitting Physician:
Tony Lee M.D.
Past Medical History
Allergies
Aspirin (Hives)
Medical Problems
Sickle cell disease (HbSS), previous acute pain crises, splenic sequestration as a child.
Surgical History
No known surgical history
Up to date on all immunizations
Family History
Both parents are alive. Mother has sickle cell trait (AS), and father has sickle cell trait (AS). No siblings.
Medications
Hydroxyurea 1100mg PO once daily. Multivitamin PO once daily.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Tony Lee M.D. | 25yo patient with history of sickle cell disease presents to the emergency department with complaints of severe joint pain, back pain, fatigue, and fever. Patient reports the pain started about a week ago. They tried to self-manage at home with rest, and fluids, but the pain has been worsening the past two days. They developed a fever yesterday that prompted them to come in for assessment and care. Patient admitted for pain management and fluids.Work up initiated for possible infection. Follow up with chest x-ray. |
Vital Signs
| Time | 0800 | |
|---|---|---|
| Heart Rate | 116 bpm | |
| Blood Pressure | 130/85 mmHg | |
| Respiratory Rate | 22 breaths/min | |
| Pulse Ox | 116 bpm | |
| Oxygen in Liters | 94% | |
| Temperature | 101.2 F | |
| Pain | 3/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Albumin | 4.0 g/dL | 3.5-4.5 g/dL |
| BUN | 20 mg/dL | 10-20 mg/dL |
| Calcium | 9.2 mg/dL | 8.2-10.7 mg/dL |
| CO2 (bicarbonate) | 24 mEq/L | 22-26 mEq/L |
| Chloride | 98 mEq/L | 95-100 mEq/L |
| Creatinine | 1.4 mg/dL | 0.5-1.2 mg/dL |
| Creatinine Clearance | 83 mL/min | calculated |
| Glucose | 76 mg/dL | 65-100 mg/dL |
| Potassium | 4.0 mEq/L | 3.5-5.0 mEq/L |
| Sodium | 140 mEq/L | 135-143 mEq/L | Total Bilirubin | 1.0 mg/dL | 0.3-1.2 mg/dL |
| Total Protein | 8.0 g/dL | 6.4-8.3 g/dL |
| ALT | 26 U/L | 8.2-10.7 U/L |
| Alkaline Phosphatase | 58 U/L | 36-92 U/L |
| AST | 20 U/L | 0.0-35 U/L |
Complete Blood Count
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 15,500/uL | 5,000-10000/uL |
| RBC | 2.87 Million/uL | 4.2-5.4 million/uL |
| HGB | 7.0 g/dL | 12-16 g/dL |
| HCT | 21 % | 36-45% |
| Platelets | 400,000/uL | 150,000-400,000/uL |
| MCV | 84 fL | 80-100 fL |
| MCH | 29 pg | 27-33 pg |
| MCHC | 34% | 31-35% |
| RDW | 23.9% | 12-15 |
Blood Cultures
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Results | Pending |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| pH | 7.32 | 7.38-7.44 |
| PC02 | 55 mmHg | 35-45 mmHg |
| P02 | 60 mmHg | 80-100 mmHg |
| 02 | 95% | >95% |