Medical Record For John Smith
Patient Information
John Smith
DOB:
10/29/1957
Sex:
Male
Gender Idenity:
Male
MRN:
843201
Weight:
160 lbs or 72.58 kg
Admitting Diagnosis:
COPD exacerbation Pneumonia
Admitting Physician:
Tony Houseman, M.D.
Past Medical History
Allergies
None
Medical Problems
COPD, Hypertension, diabetes mellitus type 2
Surgical History
Appendectomy, cholecystectomy
Social History
40 pack year history (1 ppd x 40 years); social alcohol; no drugs; lives at home by himself, but children live in town and check on him periodically
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Tony Houseman, M.D. | Patient presented to the Emergency Department overnight via ambulance. They have been having difficulty breathing and feeling lightheaded. They had been sick with a productive cough for the last 4-5 days, worse from his usual baseline cough. The family reports the patient developed a fever 2 days ago that they treated with Tylenol at home. They were seen at an outpatient urgent care about 10 days ago for a COPD exacerbation. They were prescribed an inhaler and just finished a course of steroids. They initially responded to treatment but then worsened in the last few days. They continue to smoke 1 pack per day, They denies any chest pain, abdominal pain, back pain, extremity symptoms or headaches. He did feel dizzy earlier today, especially when standing. Continue to monitor. |
Vital Signs
| Time | 0600 | 0800 |
|---|---|---|
| Heart Rate | 100 bpm | 110 bpm |
| Blood Pressure | 146/86 mmHg | 150/90 mmHg |
| Respiratory Rate | 28 breaths/min | 28 breaths/min |
| Pulse Ox | 90% | 88% |
| Oxygen in Liters | Room Air | Room Air |
| Temperature | 98.8 F | 98.7 F |
| Pain | 4/10 | 4/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Albumin | 3.6 g/dL | 3.5-4.5 g/dL |
| BUN | 38 md/dL | 10-20 mg/dL |
| Calcium | 9.8 mg/dL | 8.2-10.7 mg/dL |
| CO2 (bicarbonate) | 16 mEq/L | 22-26 mEq/L |
| Chloride | 93 mEq/L | 95-100 mEq/L |
| Creatinine | 2.7 mg/dL | 0.5-1.2 mg/dL |
| Glucose | 123 mg/dL | 65-100 mg/dL |
| Potassium | 5.2 mEq/L | 3.5-5.0 mEq/L |
| Sodium | 132 mEq/L | 135-143 mEq/L |
| Total Bilirubin | 1.3 mg/dL | 0.3-1.2 mg/dL |
| Total Protein | 6.4 g/dL | 6.4-8.3 g/dL |
| ALT | 30 U/L | 8.2-10.7 U/L |
| Alkaline Phosphatase | 88 U/L | 36-92 U/L |
| AST | 32 U/L | 0.0-35 U/L |
| Lactate | 3.5 mmol/L | 0.0-35 mmol/L |
Complete Blood Count
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 18,500/uL | 5,000-10000/uL |
| RBC | 3.6 Million/uL | 4.2-5.4 million/uL |
| HGB | 12 g/dL | 12-16 g/dL |
| HCT | 35 % | 36-45% |
| MCV | 80 fL | 80-100fL |
| MCH | 27 pg | 27-33 pg |
| MCHC | 34 % | 31-35% |
| RDW | 13.5 | 12-15 |
| Platelet Count | 252,000/uL | 150,000-400,000/uL |
| Segmented Neutrophil % | 90% | 45-70% |
| Band Neutrophils % | 8% | |
| Lymphocyte % | 3% | 16-45% |
| Monocyte % | 3% | 2-10% |
| Eosinophil % | 1% | 0-5% |
| Basophil % | 1% | 0-2% |
Urinalysis
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Color/Clarity | Yellow/Turbid | |
| Bilirubin | Negative | Negative |
| Glucose | Negative | Negative |
| Keytones | Negative | Negative |
| Specific Gravity | 1.020 | 1.001-1.030 |
| Blood | Negative | Negative |
| pH | 5.0 | 5-8 |
| Protein | 15 mg/dL | Negative |
| Urobilinogen | 0.2 | 0.2-1.0 EU |
| Nitrite | Negative | Negative |
| Leukocytes | Trace | Negative |
| Microscopic | 0-2 WBCs /hpf 2-5 RBCs/hpf Negative Bacteria Mucous Negative |
0-5 WBCs/hpf 0-2 RBCs/hpf No bacteria (catheter specimen) |
| ETOH | 0.0 mg/dL | <10 mg/dL |
| Urine Drug Screen | Negative | Negative |
| Keytones | Negative | Negative |
| Serum Osmolality | 280 mOsmol/kg H2 | 275-295 mOsmol/kg H2O |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| pH | 7.35 | 7.38-7.44 |
| PC02 | 54 mmHg | 35-45 mmHg |
| P02 | 86 mmHg | 80-100 mmHg |
| 02 | 88% | >95% |