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Smith, John. 1234. 8 June. 1030. 31. B Neg. PCN. 1415. 1700. Invanz 1g 1115 IV L AC. 13.0. 14.8. Fentanyl800mcg 1145 OTM Mouth. 41. 45. Ketamine 20mg 1200 IM L Shoulder. Blast/ Shrapnel. 130K. 180K. 96.2.
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Smith, John 1234 8 June 1030 31 B Neg PCN 1415 1700 Invanz 1g 1115 IV L AC 13.0 14.8 Fentanyl800mcg 1145 OTM Mouth 41 45 Ketamine 20mg 1200 IM L Shoulder Blast/ Shrapnel 130K 180K 96.2 Ketamine Drip 1300 IV L AC 97.4 0.02 Versed Drip 1300 IV L AC 0.09 142.3 FWB 2 units 1500 IV L AC 139.5 Sucking Cx Wound R side 3.75 4. 22 TXA 1 gm 1530 IV R AC 2.30 2.36 78 105 7.28 7,34 46.4 48.2 332 35.1 Occlusive/ Needle D R mid ax 27.5 25.3 22.0 23.2 23.2 +2.2 74.3 72 1.2 .94 N/A Ammonia - 16 F Clear yellow 1300 120 Pt sustained 3 x 1cm wound from mortar shrapnel in upper right chest from blast 50 feet away, partially shielded by a wall. Pt was not wearing armor or helmet. No exit wound, No other injuries. Neuro exam unremarkable. 2015- Muffled Heart Tones, Narrowing pulse pressures “ 15 Tea - Cloudy 1530 “ Cloudy 50 1800 Dark yellow - “ yellow 2000 Dark Red 300 36 F Thick 1230 “ 200 1430 “ 1430 100 R “ 2030 20
16 18 13 20 14 11 19 15 17 12 15 30 15 45 30 30 15 15 00 00 15 30 15 30 00 00 45 45 30 30 45 00 45 00 15 30 15 00 45 45 00 15 45 45 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 98.1 97.1 98.5 98.2 96.8 98.1 97.9 97.7 96.9 97.4 99.2 97.8 97.1 98.0 97.7 97.2 97.7 98.0 97.5 97.7 4 5 3 7 3 2 4 4 3 2 5 4 3 4 4 3 5 4 2 3 Foley 50 120 15 40 25 35 30 35 CxtUBE 60 40 200 20 150 250 100 80 300