VIII.

Diagnostics and Laboratory Results

Patient Name: Patient M Permanent Address: Quezon City

Birthdate: December 06, 1989 Patient Type: Inpatient

Age: 29 years old / Male Source: NSS_SLRW #SL1A

a) HEMATOLOGY

Complete Blood Count

Test Observed Norm Unit Analysis and Interpretation

name result al
Value
s
08/07/ 08/10/
19 – 19 –
03:19p 11:44p
m m
White 17.53 15.80 5.0 – 10^9/ A high white blood cell count isn’t a specific
Blood 10.0 L disease, but it can indicate another problem,
Cells such as infection, stress, inflammation, trauma,
allergy, or certain diseases. Infection can also
lead to inflammation, which can in turn cause
the number of white blood cells to increase.

Retrieved from:

http://blog.insidetracker.com/45247913486-
high-white-blood-cell-count-what-you-should
RBC 4.0 4.4 4.7 – 10^12 A low RBC indicate oxygen deprivation.
Count 6.0 /L
Retrieved from:

https://www.healthline.com/health/rbc-
count#next-steps
Hemoglob 12.3 13.2 13.5 – g/dL A low hemoglobin count can be associated
in 18.0 with a disease or condition that causes your
body to have too few red blood cells. It also
indicates oxygen deprivation.

Retrieved from:
 https://www.mayoclinic.org/symptoms/low-
hemoglobin/basics/causes/sym-20050760
Hematocri 0.36 0.39 0.42 – A low hematocrit count indicates oxygen
t 0.54 deprivation

Retrieved from:

https://www.healthline.com/health/rbc-
count#next-steps
MCV 91 88 78 – fL
100
MCH 31 30 27 – Pg
31
MCHC 34 34 g/dL
Red Cell 0.122 0.123 0.115
Dist –
Width 0.150
Platelet 0.372 0.440 0.140 10^12
Count – /L
0.440
Segmenter 0.74 0.77 0.50 – Having a high percentage of neutrophils in
s 0.70 blood is called neutrophilia this is a sign that a
body has an infection.

Retrieved from:

https://medlineplus.gov/lab-tests/blood-
differential/
Lymphoc 0.15 0.14 0.20 – Trauma due to an injury or acute emergency
ytes 0.44 such as cardiac failure can lower lymphocyte
counts.

Retrieved from:

https://www.healthline.com/health/lymphocyto
penia#causes
Monocyte 0.09 0.07 0.02 –
s 0.09
Eosinophi 0.02 0.02 0.00 –
ls 0.04
Basophil 0.00 0.00 0.0 –
0.
0
1
 b.) URINALYSIS

Test name Observed result Normal Unit Analysis and

Values Interpretation
07/30/19 08/08/19
– –
09:34am 12:10am
Color Yellow Yellow Yellow 10^9/L
Appearance Slightly Hazy Clear 10^12/
Hazy L
Specific Gravity 1.010 1.015 1.015 – g/dL Specific gravity results
1.025 above 1.010 can
indicate mild
dehydration.

Retrieved from:

https://www.healthline.
com/health/urine-
specific-gravity#results
pH 6.0 7.5 4.8 – 7.8
Sugar Trace Trace NEGATIV fL
E
Ketones Trace Negative NEGATIV Pg
E
Blood Positive Positive NEGATIV g/dL
+3 +3 E
Nitrite Negative Negative NEGATIV
E
Protein Negative Trace NEGATIV 10^12/
E L
Bilirubin Negative Positive NEGATIV
+1 E
Urobilinogen Negative Positive NEGATIV
+3 E
Leukocytes Negative Trace NEGATIV
E
FLOWCYTOMETRY
Analysis
Urine RBC 668.20 421.30 0 – 11 A high count of red
blood cells in the urine
can indicate infection,
trauma, tumors, or
kidney stones. If red
blood cells seen under
microscopy look
 distorted, they suggest
kidney as the possible
source and may arise
due to kidney
inflammation
(glomerulonephritis).

Retrieved from:

https://www.medicinen
et.com/urinalysis/articl
e.htm#what_can_the_p
resence_of_white_bloo
d_cells_in_the_urine_
mean
Urine WBC 10.30 92.30 0 – 11 Evidence of white
blood cells or bacteria
in the urine is
considered abnormal
and may suggest a
urinary tract infection
such as, bladder
infection (cystitis),
infection of kidney
(pyelonephritis).

Retrieved from:

https://www.medicinen
et.com/urinalysis/articl
e.htm#other_than_urin
alysis_what_are_other
_common_urine_tests_
available
Urine Epithelial Cells 3.40 21.90 0 – 12 Epithelial cells (cells in
the lining of the
bladder or urethra) may
suggest inflammation
within the bladder, but
they also may originate
from the skin and could
be contamination.

Retrieved from:

https://www.medicinen
 et.com/urinalysis/articl
e.htm#other_than_urin
alysis_what_are_other
_common_urine_tests_
available
Bacteria 4.50 25.20 0 – 110
Others
Amorphous Few
Phosphate Crystals

c.) CLINICAL CHEMISTRY

Test Observed Nor Unit Analysis and Interpretation

name result mal
Valu
es
08/07/ 08/10/
19 – 19 –
03:24 11:44
pm pm
Creatinin 50.60 64.00 umol Low levels of the waste product creatinine in the
e – /L body could be a sign that the liver or muscles are
(Enzyma 104.0 not working as well as they should.
tic) 0
Retrieved from:

https://www.medicalnewstoday.com/articles/3198
92.php
Sodium 139.00 136.0 mmo
0– l/l
145.0
0
Potassiu 3.60 3.50 mmo
m – l/l
5.10
SGPT 81.00 5.00 U/L SGPT is released into blood when the liver or
(ALT) – heart are damaged. The blood SGPT levels are
55.00 thus elevated with liver damage (for example,
from viral hepatitis) or with an insult to the heart
(for example, from a heart attack).

Retrieved from:

https://www.medicinenet.com/script/main/art.asp?
articlekey=6321
Test name Observed result Normal Unit Analysis and
Values Interpretation
08/01/19 – 9:22pm
Ionized Calcium 1.29 1.18 – 1.30 mmol/L
Magnesium 0.93 0.66 – 1.07 mmol/L

d.) RADIOMETER ABL800 FLEX

Test Name Observed Normal Unit Analysis and Interpretation

result Values
Blood Gas 08/06/19 –
Values 2:59am
pH 7.374 7.35 – 7.45
pCO2 38.8 35 – 45 mmHg
pO2 106 80 – 100 mmHg High or low values indicate blood
hyperoxia or hypoxia, respectively. pO2
in venous blood is lower than arterial
blood due to oxygen extraction by
peripheral tissues.

Retrieved from:

https://www.vet.cornell.edu/animal-
health-diagnostic-
center/testing/protocols/blood-gases
Temperature
Corrected
Values
pH(T) 7.374
pCO2(T) 38.8
pO2(T) 106
Oximetry
Values
ctHb 16.0 g/dL
sO2 96.7 %
FO2Hb 92.6 %
FCOHb 1.1 %
FMetHb 3.1 %
Acid Base
Status
ctCO2(P)c 52.1 Vol%
cHCO3- 22.5 mmol/L
(P.st)c
ABEc -2.3 mmol/L
SBEc -2.3 mmol/L
Oxygen Status
p50(st)c 33.55 mmHg
ctO2c 20.9 Vol%

e.) X-RAY

08/03/19 01:22pm

Clinical data: for monitoring; with fever

FINDINGS:
Follow-up study since July 31, 2019 shows linear densities in the left lower lung, representing
subsegmental atelectasis versus fibrosis.
The rest of the lung fields show no active parenchymal infiltrates.
Heart is magnified.
Note of an endotracheal tube with its tip approximately 3.6cm above the carina and nasogastric
tube with its tip indiscernible but below the hemidiaphragm.
The rest of the study remains unchanged.

f.) CT CRANIAL W/O CONRAST

07/29/19 7:13pm
Clinical Data: fall
Comparison: none

FINDINGS:
I. In the Head
There is a V-shaped slightly depressed fracture of the left temporo-parietal bones. Mild
compression of the adjacent cerebral cortex is noted.

There is no demonstrable cortical contusion and acute intracranial hemorrhage at the time of
study.
Minimal subgaleal hematoma is seen overlying the fractured bones.
The brain parenchyma demonstrates normal tissue attenuation.
Midline structures are not displaced.
Sulci, cisterns, fissures and ventricular system are intact.
The sella turcica, pineal region, posterior fossa, orbits, paranasal sinuses, mastoids and calvarium
are normal.
IMPRESSION:
Depressed skull fracture, left temporo-parietal region. Suggest follow-up.
Minimal subgaleal hematoma, left temporo-parietal region.
No demonstrable intracranial hemorrhages is seen at the time of examination.

II. In the Cervical Spine

No fracture nor subluxation noted.
No abnormal findings in the bodies, facets, pedicles, disc spaces and alignment of the cervical
spine.
Paravertebral soft tissues structure are grossly normal.
No abnormal soft tissue nor calcification.

IMPRESSION:
No demonstrable fracture or subluxation.

08/01/19 9:12am
Clinical Data: fall
Comparison: Plain Cranial CT Scan dated July 29, 2019

FINDINGS:
Again, seen in the slightly depressed fracture of the left temporo-parietal bones with associated
mild compression of the adjacent cerebral cortex.
No demonstrable cortical contusion and acute intracranial hemorrhage is noted at the time of the
study.
There is slight decrease in the previously reported minimal subgaleal hematoma overlying the
fracture site.
Midline structure are not displaced.
Sulci, cisterns, fissures and ventricular system are intact.
Soft-tissue densities are now seen in the ethmoid, sphenoid and left maxillary sinuses indicative
of sinusitis.
Note of an endotracheal tube in place.
The rest of the study remains unchanged.

g.) ELECTROENCEPHALOGRAM REPORT

07/30/19
Description of Tracing:
The background activity consists of a medium voltage alpha rhythm of 9 – 10 Hz bilaterally
symmetric. However, there are frequent episodes wherein occasional 5 – 7 Hz theta activity is
seen admixed with the background alpha in brief runs of 2 – 3 seconds with the highest voltages
over the frontal areas bilaterally synchronous.
Photic stimulation did not elicit and occipital driving response.
Hyperventilation was not performed.
No epileptiform discharges were seen.
IMPRESSION:
This is an abnormal EEG displaying mild generalized slowing if the background activity
suggestive of a non-specific encephalopathic process. Clinical correlation is advised.

h.) ECO CARDIOGRAM & COLOR DOPPLER DATA

07/30/19
INTERPRETATION:
Normal left ventricular dimension with left ventricular mass index of 60.38 gm/m² and relative
wall thickness of 0.29 with adequate wall motion and contractility.
Normal right ventricular dimension with adequate wall motion and contractility.
Normal left atrial dimension with left atrial volume index of 21.28 ml/m². Normal right atrial
dimension.
Structurally normal aortic, mitral, tricuspid and pulmonic valves.
Normal aortic root dimensions and man pulmonary artery,
No pericardial effusion nor intracardiac thrombus.

COLOR FLOW IMAGING AND DOLLPER STUDY:

Mitral regurgitation, mild.
Tricuspid regurgitation, mild.
Normal mitral inflow profile and mitral annular velocity by TDI.
Estimated pulmonary arter systolic pressure of 22 mmHg by TR jet method.

CONCLUSION:
Normal left ventricular dimensions with adequate segmental and diastolic function with
calculated ejection fraction of 60% by teicholz method
Normal right ventricular size and function.
Physiologic regurgitations.
Normal pulmonary artery pressure.
V. REVIEW OF SYSTEMS

System Subjective cues Interpretation Analysis

Integumentary “Nakahiga lang siya A pressure ulcer (also Impaired skin
palagi, tapos naka known as bedsores or integrity related to
diaper pa, kaya siguro decubitus ulcer) is a pressure ulcer
nabababad ung puwet localized skin injury secondary to
niya sa ihi niya” as where tissues are prolonged physical
verbalized by the compressed between immobility and
patient’s S.O. bony prominences and unrelieved pressure as
hard surfaces such as evidenced by grade II
a mattress. They are pressure ulcer at L &
caused by pressure in R buttocks.
combination with
friction, shearing Reference:
forces, and moisture.
Nurse’s Pocket
Reference: Guide: Diagnoses,
Prioritized
Borromeo, A. et al, Intervention and
(2014). Lewis’s Rationales
Medical Surgical By: Marilynn E.
Nursing: Assessment Doenges, Mary
and Management of Frances Moorhouse,
Clinical Problems Alice C. Murr,pg.783
8th Edition (p. 183). – 790
Singapore. Elsevier
Pte Ltd.

Muscular system “Hindi pa siya Risk factors for Risk for fall related to
nakakatayo at galaw anticipated altered cerebral
ng masyado sa physiologic falls function as evidenced
ngayon. Katabi ko include an unstable or by low GCS score of
siya dito sa higaan abnormal gait, a 6 and
niya kapag natutulog history of falling, decreased strength in
ako” as verbalized by frequent toileting upper and lower
the patient’s SO. needs, altered mental extremities.
status, include
conditions such as Reference:
seizures and certain
medications. Nurse’s Pocket
Guide: Diagnoses,
Prioritized
Intervention and
Rationales
 By: Marilynn E.
Doenges, Mary
Frances Moorhouse,
Alice C. Murr,pg.226-
229

Ineffective tissue perfusion related to altered mental status as evidence by seizure episodes