VIII.

Diagnostics

Date and Time Diagnostic Procedure Description of the Significance/Purpose Implication of the
Procedure Conducted Procedure of the Procedure Findings

August 4, 2010 Hematology (CBDC) Hematology is a medical

specialty concerned
3:20 pm RESULTS: with the study of blood
forming tissues. The
a. Hemoglobin mass most common test done  It measures the >NORMAL
conc. is the complete blood amount of oxygen
>158g/L count, which indicates carrying proteins
Normal: the number of red blood in the blood.
M: 140-180g/L cells, white blood cells,
F:120-160g/L platelets in a given unit
of blood. This test was
done to the patient in
order to identify
abnormal blood cells
and diagnose blood
diseases which may be
related to the patient’s
b. Erythrocyte condition.  Determines the  Erythrocyte is
 1.96 amount of oxygen grater then the
• Normal: carrying cells in normal value
 M: 0.040-0.54 the blood which indicates
 F: 0.038-.47 tissue destruction.

 Leukocyte number
c. Leukocyte concentration  Increase because
 33.2 helps to detect for infection started
• Normal infection.
  4.5 – 10 x 109L

d. Neutrophils  Helps determine

 0.70 for cause of the  Slightly increase
• Normal: disease/infection. because of WBC
 .38-.68 elevation

 Determine the
client’s ability to  There is significant
e. Lymphocyte produce deviation in
 .66 antibodies for client’s immune
recognition of function which
• Normal:
materials indicates infection.
• .20-.40
classified as
foreign and
prevent its
proliferation.

 Eosinophil count
f. .Eosinophils
has normal value,
• 0.01
Possible for stress
• Normal: response when
• 0.00-0.07  Helps detect any
allergic reactions patient has
and skin diseases. decrease value of
eosinophils and
greater value is
 possible for
allergic reaction
and skin diseases.
g. Platelets
• Adequate
• Normal:
• 150-400x10^9/L  Platelet count is
adequate.
 Determine ability Abnormally low
of client when it platelet count is
regards to blood possible which can
clotting. result in
spontaneous
bleeding
abnormally high
platelet count
result in
thrombocytosis is
possible if client
has high platelet
count.

Date and Time Diagnostic Procedure Description of the Significance/Purpose Implication of the
Procedure Conducted Procedure of the Procedure Findings

April 11, 2010

2:28 pm Urinalysis Urinalysis is commonly
used to detect renal and
metabolic diseases,
diagnosis of diseases or
disorders of the kidneys
or urinary tract.
 A test used to
determine various
substances in the
urine. It helps to
detect if patient is
positive to protein,
RESULTS: albumin and
medical/nursing
management
needed.

A. Physical  The change in

examination color indicates
 To check for that there is a
a. Color- Light Yellow possible problem to the
hematuria tubular filtration.
• Normal:

 Yellow-deep
amber

 Turbid urine
contains bacteria.
 To detect
metabolic or
b. Transparency systemic disease.

• Slightly turbid

 pH reaction is
normal.

 Helps detect the

acidity or basicity
of the urine

c. pH = 6
 • Normal

• 4.5-8

 Specific gravity is
d. Specific gravity  Check for tubular normal.
1.020 filtration and re-
absorption
• Normal: problem

• 0.010-1.025

B. Chemical
Examination

 NORMAL

a. Albumin: Negative
b. Glucose: Negative

C. Microscopic
Examination.
  RBC:

 0-1

 NORMAL

b. Epithelial cells

• Few
• Normal:
 Epithelial Cells are
>Few Normal

Date and Time Diagnostic Procedure Description of the Significance/Purpose Implication of the
Procedure Conducted Procedure of the Procedure Findings

June 23, 2010 Abdominal Ultrasound

An ultrasound that  Ultrasound can
creates images that
RESULTS: allow various organs in
the body to be
The liver is normal in examined. The machine
size and outline. The sends out high-
hepatorenal interface is frequency sound waves,
which reflect off body
intact. Parenchumal
structures to create a
echogenicity is picture. A computer
increased w/ no focal receives these reflected
mass or calcifications waves and uses them to
seen. Intrahepatic duct create a picture. Unlike
are dilated. The with x-rays or CT scans,
common bile duct has there is no ionizing
radiation exposure with
diameter of 1.2cm. The
1) Fatty infiltrative
detect cysts, changes of the liver
tumors, abscesses,
considered.
obstructions, fluid
collection, and
infection within or
2) Biliary tract
obstruction most likely
around the
surrounding organs secondary to lithiasis
of the abdomen.
formation. Exact
location not well
determined.
3) Lithiase formation in
the gallbladder
neck/cystic duct.
 gallbladder is normal in
size & configuration, the this test.
wall is smooth & not
thickened. There are
two shadowing hypere
chor foci seen in the
area of gallbladder
neck/cystic duct
measuring about 1.1cm
& 0.9cm. The pancreas
is not well visualized in
this study due to
abundant bowel gas
obscuring it.

IX. MEDICAL DIAGNOSIS

Admitting Diagnosis: Calculous Cholecystitis

Final Diagnosis: Calculous Cholecystitis S/P Open Cholecystectomy