.

DIAGOSTIC AND LABORATORY EXAMS AND PROCEDURE

DONE

ECG

Date done: October 23, 2009

Impression: Diffuse interstitial disease, right cannot rule out

PTB

Rest of the study are secondary to supine position

Date done: October 23, 2009

Impression: Sinus tachycardia with premature ventricular

contractions

-Left atrial enlargement

-Antero septal wall ischemia

Date done: October 29, 2009

Impression: Residual interstitial infiltrates are still noted in the

right mid and both lower lung fields with haziness in the right
lung base

- Both hemidiaphragms are elevate

- There is lateralization of the right hemidiaphragm with

minimal blunting of the right costophrenic sulcus. Suggest right
lateral decubitus view to rule out pleural fluid

- Heart is not enlarged

- Incidentally there is minimal distention of the visualized

intestinal segments of ileus

CT SCAN

Date done: November 4, 2009

Impression: Non-contrast enhanced axial CT scan of the

brain with settings optimized for parenchymal and bone
details reveals the following findings:
 -There is chronic subdural hematoma noted in the left
fronto-temporo-parietal region with maximum depth of
approximately 2.7 cc

-There are signs of left to right midline shift and

subfalcine herniation

-The 3rd ventricle appears compressed producing

dilatation of the right lateral ventricle

-Craniotomy defect noted in the right temporo-parieto-

occipital region

-No other findings of note

X-RAY

Date done: November 7, 2009

Impression: -Remarkable further clearing of right lower

infiltrates leaving few interstitial residual infiltrates

-Heart and vascularity status are unchanged

-Rest of the previous findings are in status quo

Nursing Consideration:

BT

Blood type: Type A

Donor serial number: 09-1793

ABO and RIt type: A+

Amount: 1 unit

Date expired: 24 hours after packing

Major crossmatching: Compatible

Minor crossmatching: Compatible

Broad Spectrum ct: Compatible

Remarks: HBsAG, Anti-HIV antibody to HCU-negative

RBC packing has to be done upon receipt of request

for transfusion

CBC

Date done: November 24, 2009

Date done: October 17, 2009

RESULT UNIT REF.

VALUES

Erythrocytes 3.53 X10^/L 4.6-

NUMC 6.20x10^12/L

Hemoglobin 11.2 g/dl 13.518.0 g/dl

Hemoglobin 1.736 mmol/L 2.09-

SUBSTC 2.79mmol/L

Erythrocytes 0.35 0.42-0.50

VOL FR

Leukocytes 7.3 X10^9/L 4.5-

NUMC 11x10^9/L

Segmenter 0.64 0.56

s

Eosinophil 0.02 0.027

es

Lymphocyt 0.33 0.34

es

Monocytes 0.01 0.04

Thrombocytes Adequate X10^9/L 150-

NUMC 400x10^9/L

MCU 97.9 81 80-96fl

MCH 31.6 Pg 27-31pg

MCHC 0.32 0.32-0.36

• Culture and Sensitivity

Final Report: Growth of Klebsiella specie over 100,000
organisms/mL of urine

• Urine
Vol: 10cc

RXN: alkaline

Albumin: (-)

Sugar: (-)

Color: yellow

Character: turbid

CLINICAL RESULT REFERENCE

CHEMISTRY RANGE

Sodium 127.0mmol/l 135-148

Albumin 24.00g/l 34-48

BUN 5.17mmol/l 2.9-8.1

Sodium 116.0mmol/l 135-148

Sodium 115.3mmol/l ‘’’’

Potassium 4.69mmol/l 3.5-5.3

Albumin 21.50g/l ‘’’’

Albumin 21.6g/l ‘’’’

Sodium 133.7mmol/l ‘’’’

Potassium 2.83mmol/l ‘’’’

Creatinine 70.58mmol/l 53-106

Sodium 136.0mmol/l ‘’’’

Potassium 3.50mmol/l ‘’’’

Total Protein 53.3mmol/l 60-78

Albumin 20.60g/l ‘’’’

Globulin 32.70g/l 23-35

A/G ratio 0.63 1.0 1-3

Sodium 122.5mmol/l ‘’’’

Potassium 4.30mmol/l ‘’’’

Random Blood 5.20mmol/l 3.85-6.05

Sugar

BUN 6.85mmol/l 2.9-8.2

Sodium 119.9mmol/l ‘’’’

Potassium 4.79mmol/l ‘’’’

TSH 1.18ulu/ml 0.27-4.2

Sodium 136.4mmol/l ‘’’’

 Clinical Result Reference Conventional Date
chemistry range

Sodium 127.0mmol/l 135-148 Nov. 19

Albumin 24.00g/l 34-48 2.40g/l Nov. 18

BUN 5.17mmol/l 2.9-8.1 14.48mg/dl Nov. 17

Sodium 116.0mmol/l 135-148 Nov. 16

Sodium 115.3mmol/l ‘’’’ Nov. 15

Potassium 4.69mmol/l 3.5-5.3 Nov. 15

Albumin 21.50g/l ‘’’’ Nov. 13

Albumin 21.6g/l ‘’’’ Nov. 11

Sodium 133.7mmol/l ‘’’’ Nov. 11

Potassium 2.83mmol/l ‘’’’ 3.5-5.3 Nov. 11

Creatinine 70.58mmol/l 53-106 0.80mg/dl Nov. 8

Sodium 136.0mmol/l ‘’’’ Nov. 8

Potassium 3.50mmol/l ‘’’’ Nov. 8

Total 53.3mmol/l 60-78 5.33g/dl Nov. 8

protein

Albumin 20.60g/l ‘’’’ 2.06g/l Nov. 8

Globulin 32.70g/l 23-35 3.27g/dl Nov. 8

A/G ratio 0.63 1.0 1-3 Nov. 8

Sodium 122.5mmol/l ‘’’’ Nov. 5

Potassium 4.30mmol/l ‘’’’ Nov. 5

Random 5.20mmol/l 3.85-6.05 94.54mg/dl Nov. 1

blood sugar

BUN 6.85mmol/l 2.9-8.2 19.18mg/dl Nov. 1

Sodium 119.9mmol/l ‘’’’ Nov. 1

Potassium 4.79mmol/l ‘’’’ Nov. 1

TSH 1.18ulu/ml 0.27-4.2 Oct. 26

Sodium 136.4mmol/l ‘’’’ Oct. 25