Diagnostic Tests

TOMOGRAPHY
July 15, 2009, 5:06 PM
EXAM FINDINGS IMPRESSION
Brain
CT-Scan
No acute intracranial hemorrhage.
No acute intracranial
hemorrhage
Ischemic changes in the
periventricular white matter
and posterior limbs of both
internal capsule
Hypodensity in the right
subcortical frontal white
matter indicative of
ischemia/infarct. Edema
cannot be entirely excluded.
MRI is recommended.
Cerebro-cerebellar atrophy
Atherosclerosis on both
internal carotid and vertebral
arteries
Hypodensities are noted in the periventricular white
matter and posterior limb of both internal capsule.
Another more distinct hypodensity is noted in the
subcortical frontal white matter.
The sulci, cisterns, sylvian fissures, extraaxial spaces
and ventricles are slightly prominent.
The brainstem shows no discrete abnormality. There is
a small hypodensity in the left cerebellum which could
be volume averaging from the sulcus, however a
lacunar infarct cannot be entirely excluded.
Calcific deposits are appreciated in both internal carotid
and vertebral arteries
The visualized paranasal sinuses and tympanomastoids
are adequately aerated. Right-sided nasal septal
deviation is noted with spur formation
The calvarium are intact
BIOCHEMISTRY
July 15, 2009, 6:17 PM

CONSTITUENT
RESULT
NORMAL
FINDINGS
CLINICAL SIGNIFICANCE
Creatinine 0.76 0.6-1.2 mg/dl Normal
Urea Nitrogen 8.0 7-21 mg/dl Normal
Sodium 145 135-145 mmol/L Normal
Potassium 3.29 3.6-5.5
mmol/L
Low; hypokalemia
Ionized Calcium 1.1 1.05-1.25 mmol/L Normal
Magnesium 1.81 1.7-2.2 mg/dl Normal
HEMATOLOGY
July 15, 2009, 6:21 PM

CONSTITUENT
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Hemoglobin 11.4 11.6-15.5 g/dl
Slightly low,
indicates low
oxygen carrying
capacity of the
blood
Hematocrit 33.8 36-47%
Red Blood Cell
(RBC)
3.69
4.2-5.4
mil/mm3
White Blood Cell (WBC) 10,610 4,800-10,800/mm3 Normal
DIFFERENTIAL COUNT
Neutrophils 80 40-74%
Elevated
Lymphocytes 12 19-48%
Low
Eosinophils 1 0-7% Normal
Monocytes 6 3-9% Normal
Basophils 1 0-2% Normal
Platelet Count 385,000
150,000-
400,000/mm3
Normal
Mean Corpuscular
Volume
92 82-98 fl Normal
Mean Corpuscular
Hemoglobin (MCH)
31 28-33 pg Normal
Mean Corpuscular
Hemoglobin
Concentration (MCHC)
34 32-38% Normal
Partial Thromboplastin
Time
33.6 28-44 sec Normal
RADIOLOGY
July 15, 2009, 5:26 PM

EXAM
FINDINGS IMPRESSION
Bedside Chest PA
Apical pleural thickening is appreciated in
both sides
Apical pleural
thickening,
bilateral
Cardiomegaly
Atheromatous
aorta
No definite parenchymal infiltrate is seen
Heart is enlarged
Aorta is tortuous and calcified
Hemidiaphragms and sulci are intact
Degenerative osseous changes are noted
ELECTROCARDIOGRAPHY
July 15, 2009

EXAM
FINDINGS INTERPRETATION
EKG
Normal sinus
rhythm
Non-specific ST
wave changes
Clinical correlation
required
QT
Corrected
0.41
0.32-0.40
seconds
Indicates patients at risk for
lethal ventricular dysrrythmia
called tarsades de pointes (if
prolonged)
BIOCHEMISTRY
July 16, 2009, 11:42 AM

CONSTITUENT
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Cholesterol 245 150-240
mg/dl
Slightly elevated; indicates
hypercholesterolemia/ hyperlipidemia
which is a predisposing factor to her
present condition
Triglycerides 135 35-160 mg/dl Normal
HDL Cholesterol 34 30-90 mg/dl Normal
LDL
Cholesterol
162 0-150 mg/dl
High;
Harmful to the blood vessels and can
aggravate atherosclerosis that leads to
severe heart ailments
VLDL 27 0-35 mg/dl Normal
TOMOGRAPHY
July 16, 2009, 8:21 PM(OLFU)

EXAM
FINDINGS IMPRESSION
Brain-Plain
Follow-up examination to July 15, 2006 now shows a
well-defined focus of hypodensity in the lentiform
nucleus and corona radiate indicative of acute infarct.
The foci of hypodensities in frontal lobes are again
noted.
Acute infarct, left lentiform
nucleus and corona radiate.
Consider old infarcts, both
frontal lobes which affected
the patients emotional
behavior and voluntary
movements
Ischemic changes and/or
areas of degeneration,
periventricular white matter
and corona radiate which
affected the patients sensory-
motor responses
Cerebro-cerebellar atrophy
Atherosclerotic vertebral and
internal carotid arteries
The inhomogeneous decrease in density of the
periventricular white matter/corona radiate are the
same.
The cerebro-cerebellar atrophy is again noted.
The atherosclerotic vertebral and internal carotid
arteries are the same
The rest of the findings remain stationary
URINALYSIS
July 17, 2009, 6:56 AM

CONSTITUENT
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Blood
trace
intact
negative
Indicates kidney infection or
presence kidney stones.
Leukocytes moderate negative
An indication of urinary
infection.
Red Blood
Cells
6 0-4.3/hpf
Elevated; indicates kidney
infection or presence of
kidney stones.
White Cells 21 0-6.0/hpf
Highly Elevated; indicates
Urinary Tract infection
Epithelial
Cells
5 0-4/hpf
Elevated; came from injury
on urinary tracts, or from
infection sites.
MICROBIOLOGY
July 17, 2009, 6:56 AM
Specimen: Urine

EXAM
RESULT
NORMAL
FINDINGS
CLINICAL
SIGNIFICANCE
Growth
None after
2 days
None Normal
Type of
Incubation
Aerobically N. A. _________
BIOCHEMISTRY
July 18, 2009, 5:21 AM

CONSTITUENT
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Sodium 142 135-145 mmol/L Normal
Potassium 3.5
3.6-5.5
mmol/L
Slightly lowered which indicates mild
hypokalemia. Condition has slightly
improved from the last exam which was
3.29.
HEMATOLOGY
July 18, 2009, 6:18 AM

CONSTITUENT
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Hemoglobin 13.2 11.6-15.5 g/dl Normal
Hematocrit 39.5 36-47% Normal
Red Blood Cell (RBC) 4.35 4.2-5.4 mil/mm3 Normal
White Blood
Cell (WBC)
11,460
4,800-
10,800/mm3
Elevated; An indication of Leukocytosis
which occurs due to the presence of
infection as part of the bodys defense
mechanism.
DIFFERENTIAL COUNT
Neutrophils 67 40-74% Normal
Lymphocytes 22 19-48% Normal
Eosinophils 3 0-7% Normal
Monocytes 8 3-9% Normal
Platelet Count 332,000
150,000-
400,000/mm3
Normal
HEMATOLOGY
July 19, 2009, 5:15 AM

CONSTITUENT
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Hemoglobin 12.4 11.6-15.5 g/dl Normal
Hematocrit 36.6 36-47% Normal
Red Blood Cell
(RBC)
3.93
4.2-5.4
mil/mm3
Lowered due to lack of necessary
structural components like iron which is
primarily acquired from iron-rich foods
White Blood Cell (WBC) 10,200 4,800-10,800/mm3 Normal
DIFFERENTIAL COUNT
Neutrophils 65 40-74% Normal
Lymphocytes 20 19-48% Normal
Eosinophils 6 0-7% Normal
Monocytes 8 3-9% Normal
Basophils 1 0-2% Normal
Platelet Count 318,000 150,000-400,000/mm3 Normal
MICROBIOLOGY
July 19, 2009, 7:33 AM
Specimen: Urine

EXAM
RESULT NORMAL FINDINGS CLINICAL SIGNIFICANCE
Growth None after 2 days None Normal
Type of Incubation Aerobically N. A. --------
URINALYSIS
July 20, 2009, 7:30 PM

CONSTITUENT
RESULT
NORMAL
FINDINGS
CLINICAL
SIGNIFICANCE
Color Dark yellow
Pale yellow to
amber
May indicate kidney
problems
Turbidity Clear
Clear to slightly
hazy
Normal
Glucose Negative Negative Normal
Bile Negative Negative Normal
Ketone Negative Negative Normal
Specific Gravity <=1.005 1.010-1.025
Lowered; Indicates kidney
disease or renal
malfunction.
pH Acidic (6.5) 4.5-8.0 Normal
Protein Negative Negative Normal
Urobilinogen 0.2 EU/dl 0.1-1 EU/dl Normal
Nitrites Negative Negative Normal
Blood Negative Negative Normal
Leukocytes Negative Negative Normal
Red Blood Cells 2 0-4.3/hpf Normal
White Cells 1 0-6.0/hpf Normal
Epithelial Cells 1 0-4/hpf Normal
HEMATOLOGY
July 22, 2009, 9:28 PM

CONSTITUENT
RESUL
T
NORMAL FINDINGS CLINICAL SIGNIFICANCE
Hemoglobin 12.5 11.6-15.5 g/dl Normal
Hematocrit 37.3 36-47% Normal
Red Blood Cell (RBC) 4.0 4.2-5.4 mil/mm3 Normal
White Blood Cell (WBC) 9,400 4,800-10,800/mm3 Normal
DIFFERENTIAL COUNT
Neutrophils 70 40-74% Normal
Lymphocytes 16 19-48% Low
Eosinophils 6 0-7% Normal
Monocytes 8 3-9% Normal
Platelet Count 360,000 150,000-400,000/mm3 Normal
Nursing Theory


Loss of appetite
Often troubled
Doesnt display interest
in her surroundings
The patient
Is sad and
lonely
Needs
attention and
care
Is physically
weak &
psychologically
disturbed
Encouraged
to eat
Stayed with
the patient
and
encouraged
verbalization
of feelings
Needs
attended

Nurses Action
Nurses Assessment
Patients Behavior
STRUCTURAL INTEGRITY
Medications given as
prescribed
Repositioned the
patient
Performed
independent nursing
functions
PERSONAL INTEGRITY
Listened intently to
expression of
thoughts and feelings
Acknowledged
progress
ENERGY
Encouraged to rest
Encouraged to eat
Provided needs
SOCIAL INTEGRITY
Socialized with the
patient
Encouraged
verbalization of
feelings
Encouraged to
socialize with room
mates