XIII. DIAGNOSTIC EXAMS Laboratory Tests Name: L.M Age: 30 yrs.

old Brirthdate: August 20, 1982 Hospital No.: 346612 Date of Test: March 3, 2013 Physician: Dr. Samaniego

a. Hematology
Laboratory Test INDICATION NORMAL FINDINGS M: 4.6-6.2 Erythrocytes This test is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, State of hydration and dehydration, Polycythemia, Hemolytic disease of the newborn, to manage chemotherapy decisions 3.56 ACTUAL FINDINGS NURSING RESPONSIBILI TIES The patient does Pre have decreased RBC for that maybe due to -Check nutritional doctors order. deficiencies of iron and vitamin B12. -Identify the Patient LM was patient using at taking IBERET as least two unique his vitamins due to identifiers before decreased RBC. Another factor of providing care, or low level of RBC of treatment, services. the patient was the upper -Inform the gastrointestinal bleeding or patient this test hemorrhage. can assist in Hemoglobin is the evaluating the protein of RBC. amount of Patient LM does in have low hemoglobin the blood to assist hemoglobin count or in diagnosis and below-average concentration due to monitor therapy. low RBC. RBC produced by the bone marrow which carries O2 to other Intra parts of the body. When RBC is low, parts of the body do the not get enough O2. -Instruct to In case of the patient patient, His liver and cooperate fully lungs are affected CLINICAL SIGNIFICANCE

Hemoglobin

M: 140-180

96.6

Hematocrit M: 42.0 52.0

28.4

50.0 70.0 NEUTROPHIL S

23.2

EOSINOPHILS BASOPHILS LYMPHOCYT ES

1.0 4.0 0.0 1.0 25.0 40.0

2.7 0.7 9.9

maybe due to insufficient O2 delivery caused by low RBC. Decreased level of hematocrit may indicate acute massive blood loss or bleeding which was present in the patient. He was diagnosed to have UGIB. Low hematocrit of the patient was also due to destruction of RBC and nutritional deficiency of Iron and Vitamin B12. Neutrophils are matured WBC made from bone marrow. Patient LM was positive to bacterial infection. And neutrophils are responsible for fighting infections. Due to multiplication of bacterias, the level of neutrophils goes down. NORMAL

and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. -Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. Post Label the specimen tube. Complete the necessary information on the specimen tube such as name of the patient, the time and date.

MCH MCV

27.0-31.0 M: 80-94

27.0 79.9

-A report of the results will be NORMAL sent to the requesting Increased physician, who lymphocytes indicate bacterial will discuss the infection. Patient results with the LM does have patient. bacterial infection in his lungs caused by -Depending on the results of this Myobacterium procedure, Tuberculosis. additional testing NORMAL may be performed to NORMAL

MCHC RDW

33.0 37.0 11.5 14.5

33.8 17.5

NORMAL High RDW may indicate Iron Deficiency. It was due to low RBC. This was present in Patient LM. A high RDW indicates that RBC is more variable in volume than normal. The patient does have low platelet count. Due to these instances, the MPV also decreases and indicates abnormal platelet production. A low platelet count refers to an abnormally low no. of platelets, the particles in blood that help with clotting. In result of this, the patients clotting time was pro-long. He has low platelet count thats why bleeding is more likely to occur.

MPV

7.2-11.1

12.6

evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed.

Platelets

150-450

61

Name: L.M Age: 30 yrs. old Brirthdate: August 20, 1982 B. Abdominal Ultrasound
Laboratory Test INDICATION NORMAL FINDINGS

Hospital No.: 346612 Date of Test: March 3, 2013 Physician: Dr. Samaniego

ACTUAL FINDINGS Mild fatty liver with calcification Biliary ductal ectasia Consider cholelithiasis Mild splenomegaly Non visualized gall bladder Pancreas, kidney and urinary bladder normal Suspicious densities are seen at right upper lungs.

Abdominal ultrasou nd is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound. USED to: Determine the cause of kidney infections Look for stones in the gallbladder or kidney Look for the cause of abnormal blood tests such as liver function tests or kidney tests HBT Pancreas

The liver is not enlarged with multiple echogenic foci, with posterior shadowing at varying sizes scattered in the right and left

NURSING RESPONSIBILI TIES The patient was Pre suggest to have apicolordotic view. -Check for Fatty liver of the doctors order. patient was may be due to chronic -Identify the alcoholism. patient using at Cholelithiasis is the least two unique presence of stone in identifiers before the common bile providing care, duct. The patient treatment, or was seen with 1.9 services. cm stone in biliary duct. He was -Inform the diagnosed as UGIB patient why secondary to he/she was extrapulmonary TB. undergoing this type of diagnostic test. What was the purpose of the test to his/her condition. Fast for 8-12 hours before the test. This will decrease the amount of gas in your intestines and make your organs easier to LIVER see. PARENCHYMAL CALCIFICATIONS -Have a full AS DESCRIBED bladder before THESE COULD BE the test. You may INFECTIOUS IN need to drink six NATURE LIKELY or more glasses TUBERCULOSIS of water without CONTRACTED going to the GALLBLADDER bathroom. WITH

CLINICAL SIGNIFICANCE

sides with no masses effect. Intrahepatic ducts are not dilated.

CHOLELITHIASIS Intra UNREMARKABLE ULTRASOUND OF Tell the patient THE PANCREAS that this diagnostic examination will The gall last for about 30 bladder measures minutes. 2.43 x 1.59 cm with a highly Post reflective intraluminal echo A report of the measuring 1.1 cm results will be sent to the The requesting common bile duct physician, who measures 0.79 cm will discuss the in diameter results with the The pancreas is homogenous and not enlarged. It measures 0.05 cm (right) patient.

0.76cm (body) and 0.06cm (left)

Name: L.M Age: 30 yrs. old Brirthdate: August 20, 1982

Hospital No.: 346612 Date of Test: March 3, 2013 Physician: Dr. Samaniego

C. Clinical Chemistry
Laboratory Test INDICATION NORMAL FINDING S 2.14-7.14 mmol/L ACTUAL FINDINGS 10.32 NURSING RESPONSIBILITI ES Increased BUN level Pre may indicate impaired kidney function, -Check for doctors damage or failure. Due order. to patients lifestyle, he was considered to -Identify the patient have chronic using at least two alcoholism resulting to unique identifiers liver damage. before providing Concentrations may care, treatment, or elevate when there is excessive protein services. breakdown significantly increased - Prior to taking the protein in diet, or GIB blood sample, the (because of the nurse should inform proteins in the blood) the patient about the NORMAL test(s) to be performed and the preparation for the NORMAL test. Nurse should: NORMAL 1. define and explain the test 2. state the specific purpose of the test 3. explain the procedure 4. discuss test preparation, procedure, and post test care 5. CLINICAL SIGNIFICANCE

BUN

Clinical chemistry (also known as chemical pathology, clinical biochemistry or m edical biochemistry) is the area of clinical pathology that is generally concerned with analysis of bodily fluids.

Creatinine

M- 66-106 umol/L 135-148 mmol/L 3.6-5.5 mmol/L 98-106 mmol/L

66.92

Sodium

138.7

Potassium

4.15

Chloride

108.8

Glucose

4.11-5.39 mmol/L 4.11-5.39

5.29

High chloride was manifested on the patient. The patient vomited and do have imbalanced electrolyte. Since the patient do have TB, decreased level of blood chloride occurs. NORMAL

Cholesterol

4.39

NORMAL

mmol/L Triglyceride s HDL Up to 2.3 mmol/L M: greater than 1.45 mmol/L Less than 2.59 mmol/L 1.91 NORMAL

Intra -Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Post Label the specimen bottle. Complete the necessary information on the specimen bottle such as name of the patient, the time and date. A report of the results will be sent to the requesting physician, who will discuss the results with the patient.

0.271

LDL

3.2

VLD

Less than 1.04 mmol/L M: up to 40 U/L

0.87

Low HDL levels can put the patient to a greater risk of heart attack. The patient may be anemic. He has low RBC. Increased LDL indicates untreated pernicious anemia. And based on other laboratory results, the patient does have fatty liver. This was a factor why LDL was high in level. NORMAL

SGOT

205.7

SGPT

M: up to 41 U/L

144.7

Increased level of SGOT may indicate liver damage. When the liver is damaged, AST leaks out into blood stream and the level of AST in the blood becomes increased than the normal. High level of ALT in the patient may be caused by his liver damage. This was a factor why the SGPT increases. When the liver cells are damaged, ALT leaks out into the blood stream and level of ALT in blood is increased than the normal.

Name: L.M Age: 30 yrs. old Brirthdate: August 20, 1982

Hospital No.: 346612 Date of Test: March 3, 2013 Physician: Dr. Samaniego

D. PROTIME/PARTIAL THROMBOPLASTIN TIME

Laboratory Test

INDICATION

NORMAL FINDINGS

ACTUAL FINDINGS

CLINICAL SIGNIFICANCE

PROTIME/PA RTIAL THROMBOP LASTIN TIME

Performance 10-14 indicator measuring efficacy of both intrinsic and common coagulation pathways. Also detects blood clotting 22-35

Protime: 15.8 secs Control: 13.5 secs % Activity: 85.4 % % INR: 1.22

Based on the result, the patient does have prolonged blood clotting time.

APIT: 33.7 secs. Control 29.9 secs.

Name: L.M Age: 30 yrs. old Brirthdate: August 20, 1982 E. Urinalysis
Laboratory Test INDICATION
NORMAL FINDINGS

Hospital No.: 346612 Date of Test: March 3, 2013 Physician: Dr. Samaniego

ACTUAL FINDINGS Microscopic COLOR: yellow TRANSPARENC Y: slightly turbid REACTION: acidic SP. Gravity: 1.015 ALBUMIN: negative SUGAR: negative PUS CELLS: 1.3/HPF RBC: 0-2 EPITHELIAL CELL: few AMORPHOUS URATES: few

CLINICAL SIGNIFICAN CE

NURSING RESPONSIBILITIES

Urinalysis

Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine. A urinalysis may be done as part of a routine medical exam to screen for early signs of disease and for kidney disease, or to monitor you if you are being treated for these conditions

COLOR: amber yellow TRANSP ARENCY : Clear to slightly hazy

Urine specific gravity laboratory test that measures the concentration of all chemical particles in the urine. 0-2 RBC indicates cystitis.

Pre -Check for doctors order. -Identify the patient using at least two unique identifiers before providing care, treatment, or services. Define and explain the test. 1. state the specific purpose of the test 2. explain the procedure Intra - Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. It should always have a cleancatch specimen if a microscopic examination is ordered. Post Cover the specimen tightly, label properly and send immediately to the laboratory. A report of the results will be sent to the requesting physician, who will discuss the results with the patient.

Name: L.M Age: 30 yrs. old Brirthdate: August 20, 1982 A. Fecalysis Laboratory Test INDICATION NORMAL FINDINGS

Hospital No.: 346612 Date of Test: March 4, 2013 Physician: Dr. Samaniego

ACTUAL FINDINGS

CLINICAL SIGNIFICANCE

NURSING RESPONSIBILITIES

F. Fecalys Refers to a series of laboratory test COLOR: is done on fecal BROWN samples to analyze the condition of a persons digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as WBC, sugars, or bile enzymes of a poor absorption as well as screen for colon cancer.

COLOR: black CONSISTEN CY: Soft OCCULT BLOOD: positive

NO ova nor Pre parasites seen. -Check order.

for

doctors

-Identify the patient using at least two unique identifiers before providing care, treatment, or services. - The nurse should inform the patient about the test(s) to be performed and the preparation for the test. You should: 1. define and explain the test 2. state the specific purpose of the test If the patient can go to the comfort room, instruct the patient what to do. Intra Instruct the patient to defecate. Void before collection.

Obtain 2.5 (1 inch) formed stool. 15 to 30 ml of liquid stool. Post Cover the specimen tightly, label properly and send immediately to the laboratory. A report of the results will be sent to the requesting physician, who will discuss the results with the patient.

Name: L.M Age: 30 yrs. old Brirthdate: August 20, 1982

Hospital No.: 346612 Date of Test: March 10, 2013 Physician: Dr. Samaniego

A. WHOLE ABDOMEN CT SCAN W/ CONTRAST

Laboratory INDICATION Test WHOLE Looking ABDOMEN for infection, CT SCAN W/ inflammation, or CONTRAST cancer. Evaluating blood vessels. ACTUAL CLINICAL FINDINGS SIGNIFICANCE The liver is IMPRESSION: normal in size and ASCITES configuration with HEPATIC smooth contour. DUCTAL Parenchymal density CALCIFICATIO is homogenous. No NS, MOST mass, lesion seen. LIKELY DUE Multiple small TO calcifications are EXTRAPULMON noted. The ARY TB intrahepatic bile BILIARY ducts are slightly DUCTAL dilated. Minimal ECTASIA, TO perihepatic fluid RULE OUT AN collection is noted. OBSTRUCTING PATHOLOGY IN The THE DISTAL gallbladder is not CBD, ERCP IS visualized and is SUGGESTED most likely FOR RURTHER contracted. The EVALUATION. extrahepatic bile SPLENOMEGAL ducts including the Y common bile duct are slightly dilated. The spleen is enlarged measuring 15.0 x 13.5 x 7.0 cm.Nomass lesion seen. Perisplenic fluid collection is noted. The pancreas and adrenal glands are normal in size NURSING RESPONSIBILITIES Pre -Check order. for doctors

-Identify the patient using at least two unique identifiers before providing care, treatment, or services. - The nurse should inform the patient about the test(s) to be performed and the preparation for the test. You should: 1. define and explain the test 2. state the specific purpose of the test Instruct the patient to avoid eating or drinking anything for four hours before the test if contrast will be used. Remove any metal objects (eg, jewelry, hearing aids, dentures). Intra Instruct the patient to lie on the table. Tell the patient that The

and configuration. No mass lesion or calcification seen. The kidneys are normal in size. No mass lesion or lithiasis seen. The pelvocalyceal systems and ureters are within normal limits. No hydronephrosis seen. The urinary bladder is physiologically distended. Wall is not thickened. No mass lesion or lithiasis seen. Fluid is noted in the pelvic cavity.\ The prostate gland is normal in size. Outline is intact. No enlarged lymph nodes seen. The great vessels are within normal limits. Bony structures are intact with no osteoblastic or osteolytic lesions seen.

test will take for about 10-60 minutes Post Tell the patient that If he had contrast, he may be told to drink extra fluid. This will flush the contrast from your body. He may feel flushed if you received contrast. He may notice a salty or metallic taste in your mouth. He may also feel nauseous.