Diagnostic test

Complete Blood Count

Blood Serum
Test Requested Feb. 10, 2009 Feb. 11, 2009 Feb. 12, 2009 Normal Values
1:00 pm 6:00 am 8:00 pm
Hemoglobin 80 90 108 120.00 -170.00 g/L
Hematocrit 0.22 0.25 0.31 0.40 - 0.54
RBC Count 2.52 2.91 3.34 4.00 - 5.5 x 10^12/L
WBC Count 11.7 11.0 8.1 5.00 - 10.00 x 10^9/L
Differential Count:
Neutrophil 0.59 0.57 0.64 0.50 – 0.70
Lymphocyte 0.25 0.28 0.18 0.20 – 0.40
Eosinophil 0.05 0.06 0.09 0.00 – 0.05
Monocyte 0.11 0.09 0.09 0.00 – 0.09
Basophil 0.00 0.00 0.00 0.00 – 0.01
RBC: Hypochromic

Blood Chemistry
Test Requested Results Normal Values
Feb. 10, 2009 Feb. 12, 2009
Creatinine 2129.30 2357.60 71.00 – 133.00 mmol/L

Blood Urea 149.75 165.81 2.50 – 6.10 mmol/L

Nitrogen
Prothrombin time 11 12.7 10.8 – 13 seconds
APTT 35 65.4 29 – 40 seconds

Clinical Laboratory Report – Clinical Chemistry Section February 10, 2009 1:00 pm
Test Requested Result Normal Values
SGPT 348 21 – 72 u/L
Sodium 109.3 136.00 – 145.00 mmol/L
Potassium 4.09 3.50 – 5.50 mmol/L
Glucose RBS 11.99 2.5 – 7.2 mmol/L
Albumin 2.46 3.5 – 5.5 g/dl
Calcium 7.3 8.4 – 10.2 mg/dl

URINALYSIS
February 10, 2009 February 12, 2009
PHYSICAL
Color: Straw Dark Straw
Reaction: pH 6.5 pH 6.5
Transparency: Hazy Cloudy
Specific Gravity: 1.015 1.030
CELLS
Pus Cells 1-3/ HPF 1-2/ HPF
RBC 18 – 23/HPF 21 – 26/HPF
CHEMICAL
Albumin 4+ 4+
Sugar 1+ 1+
Mucus Shreds Occasional/LPF Occasional/LPF
Bacteria Moderate/LPF Moderate/LPF

February 10, 2009

Test Requested Result
Troponin I Positive
2D ECHO

February 10, 2009

Interpretation:

Dilated left ventricle with hypertrophied walls and mild hypokinesia of the anterior
ventricular septum and anterolateral left ventricular free wall from mid to apical left
ventricle.

Dilated left atrial chamber

Normal right atrium, right ventricle, main pulmonary artery

Intact intraatrial septum and intraventricular septum

Aortic annular calcification, moderate

Thickened mitral leaflet

Mitral regurgitation

Structurally normal tricuspid valve leaflets and pulmonic valve leaflets

ECG
February 10, 2009

Anteroseptal MI

ST abnormality- sub endocardial injury (high lateral) with T-wave inversion in

anterolateral

ABG
February 10, 2009
Result Normal value
pH 7.26 7.35 - 7.45
pCO2 50 35 – 45
HCO3 18.5 22 – 26
O2 Saturation 95% 96 – 100%
Interpretation: Metabolic acidosis, partially compensated

Ultrasound
February 10, 2009

Mapping of the Hemidiaphragm. There is about 139cc of free fluid in the pleural space at
Left.
Remarks: Minimal Pleural Effusion at Left Lung

Ultrasound Entire Abdomen

February 10, 2009

Follow up examination to the study dated September 12, 2009 shows the following
findings. There is moderate ascites, predominantly in the pelvic area and both lower
quadrants. The liver is slightly enlarged with a craniocaudal span of 17 cm at the right
lobe and 14 cm at the right midclavicular line. Contour smooth but edges are mildly
blunted. There is no focal parenchymal lesion. There is normal branching of the hepatic
and portal veins. The intrahepatic ducts and common duct (5.00 mm) are undilated. The
gallbladder measures 7.8 x 2.5 cm. its wall is mildly thickened measuring 4mm. minimal
medium level echoes are seen within the lumen.

The pancreas is normal in size and homogenous echo texture. There is no focal
parenchymal lesion. The pancreatic duct is not dilated. The spleen is normal in size with
homogenous texture. There is no focal parenchymal lesion. The aorta is atherosclerotic.
Both kidneys are normal in size but exhibit increase parenchymal echogenecity with poor
corticomedulllary differentiation. The right kidney measures 9.7 x 4.5 x 4.9cm with a
cortical thickness of 1.1cm while the left kidney measures 9.7 x 4.0 x 4.0cm. There is no
parenchymal lesion.

Impression:

Moderate Ascites
Slight Hepatomegaly
Slightly thickened Gallbladder wall
Minimal gallbladder sludge
Atherosclerotic Aorta
Bilateral Renal Parenchymal disease, likely chronic
Unremarkable partially filled urinary bladder
Sonographically normal pancreas, spleen, and prostate gland

3 units PRBC O+

February 11, 2009

09 – 1827 expiration date: March 10, 2009

Started: 10:00 am
Terminated 3:30 pm

09 – 1828 expiration date: March 10, 2009

Started: 4:30 pm
Terminated: 9:45 pm

February 12, 2009

09 – 1829 expiration date: March 10, 2009
Started: 9:30 am
Terminated: 2:00 pm