D.

Diagnostic/ Laboratory Procedures PROCEDURE DEFINITION INDICATION NORMAL VALUES RESULT INTERPRETATI ON Normal NURSING RESPONSIBILITI ES

HEMATOLOGY REPORT (September 11, 2010 9:59 pm) Hemoglobin 110-160 g/ L OxygenThe transporting concentration of substance in Hgb, the oxygen blood: an ironcarrier and the containing blood found in protein in RBCs the RBCs. that transports oxygen around the body. Hematocrit 0.370-0.540 Percentage of Determines the blood that is percent of blood g/L cells: the volume that is percentage of a RBCc blood sample that consists of RBCs measured after the blood has been centrifuged and the cells compacted. RBC count 3.50-5.50 Blood cell carrying oxygen: 10^12/L any red colored cell in blood that contains hemoglobin and carries oxygen to the tissues. A measure of the MCV (mean 80.0-100.0 fL

113

0.371

Normal

3.93

Normal

94.5

Normal

corpuscular volume) MCHC (Mean corpuscular hemoglobin concentration)

MCH

average volume of a red blood cell. an expression of the average percentage hemoglobin concentration obtained by multiplying the hemoglobin in grams by 100 and dividing by the hematocrit determination. A measurement of the average weight of hemoglobin in a red blood cell.

27.0 -34.0 pg

28.8

Rarely seen

32.0-36.0 g/dl

30.5

Normal

RDW-CV WBC Count

Infectionfighting cell: an unpigmented large cell in blood that helps protect the body against infection and also plays a role on inflammation and allergic reactions.
a condition where a person has a high number of neutrophil granulocytes in their blood.

Helps determine infection or inflammation.

11.0-16.0% 4.00-10.00 10^9/L

12.4 6.83

Normal Normal

Neutrophils

50.0-70.0 %

55.6

Normal

Lymphocytes

Basophils

Monocytes

Eosinophils

white blood cells of the agranulocyte type, originally from stem cells, that produce antibodies and attack harmful cells A cell, especially a white blood cell, having granules that stain readily with basic dyes. the largest of the white blood cells. They have one nucleus and a large amount of grayish-blue cytoplasm. white blood cells of the granulocyte type that have rough, round granules of cytoplasm that stain with eosin.

20.0-40.0%

34.2

Normal

0.0-1.0%

0.2

Normal

Develop into macrophages and both consume foreign material and alert T cells to its presence.

3.0-8.0%

5.3

Normal

0.5-5.0

4.7

Normal

Platelet

A tiny colorless disk-shaped particle found in large quantities in the blood and playing an important part in the clotting process.

Blood particle involved in clotting

100-300 10^9/L

246

Normal

MPV 6.5-120 fL HEMATOLOGY REPORT (September 11, 2010 9:59 pm)

8.9

Normal

Hemoglobin

Hematocrit

RBC count

Oxygentransporting substance in blood: an ironcontaining protein in RBCs that transports oxygen around the body. Percentage of blood that is cells: the percentage of a blood sample that consists of RBCs measured after the blood has been centrifuged and the cells compacted. Blood cell carrying oxygen: any red colored cell in blood that contains hemoglobin and carries oxygen to the tissues.
A measure of the average volume of a red blood cell. an expression of the average percentage hemoglobin concentration

The concentration of Hgb, the oxygen carrier and the blood found in the RBCs.

110-160 g/ L

122

Normal

Determines the percent of blood volume that is RBCc

0.370-0.540 g/L

0.375

Normal

3.50-5.50 10^12/L

4.10

Normal

MCV (mean corpuscular volume) MCHC (mean corpuscular hemoglobin concentration)

80.0-100.0 fL 27.0 -34.0 pg

91.5 29.8

Normal Normal

MCH (mean corpuscular hemoglobin) RDW-CV WBC Count

obtained by multiplying the hemoglobin in grams by 100 and dividing by the hematocrit determination A measurement of the average weight of hemoglobin in a red blood cell.

32.0-36.0 g/dl

32.5

Normal

Infectionfighting cell: an unpigmented large cell in blood that helps protect the body against infection and also plays a role on inflammation and allergic reactions.
a condition where a person has a high number of neutrophil granulocytes in their blood. white blood cells of the agranulocyte type, originally from stem cells, that produce antibodies and attack harmful

Helps determine infection or inflammation.

11.0-16.0% 4.00-10.00 10^9/L

12.0 9.58

Normal Normal

Neutrophils

50.0-70.0 %

65.0

Normal

Lymphocytes

20.0-40.0%

23.6

Normal

Basophils

Monocytes

Eosinophils

cells. A cell, especially a white blood cell, having granules that stain readily with basic dyes. the largest of the white blood cells. They have one nucleus and a large amount of grayish-blue cytoplasm. white blood cells of the granulocyte type that have rough, round granules of cytoplasm that stain with eosin.

0.0-1.0%

0.3

Normal

Develop into macrophages and both consume foreign material and alert T cells to its presence.

3.0-8.0%

4.6

Normal

0.5-5.0

6.5

corticosteroid therapy

Platelet

A tiny colorless disk-shaped particle found in large quantities in the blood and playing an important part in the clotting process.
a blood test that measures the volume of a large number of platelets as determined by an automated analyzer.

Blood particle involved in clotting

100-300 10^9/L

232

Normal

MPV (mean platelet volume)

use in the differential diagnosis of thrombocytopenic disorders.

6.5-120 fL

7.9

Normal

CLINICAL CHEMISTRY (September 11, 2010) Creatinine A derivative of creatine found in muscle, blood, and urine. Sodium A soft silver white metallic element that reacts readily with other substances and is essential to the bodys fluid balance. Potassium A soft silvery white highly reactive element of the alkali metal group Protein & Protein Metabolites (September 14,2010) Blood Urea A measure of Nitrogen (BUN) the amount of nitrogen in the blood in the form of urea, and a measurement of renal function. Protein & Protein Metabolites (September 23,2010) Creatinine A derivative of creatine found in muscle, blood, and urine.

45-104 umol/

75.04umol/L

Normal

135-145 mmol/L

139.70 mmol/L

Normal

3.6- 5.5 mmol/L

3.91mmol/L

Normal

ADULT: 2.87.2 mmol/L NEW BORN: 1.4- 4.3 mmol/L INFANT: 1.86.4 mmol/L 45-104 mmol/L

1.54 mmol/L

Hepatic damage, malnutrition

52.27 mmol/L

Normal

URINE EXAM RESULT PHYSICAL MICROSCOPIC

Color : Characteristics: Reaction Ph Specific Gravity Sugar Protein Bilirubin Ketone Urobilirogen Nitrite Ascorbic Acid

RESULT Light yellow Clear 6 1.015 CHEMICAL Negative Negative Negative Negative Negative Negative Not done yet

NORMAL VALUES Amber Clear 5-6 1.010-1.030 Negative Negative Negative Negative Negative Negative Negative

RBC WBC Crystals-A morphous urates Epithelial cells Bacteria Mucus threads Casts

RESULT 0-1/Hpf 0-1/Hpf Moderate Many few Few None found

NORMAL VALUES 0-2/hpf 0-5/hpf none Few few None

HEMATOLOGY SECTION (September 12, 2010) PROCEDURE DEFINITION INDICATION Prothrombin time
the rate at which prothrombin is converted to thrombin in citrated blood with added calcium; used to assess the extrinsic coagulation system of the blood The PT test is used to monitor patients taking certain medications as well as to help diagnose clotting disorders.

NORMAL VALUES 11.3 15.3 sec

RESULT 12.6 sec

INTERPRETATI ON

NURSING RESPONSIBILIT IES

PT control PT INR PT % activity APTT 70 -100% 28 37 sec

13.2 sec 0.94 111.0% 30.6 sec

the period required for clot

formation in recalcified blood plasma after contact activation and the addition of platelet substitutes; used to address the intrinsic and common pathways of coagulation.

ApTT control September 11,2010 PROCEDURE DEFINITION Clotting time Bleeding time
the time required for blood to clot in a glass tube the duration of bleeding after controlled, standardized puncture of the earlobe or forearm; a relatively inconsistent measure of capillary and platelet function.

32.9 sec

INDICATION

NORMAL VALUES 2 4 mins 2 4 mins

RESULT 230 mins 200 mins

INTERPRETATI ON Normal Normal

NURSING RESPONSIBILIT IES

September 12, 2010 the time required Clotting time Bleeding time

for blood to clot in a glass tube the duration of

2 4 mins 2 4 mins

230 mins 200 mins

Normal normal

bleeding after controlled, standardized puncture of the earlobe or forearm; a relatively inconsistent measure of capillary and platelet function.

Galag, Carmen/ 31-Female/ September 10,2010/ 10-6264/ OPD MRI OF THE HEAD WITH MRA CLINICAL HISTORY: Aneurysm COMPARISON: Correlated with CT of the brain dated September 07, 1010 TECHNIQUE: 1.5 T plain and contrast MRI of the brain and MRA of the circle of Willis were done. FINDINGS:

Gray- white matter differentiation is preserved Midline structures are in place No cisterns and sulci are not effaced. The ventricles are normal in size and configuration. The brainstem and cerebellum are intact the cerebello-dontine angle regions are clear. The cavernous sinuses are fairly symmetrical. The sellar/ juxtasellar region is unremarkable. Contrast study shows no abnormal parenchymal or meningeal enhancement. 3D-TOF MRA with MIP images shows a saccular outpunching that appears to emanate from the supraclinoid portion of the left internal carotid artery measuring approximately 0.5 x 0.4 x 0.5 cm anterior, middle and posterior cerebral arteries show no evidence of stenosis. The vertebral and basilar arteries are uunremarkable. The nasopharynx, rest of the paranasal sinuses, mastoids and orbits are unremarkable.

IMPRESSION: 1. 0.5 x 0.4 x 0.5 cm saccular aneurysm that appears to internal carotid artery. 2. Unremarkable MRI of the brain.