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Diagnosis and Laboratories

Diagnosis and Laboratories

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Published by: Kathleen Merioles Barredo on Feb 25, 2012
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IX.

DIAGNOSIS AND LABORATORIES
February 5, 2012

Hematology
TEST NORMAL VALUES RESULT ANALYSIS

COMPLETE BLOOD COUNT WBC Count RBC Count 5-10 x 10 3/uL 8.90 Within normal range

4.2

5.4 x 10

6/uL

4.89

Within normal range

Hemoglobin

12.0

16.0 g/dL

10.8

It decreases when there is anemia, recent hemorrhage and fluid retention. It decreases when there is anemia and hemodilution.

Hematocrit

38.0

47.0%

35.0

Platelet Count DIFFERENTIAL COUNT Basophil (%)

150

450 x 10 3/uL

436

Within normal range

0.1

1.0 %

2.0 %

It increases when there is bone marrow disorders and viral infection.

Age: 56 yrs. The gallbladder is not visualized. The rest of gastrointestinal system is not unusual.5 cm exophytic focus is seen arising from the inferior pole of the right kidney. a malignant process is primarily considered. Mucosal irregularities are detected in the posterior body of the stomach. The bilateral pelveocalyceal system and ureters are not dilated. 8 mon Ward/Rm.: 327 File No.V contrast reveals irregular wall thickening of middle segment of the ascending colon with luminal narrowing. SCAN CONTRAST Patient: T. The more proximal segments of bowel are dilated.: CT-1832 RESULT CT SCAN OF THE WHOLE ABDOMEN Axial CT scan of the whole abdomen with oral and I. There are no enlarged retroperitoneal or pelvic lymph nodes.M Datetime Performed: 01/13/2012 10:19 AM Requesting Doctor: P. The common hepatic and common bile duct are prominent. The kidneys show good excretion of contrast. the 3.D. probably a cyst . may be from gastritis or ulcers Prominent common hepatic and common bile ducts with nonvisualized gallbladder. IMPRESSION Ascending colon mass with pericolic fat infiltration and lymphadenopathy. The adrenal glands and left kidney are grosstly intact. SD M. No.4 not the The liver is not enlarged.CTSCAN WHOLE ABDOMEN C. A 0. The urinary bladder. No ascites is detected. Pericolic fat stranding and nodularities are observed. It has a maximal wall thickness of cm. probably post cholecystectomy changes Right renal nodule. Mucosal irregularities in the posterior body of the stomach.T. and adnexae are not unusual. uterus. The rest of the visualized soft tissues and osseous structures are unremarkable. The pancreas and spleen are not unusual.

ASCENDING COLON T/C MALIGNANT RECOMMENDATIONS: REFER TO SURGERY . PRELIMINARY RECTAL EXAMINATION IS UNREMARKABLE THE SCOPE WAS INSERTD UP TO 90CM LEVEL (ASCENDING COLON) DUE TO NARROWED LUMEN TOWARDS THE CECAL AREA THE MASS APPEARS FUNGATING OCCUPIIES CIRCUMFIRENTIALLY THE OVERLYING MUCOSA IS NODULAR.COLONOSCOPY REPORT INDICATION: HISTORY: MEDICATION: ENDOSCOPIC FINDINGS: THE PROCEDURE WAS PERFORMED BY MEANS OF OLYMPUS VIDEOENDOSCOPE CFQ 160L UNDER SEDATION AND MONITORING BISCODYL AND MAGNESIUM CITRATE WERE GIVEN THE NIGHT BEFORE WITH GOOD RESULTS. PINK AND SHINY WITH GOOD VASCULAR PATTERN THE HEMORRHOIDAL VESSELS ABOVE THE DENTATE LINE ARE INTACT. FENTANYL 50MCG. FRIABLE COVERED WITH NECROTIC PURELENT MATERIAL WITH BLOOD CLOTS THE REST OF VISUALIZED COLONIC MUCOSA IS SMOOTH. ANEMIA AND ABDOMINAL PAIN CT SCAN RESULT SHOWS MASS AT ASCENDING COLON MIDAZOLAM 2MG. PROPOFOL 30MG PATIENT TOLRATED THE PROCEDURE WHICH LASTED FOR 15 MINUTSWITH WITHDRAWAL TIME OF 11 MINUTES DIAGNOSIS: COLONIC MASS.

Ward/Rm.: X-34454 RESULT FINDINGS: Lungs are clear and normoaerated with normovascular pattern Heart. SD M. 8 mon. IMPRESSION ATHEROMATOUS AORTA.M Datetime Performed: 01/1/2012 06:39 PM Requesting Doctor: P. cosdophrenic sinuses and underlying osseous structures are intact. OTHERWISE. great vessels.D. Atheromatous aorta noted.: 327 File No. NORMAL CHEST FINDINGS . Age: 56 yrs. No. diaphragms.X-RAY CHEST PA VIEW Patient: T.

14 5.03 1.2 0.CLINICAL CHEMISTRY PATIENT NAME: AGE: 50 T. 40. 106. mg/dL 23.08 mmol/L 1. mg/dL 48.25 mmol/L 4. 60. 5. 200. 0.94 0.9 Cholesterol Information : * NCEP Guidelines Total Cholesterol Risk Levels Desirable Level < 200 mg/dl Borderline Risk Level 200 239 mg/dl High Risk Level > 240 mg/dl HDL-Cholesterol Risk Levels * LDL Cholesterol Risk Levels * Decreased < 40 mg/dl Optimal < 100 mg/dl Acceptable 40 60 mg/dl High 160 189 mg/dl Desirable > 60 mg/dl Very High > 190 mg/dl Near Optimal 100 129 mg/dl Borderline High 130 159 mg/dl * Analysis High Cholesterol/LDL contributes to clogged arteries and increases the risk of heart attack or stroke.49 mmol/L 6. 150. mg/dL HIGH 234.65 0. 150. 40. 3. mg/dL HIGH 162.55 0. mg/dL REF RANGE 74. SI RESULT 5. 0. 1.29 mmol/L 0.6 mmol/L 1. 0. M SEX: F LAB # SAMPLE ID SPECIMEN: PHYSICIAN: 2067 6 SERUM DRPEZA WARD: 327 DATE: JAN 13 2012 TEST NAME  FASTING BLOOD SUGAR CHOLESTEROL TRIGLYCERIDES VLDL DIRECT HDL LDL COMMENTS 6AM CONVENTIONAL RESULT 96. 0. mg/dL 117. .21 mmol/L REF RANGE 4. 1.03 1.

CLINICAL CHEMISTRY PATIENT NAME: AGE: 50 T. 17. gastrointestinal bleeding. mg/dL 0. congestive heart failure. burns. such as corticosteroids and high protein diet. M SEX: F LAB # SAMPLE ID SPECIMEN: PHYSICIAN: 1991 102 SERUM DRPEZA WARD: 327 DATE: JAN 12 2012 TEST NAME BLOOD UREA NITROGEN CREATININE SGPT (ALT) COMMENTS CONVENTIONAL RESULT HIGH 18. * Analysis High Blood Urea Nitrogen indicates that kidneys are not working properly. shock. dehydration. 92. fever and certain medications.1 46.46 umol/L 14. . 9. U/L REF RANGE 2. 0.52 1.43 mmol/L 57. 52. 52.5 6. It can also be due to urinary tract obstruction.04 9. U/L REF RANGE 7. SI RESULT 6.65 mg/dL 14.

BJ12-090 Date Requested: 1/13/2012 Date Received: 1/13/2012 Date Released: 1/17/2012 Encoded by: MELVIN JOY M. No H. 8 mo. M Birth Date 5/10/1953 Age: 58 yrs. No. GROSS/MICROSCOPIC RESULT: Consists of 2 white. STOMA CH. gastritis Requesting/Attending Doctor: SARAH D.1x0.D. PREZA.1x0. pylori seen.SURGICAL PATHOLOGY Patient Name: T. Specimen: Gastric polyp distal body Sp. M. some cystic. Sex: Female Civil Status: Married Ward/Room: 327 Examination Desired: BIOPSY: _____________ Operation Performed: Gastroscopy for gastric polyp.1cm. irregular tissue fragments 0. . CERDENA PATHOLOGIC DIAGNOSIS: FUNDIC GLAND POLYP. SECTIONS disclose a polyp composed of fundic gland. soft.

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