YONA ALAN JONES - 249

IMD 18 BATCH 5

IM CLINICS CASE 1 PART II

1. INTERPRETATION OF LABORATORY RESULTS

CBC – NORMAL

URINALYSIS – NORMAL except sugar level which is 1+ but the patient is diabetic and is already
under medications

Test name result units interpretation

Total cholesterol 7.0 mmol/L normal
Triglycerides 2.41 mmol/L normal
HDL 1.12 mmol/L normal
LDL 5.58 mmol/L normal
SGPT/ALT 61 u/L normal
Creatinine 92.7 umol/L normal
FBS 8.6 mmol/L Increased
Hba1C 6.5 % Normal
Troponin I 38 normal
D dimer 10 mcg/mL High.
D dimer is fibrin
degradation product, it is
present in blood after a
blood clot is degraded by
fibrolysis. D dimer conc.
Is indicative of
thrombosis.

INTERPRET THE CHEST X-RAY

Evaluate Describe
Exposure Good exposure, well penetrated.

Expansion Equal expansion.

view PA view

Airways trachea is in midline

Bones No bone deformities and dislocation.

CT ratio CT ratio is high 0.40 – cardiomegaly.

Diaphragm normal
Costophrenic and shows normal ,sharp coastophrenic and cardiophrenic angle is not well defined.
cardiophrenic angles

Lung Fields Clear lung fields bilaterally.

Cardiomegaly
Final reading:

INTERPRET THE 12 LEADS ECG

Evaluate Answer

Rate: ● 125 bpm

Rhythm: ● Regular sinus rhythm

PR: ● 0.16 sec – normal

QRS: ● 0.08 sec – normal

Axis: ● Normal axis deviation

QT: ● 0.32 sec – normal

ECG reading: ● Tachycardia w/ regular sinus rhythm.

2. Management

I will admit this patient because based on the lab results, the patient seems to have Pulmonary
embolism. The exact location of the emboli is yet to be determined and requires further tests.
Based on the tests, specific treatment as to whether if the emboli will be treated with
medications or surgery will be decided. Also the patient is high risk therefore she must be
admitted.

ADMITTING ORDER

DATE 09-12-2021 23:04 DOCTORS ORDER

79 Y/O female Admit patient under the service of DR. Tarongoy

Cc: shortness of breath
Associated symptoms: Secure consent to care
left calf muscle swelling
Pertinent PE: awake, Diet – as tolerated
conscious, afebrile and
tachycardic and PMI was  Monitor vital signs every 1 hour and record please.
noted at the 6th
intercoastal space.  IVF not needed.
Vital signs: BP  GIVE 02
100/70mmHg
 RR 20 cpm, HR 115BPM  Lab – cbc / urinalysis done.
Temperature 36 C  Imaging – CXR PA view(done)
02 sat – 90 %  ABG
Admitting Diagnosis –  CT pulmonary angiography stat.
pulmonary embolism
secondary to deep vein  Medication
thrombosis. 5000 units IV Bolus, THEN continuous infusion of 1000
units/hr
Co-morbidities –
hypertension, diabetes.  MONITOR
RR, HR, BP, SENSORIUM AND 02 SAT.
Watch out for any unusuality’s.

Refer to Pulmonologist.

Alan jones
09-12-2021

Final diagnosis

pulmonary embolism secondary to deep vein thrombosis.

(because of +D dimer, +ve wells test, PE AND SYMPTOMS, and normal cbc and CXR)