Case Study 2022.

By: Power Team

General Objectives
This case presentation seeks to demonstrate the student’s knowledge
regarding the general health and disease condition of this specific patient, with its
diagnosis, disease process, possible complications, treatment plan, medical and
nursing management. This is done through general assessment of the patient, the
patient's history while recognizing the contributing factors associated in the
developmental of the diagnosis. We will also go in deep understanding of the
anatomy for its normal status and the pathophysiology of the diagnosis.

Patient’s Data

● Demographic profile
Name: Ms. S
Status: Single
Sex: Female
Religion: Roman Catholic
Age: 62h
Date of Birth: 10/14/1960
Citizenship: Filipino
Address: San Lorenzo, Tabaco City Albay 4511

Date of Admission: October 24, 2022, 6:35pm

Date of Discharge: November 10, 2022
Admitting Diagnosis: CVD Infarct vs. Hemorrhage
Admitting Physician: Dr. Jose Cope
Ward: Female Ward
Bed number: 3
Final diagnosis: CVA infarct with left side hemiparesis

● Chief Complaints
Objective: Slurring of speech, legs and body weaknesses especially on the left side.
Subjective: “Nakita po namin, nakaupo tapos nakayuko hindi na gumagalaw, kaya
namin dinala sa ospital” as stated by the nephew.

● History Of present illness

Present condition of the patient stated a few hours prior to admission, including signs
and symptoms of slurring of speech and left side body weakness.
 ● Past Medical history.
The patient’s relatives confirmed that the patient has an underlying condition such as
hypertension and is taking medication for her condition. Patient does not go to
regular check ups. This is the first time being confined in a hospital.
(+) HPN
(-) Asthma
(-) DM
(-) Surgical History
(-) Medical History

● Socio-economic Profile
Ms. S., a 62-year-old single woman, without a child. She lives with her teenage
nephew and takes care of them, while working on her small sari-sari store.

● Social & personal History

The patient’s relative stated that the patient never consumed alcohol, nor smoked
tobacco.
(-) Alcohol
(-) Smoking

● Family History
The patient’s relatives stated that the patient has positive Hypertension and Diabetes
Mellitus.
(+) DM
(+)HPN
(-) Asthma

Gordon’s Functional Health Pattern

(Information is from patient’s relatives)

Pattern Before During Interpretation/

Hospitalization Hospitalization Analysis

Health Perception “Nagtitinda siya sa She has body Her health declined
/ Health tindahan niya” as weakness, especially after the patient’s
Management stated by her cousin on her left side. She is stroke.Cardiovascula
bed ridden, cannot r accidents can
“Ngayun lng po siya swallow and cannot cause weakness and
naospital ng ganito speak. paralysis to the
kalala” as stated by patient hence
her cousin affecting their
infectivity to do their
activities of daily
living.
Nutritional / Nephew stated “ Patient is being fed via Inability to eat
Metabolic kumakain naman nasogastric tube with independently, or
siya ng normal, NGT milk and water. through swallowing.
mahilig sa gulay at Nutrition is important
kanin” and by NGT milk, the
patient is still able to
gain proper nutrition
needed by the body
to function.

Elimination Cousin said that the Patient is in a complete Self care and
patient did not state bed rest without elimination pattern is
any problems bathroom privileges lost. Elimination is
regarding elimination. and is defecating via important to remove
adult diaper and a waste from the body
urinary indwelling and to maintain
catheter. proper Body PH.

Activity / Exercise “Nag Eexercise Patient is bed ridden, This is caused by the
naman po siya, lalo has slight mobility but patient’s left side
na po nagtitinda po is not able to perform weakness. Patient’s
siya kaya galaw po self care and position consciousness can
ng galaw.” as stated changes by herself. be affected because
by her nephew of their inability to
move due to the CVA
that damaged parts
of the brain

Sleep / Rest Nephew stated “okay Patient is constantly Patient's sleeping

naman po tulog niya, sleeping, and has a pattern has
nakakatulog naman weak consciousness drastically changed,
po siya, wala naman and alertness. this may be because
po siyang sinasabi of her meds and
dati” because of her
current situation after
the stroke. According
to studies 13% - 48%
of patients that
suffered stroke
decreased their
consciousness and
even coma.

Cognitive/ Nephew stated Is able to answer yes Because of her

Perceptual “nagtitinda po siya sa or no questions but is speech being
sari-sari store, able to fully aware of affected, she can no
masipag po her surroundings. longer speak and is
magtrabaho” left by only
answering a yes or
no question. Patient
 developed apraxia,
especially in her left
extremities that is
caused by the
damage in her right
brain and aphasia
that is from the
damaged broca’s
area.

Self-Perception Not Applicable Not Applicable We are unable to

/ Self-Concept gather Information
about the patient’s
self perception or
self-concept because
the patient can only
answer a yes or no
question and is
unable to express
feelings about her
perception.

Role/Relationship Cousin stated that “Kami na po Before her accident,

“May tindahan siya, magaalaga sakanya she takes care of her
tapos siya nagaalaga “ as stated by her pamangkin as her
sa mga pamangkin nephew and cousin own children but
niyang iba” because of her
situation, she can no
longer take care of
her pamangkin like
before.

Sexuality Cousin stated “wala Not applicable The relatives

/ Reproductive po siyang anak, o believed that the
asawa. Wala naman patient did not have
po sa alam ko na any past relationship
nagkaroon po siya ng nor express her
relasyon”. sexuality even in the
past

Coping Cousin stated Cousin stated that the Patient looks tired
/ Stress Tolerance “mahirap talaga ang patient is responsive and frustrated as
buhay, kahit may when questions are evidence of her trying
sakit kami kailangan asked, she can still be to move to position or
pa rin magtrabaho asked a simple yes or help position herself
para magkapera. no question and is able but is unable to. I can
Siya (patient) kahit to nod yes or no. also observe through
may high blood kami Cousin stated that she her facial reactions
kailangan pa rin is frustrated but is still that she has a high
magtrabaho” fighting to be better. risk for feeling like a
 burden to her family.

Value / Belief Cousin stated “Ngayun naniniwala Patient’s relatives

“naniniwala kami sa kami sa albularyo pero believe in both
hilot, ganito ngayun nasa medicine and faith
pagnagkakasakit hospital dae na man healers. Even with all
baga. Sa mga kaipuhan siguro” as these medical
albularyo ganun” stated by her cousin technologies,most of
the population here
in the philippines
believes that
traditional culture of
albularyo and herbal
medicines for healing
diseases

Physical Assessment/Examination And Review of the Systems

(Assessed during day 7th)

Patient’s Physical Normal Physical Analysis

Assessment/Examination Assessment/Examination

BP: 150/80mmHg >90/60 mmHg to <120/80 mmHg Patient is hypertensive

PR: 97 bpm 60 to 100 bmp Normal

RR: 22 bpm 12-20 bpm Patient’s respiratory

rate is above normal.
Slightly tachypneic.

T: 38.6 °C (axillary) 36.2°C to 37.5°C Patient is experiencing

hyperthermia

02 SAT: 95% (w/ N.C 2 lmp) >95% Patient is experiencing

normal but slight
hypoxemia.

● Neurological: Weak Conscious and Coherent Patient is always in a

consciousness sleeping state, is tired-
looking but is still
conscious when called.

● Respiratory: Shortness Lung Auscultation: Loud, high- Even with nasal

of breath pitched bronchial breath sounds cannula at 2lmp,
Lung Auscultation: over the trachea oxygen saturation is
low because of the
Crackles presence of excess
mucus as evidence of
crackles when
auscultate.

● Musculoskeletal: Muscle strength: 5/5 Patient’s left side is

● Muscle Strength Range of motion: Active scaled ⅖ means that it
L: ⅖ is weak with poor
strength. Left side also
R: ⅘
needs a passive range
● Range of motion: of motion. Patient’s
L: Passive right side has close to
R: Active Assistive normal strength but still
needs assistance when
performing a range of
motion.

● Digestive: NGT With good appetite and can tolerate Patient has an absent
normal diet gag reflex and
therefore is at high risk
for aspiration.

● Gastrointestinal Tract: Well formed stool 1 - 2 times a day The patient needs
Soft runny stool 2x a laxative in order to
day with laxative defecate.

● Integumentary: With With good skin turgor with no Patient’s skin is in good
good skin turgor with no cracks and mucus are not dry. condition, mucus is dry
cracks. Mucous are dry. as she is unable to
With normal sensation when hydrate through
● Sensation
stimulated drinking. Patient’s
L: (+) weak sensation is normal on
R: (+) the right side and weak
on the left side.

● Genitourinary: Urine output 30-50 ml/hr. Normal Patient's urine output is

● Contraption: Foley urine output per day is 1500ml normal
catheter
● Color: Yellow
● Normal urine output: 31
- 43 ml per 8 hr shift

● Cardiovascular: Cardiac Auscultation: normal Patient's

● Cardiac Auscultation: sounds of S1 (lub) and S2 w/o cardiovascular system
normal sounds of S1 presence of abnormal sounds or is normal.
murmurs.
(lub) and S2 w/o
 presence of abnormal Pulse Palpation: 2+
sounds or murmurs 0 absent pulse
● Pulse Palpation: 2+ 1+ diminished pulse
2+ normal
3+ Full pulse, increase in strength
4+ Bounding pulse

F.A.S.T (Facial drooping, Arm weakness, Speech difficulties and Time to call
emergency services)
Facial drooping: -
Arm weakness: +
Speech difficulty: +

10
score
 COURSE IN THE WARD:
Upon Admission

This is the case of Ms. S, 62 years old, female and currently residing at San
Lorenzo, Tabaco City, Albay who came for admission. On October 24, 2022, at
6:35pm, she was brought to the ER and was ambulated via stretcher with her
nephew and cousin to Amando Cope Memorial Hospital with a chief complaint of
slurry of speech and left side body weakness. Her Vital signs are: BP:160/80 mmHg,
PR: 98 bpm, RR: 21 bpm, T: 36.5°C. The admitting diagnosis is CVA infarct vs.
Hemorrhage. Upon admission at 6:35pm, she was examined by Dra. Sunga with an
order to admit a patient. Consent was secured, she was placed in a semi-fowler’s
position, temperature, pulse and respiration was also monitored every 4 hours. An
IVF of PNSS 1L administered and regulated at KVO. At 6:45pm, the doctor ordered
a Nicardipine drip, at 7:25pm Mannitol 100 cc IV was administered, and Omeprazole
4g via IV push at 7:50pm. The doctor then ordered to place her into an NGT for
nutrition. Oxygen was also administered via nasal cannula. Her Laboratory exams
were CBC, CBG, CREA, Na K, SGOT, HbA1 c, FBS, Lipid Profile, SARS CoV-2 and
Serum Amylase.

Day 7 (October 27, 2022)

On the 7th day of hospitalization, the patient is still weak-looking. She is
always sleeping, but shows responsive eye contact when called. She is placed in a
semi-fowler’s position with oxygenation via nasal cannula intact running at 2 lpm and
with her foley catheter intact. Her vital signs: BP: 150/80 mmHg, PR: 97 bpm, RR: 22
bpm, T: 37.8°C and 02 Saturation of 95%. IVF of PNSSL is intact and regulated at
KVO. During my shift, Cefriaxone is given once a day. Omeprazole 40 mg is given
via IV push every 12 hours. Citicoline 1g is given every 12 hours. And
Albutamol/ipratropium 1cc every 8 hours is administered via nebulization. RI 5 units
is administered via subcutaneous 30 mins before meals.

Day 10 (November 2, 2022)

Patient is still weak but is slightly improving her ROM especially on her right
side. She is placed in a semi fowler’s position, with IVF intact at KVO, nasal cannula
at 2 lpm, and foley catheter intact. Vital signs: BP: 150/90, PR: 95 bpm, RR: 21 bpm,
T: 38.1°C, 96% O2 SAT. CBG is checked, at 195 then RI 12 units subcutaneously is
given. During my shift Paracetamol 300 mg stat is given. Cilostazol 10mg, Mucosta
1tab, and Citicoline 500mg is given through NGT. Omeprazole 40mg is also given
via IV push and Piperacillin + Tazobactam 4.5g is administered through IV every 6
hours.
Day 11 (November 3, 2022)
Patient is more responsive with head movement and eye contact. All
contraptions are intact such as IVF, Foley Catheter, NGT and oxygenation via nasal
cannula. Relative of the patient stated that she is improving, but is still weak, and
stated that she is not able to move patient to a different position as frequently as she
should. During my shift, I was able to help move the patient every 2 hours to prevent
bed sores. Vital signs: BP: 140/80, PR: 87 bpm, RR: 20 bpm, T: 36.8°C, O2 Sat:
96%. RI 8 units are administered before NGT feeding. During my shift Cilostazol
10mg, Mucosta 1tab, Citicoline 500mg, levofloxacin 500 mg OD and Omeprazole 40
mg is given through NGT. Piperacillin + Tazobactam 4.5g is administered through IV
every 6 hours.

Day 17 (November 9, 2022)

On the 17th day of hospitalizations, Ms. S is still weak, especially on the left
side of her body. She is always sleeping, but shows responsiveness. She is placed
in a semi-fowler’s position to maintain normal oxygen saturation. Her vital signs: BP:
120/80 mmHg, RR: 20 bpm, PR: 102 bpm, T: 36.5 and 02 Saturation of 93%. IVF of
PNSSL is intact and regulated at KVO. During my shift, @ 12nn I mixed in the NGT
the following medications OD: Cilostasol 50 mg, Mucosta 1 tab, Citicoline 500mg,
Omeprazole 40, Clindumycin 300 mg, Fluconazole 150mg, Proglin met, Losartan
50mg. And I monitor her sugar: @8am: 238. But not available for subcutaneous
insulin. So I gave her an oral med for her sugar.

Day 18 (November 10, 2022)

On the 18th day of hospitalization, Ms. S is still weak, especially on the left
side of her body, but if we rate yesterday 2/5 then now 3/5 She is always sleeping,
but shows responsiveness. She is placed in a semi-fowler’s position to maintain
normal oxygen saturation. I monitor her sugar. @8am: 230 and @12nn: 245. I gave
her subcutaneous insulin, 10 units OD.

Disease Condition
Anatomy and Physiology
Cerebrovascular Accident (CVA)
Commonly called stroke, sometimes called a “brain attack”.
A condition where the blood supply to the brain is disrupted, resulting in oxygen
starvation, brain damage and loss of function.
ISCHEMIC - wherein you can have blood clot within the vessel or you can have
stenosis (narrowing) of the artery. It is not able to provide the brain tissue and limits
the blood from reaching the brain cells
Due to:
embolism - a clot has left a part of the body and has traveled to the brain which has
stopped the blood flow
thrombosis - a clot forms within the artery wall.
TRANSIENT ISCHEMIC STROKE - It is not a full blown stroke. We call it mini
strokes. Symptoms can only last for a few minutes.

HEMORRHAGIC - There is a bleeding in the brain due to a break in a blood vessel

leading to no blood perfusion to the brain cells and get excessive swelling from the
leakage

Due to:
Brain aneurysm bursts, uncontrolled hypertension or older age which vessel has less
resiliency and tends to break.

Frontal lobe
Personality, behavior, emotions
Judgment, planning, problem solving
Speech: speaking and writing (Broca’s area)
Body movement (motor strip)
Intelligence, concentration, self awareness

Parietal lobe
Interprets language, words
Sense of touch, pain, temperature (sensory strip)
Interprets signals from vision, hearing, motor, sensory and memory
Spatial and visual perception

Occipital lobe
Interprets vision
(color, light, movement)

Temporal lobe
Understanding language (Wernicke’s area)
Memory
Hearing
Sequencing and organization

Anterior cerebral circulation

Internal Carotid Arteries
an artery in the neck which supplies the anterior circulation of the brain. the internal
carotid artery branches into the anterior cerebral artery and continues to form the
middle cerebral artery.
Anterior Cerebral Artery (ACA)
one of a pair of cerebral arteries that supplies oxygenated blood to most midline
portions of the frontal lobes and superior medial parietal lobes of the brain.
Anterior Communicating Artery ( ACom)
Connects left and right anterior cerebral arteries
Middle Cerebral Artery ( MCA)
supplies many deep brain structures, the majority of the lateral surface of the
cerebral hemispheres, and the temporal pole of the brain.

Posterior cerebral circulation

Vertebral Arteries
Paired vertebral arteries provide blood supply for the upper part of the spinal cord,
brainstem, cerebellum, and posterior part of the brain
Basilar Artery
midline structure formed from the confluence of the vertebral arteries and branches
into the posterior cerebral arteries (PCA)

Posterior cerebral circulation

Posterior Cerebral Arteries (PCA)
Terminal branches of basilar artery.
It mainly supplies the occipital lobe, the inferomedial surface of the temporal lobe,
midbrain, thalamus and choroid plexus of the third and lateral ventricles.
Posterior Communicating Artery (PComm)
The posterior communicating artery connects the internal carotid with the posterior
cerebral arteries, thus connecting the anterior and posterior cerebral circulations.
Circle of willis
( CEREBRAL ARTERIAL CIRCLE OR CIRCULUS ARTERIOSUS
Anastomotic ring of arteries located at the base of the brain
Main function is to provide a collateral blood flow between anterior and posterior
arterial systems of the brain

PATHOPHYSIOLOGY
ISCHEMIC STROKE
- Ischemic stroke occurs when a blood clot blocks or narrows an
artery leading to the brain. A blood clot often forms in arteries
damaged by the buildup of plaques (atherosclerosis). It can occur
in the carotid artery of the neck as well as other arteries. This is
the most common type of stroke.
-

Risk Factors
Non-modifiable
● AGE (62 YEARS OLD)
● FAMILY HISTORY (+HTN)

Modifiable
● SEDENTARY LIFESTYLE
● POOR DIET
● DM
● HIGH BLOOD PRESSURE
● HYPOSTATIC PNEUMONIA

Pathophysiology
Ischemic Stroke

Signs and Symptoms

1. Aphasia
2. Headache
3. Mental Changes (Disorientation)
4. Left Hemiparesis

Medical & Nursing Management

Ischemic CVA Infarct

Medical Management
● Psychostimulants and nootropic (cognitive enhancers) such as Citicoline
● Platelet-aggregation inhibitors or antiplatelet drugs such as Cilostazol,
Clopidogrel
 ● Stool softeners or laxatives such as Lactulose
● Continuous hemodynamic monitoring
● Neurologic assessment to determine if the stroke is evolving and if other
acute complications are developing

Nursing Management
● Assess mental status and level of consciousness
● Observe for neurological deficits with frequent and serial neurological
assessments
● Measure and monitor pupil size
● Assess breathing
● Monitor vital signs
● Assess higher functions like speech, memory, and cognition
● Provide a quiet environment with the head of the bed elevated
● Elevate bed rails to prevent falls
● Prevent constipation and straining with stool softeners
● Watch for seizures
● Observe for changes in mood

Hypertension

Medical Management
● Calcium channel blockers such as Nicardipine
● Prescription of Angiotensin II receptor antagonists such as Losartan for the
patient’s maintenance drug.

Nursing Management
● Monitor blood pressure frequently.
● Administer antihypertensive medications as prescribed
● Listen to the heart for murmurs and lungs for rales and crackles
● Check if the patient has edema
● Encourage rest and provide a quiet room
● Educate the relative of the patient on the importance of taking
antihypertensive medications

Diabetes mellitus Type 2

Medical Management
● Antidiabetic such as Insulin regular human (Humulin R)

Nursing Management
● Administer fluids
● Insulin
● Prevent fluid overload
● Strict I & O
● CBG Monitoring
 ● Vital Signs
● Monitor patient responses to treatments

Community Acquired Pneumonia

Medical Management
● Antibiotics such as Ceftriaxone, Piperacillin, Tazobactam, Levofloxacin,
Clindamycin
● Bronchodilators or relievers such as Salbutamol, Ipratropium
● Antipyretic such as Paracetamol
● Warm moist inhalation to relieve irritation
● Oxygen & respiratory supportive measures

Nursing Management
● Hydrate the patient
● Administer antibiotics as ordered
● Keep patient comfortable and warm
● Measure input and output
● Promote nutrition
● Administer oxygen as needed
● Provide rest
● Teach caregiver proper handwashing

Laboratory findings

Brain CT-Scan

Impression:
No intracranial hemorrhage, acute territorial infarct and focal mass lesion
Chronic lacunar infarcts in both centrum semivale, corona radiata, basal ganglia,
right pons and right cerebellum.
Small patchy hypodensities in the white matter of both frontal and parietal lobes.
Consider small vessel ischemia, demyelination and/or gliosis
Mild cerebral and cerebellar volume loss
Atherosclerotic vessel disease.

Chest - AP
Date: october 31, 2022

Impression:
Pneumonia, right lung
Magnified cardiac size. Please correlate clinically to rule out true cardiomegaly.
Atheromatous aorta.

October 24,2022 / 11:19pm

COMPLETE BLOOD COUNT

PARAMETERS RESULTS NORMAL UNIT

VALUES

Hemoglobin 132 120-140 g/Dl

Hematocrit 39.90 36-42 g

White Blood Cells 7.4 5.0-10.0 x10^9/L

Red Blood Cells 4.80 4.2-5.4 x10^12/L

DIFFERENTIAL COUNT

Neutrophil 69.00 55-70 g

Lymphocytes 26.70 20-40 g

Monocytes 3.50 0-6 g

Eosinophils L 0.30 1-5 g

Basophils 0.50 0-1 g

Platelet Count 235 150-350 x10^9/uL

MCV 83.1 80-100 fL

MCH 29.2 28-32 pg

 MCHC H 351 310-350 g/dL

CLINICAL CHEMISTRY / 11:42 PM

Test Normal Values Results

Glucose (FBS) 3.33-6.1 mmol/L

BUN 2.5-7.5 mmol/L 4.32

Creatinine 53-124 umol/L 76

Uric Acid (Male) 214-458 umol/L

Uric Acid (Female) 149-405 umol/L 270

SGOT/AST up to 38 U/L

SGPT/ALT up to 40 U/L

Na+ (Sodium) 136-146 mmol/L 140.7

K+ (Potassium) 3.5 -5.1 mmol/L 2.68

CT (Chloride) 98-106 mmol/L 101.7

HbAlc < 6.5 % NGSP

Calcium 2.1 -2.6 mmol/L

Alkaline Phosphatase 26-117 U/L

OCTOBER 25, 2022 / 6:07 AM

 TEST NORMAL VALUE RESULTS

Glucose (FBS) 3.33-6.1 mmol/L 13.776

Cholesterol < 5.2 mmol/L 6.1

Triglycerides (M) 0.45-1.81 mmol/L

Triglycerides (F) 0.38-1.53 mmol/L 0.54

HDL 0.98 -1.9 mmol/L 2.07

LDL 2.7-4.2 mmol/L 4.0

BUN 2.5-7.5 mmol/L

Creatinine 53-124 umol/L

Uric Acid (M) 214-458 umol/L

Uric Acid (F) 149-405 umol/L

SGOT / AST up to 38 U/L

SGPT / ALT up t0 40 U/L

HbAlc < 6.5 % NGSP

CLINICAL CHEMISTRY / 8:17 AM

TEST NORMAL VALUES RESULTS

Glucose (2 PPBS) 3.33-6.1 mmol/L

Glucose (RBS) 4.4-7.8 mmol/L

 BUN 2.5-7.5 mmol/L 4.32

Creatinine 53-124 umol/L 76

Cholesterol < 5.2 mmol/L

Triglycerides (M) 0.45- 1.81 mmol/L

Triglycerides (F) 0.38-1.53 mmol/L

HDL 0.98-1.9 mmol/L

LDL 2.7-4.2 mmol/L

Uric Acid (M) 214-458 umol/L

Uric Acid (F) 149-405 umol/L 270

Alkaline Phosphatase 26-117 U/L

Amylase < 90 U/L

Calcium 2.1-2.6 mmol/L

SGOT up to 38 U/L

SGPT up to 40 U/L

Na+ ( Sodium) 136-146 mmol/L 140.7

K+ (Potassium) 3.5 -5.1 mmol/L 2.68

CT (Chloride) 98-106 mmol/L 101.7

Total Protein 66-83 g/L

 Albumin 35-50 g/L

Globulin 28-32 g/L

A/G Ratio 1.3-1.6 g/L

Total Bilirubin 3.42-18.81 umo/L

Direct Bilirubin 1.02 – 4.27 umol/L

Indirect Bilurubin 24-14.5 umol/L

HbAlc < 6.5 % NGSP

Magnesium 0.66 – 1.03

CLINICAL CHEMISTRY / 8:17 AM

HbAlc

Specimen Whole Blood

Results : 7.3

Normal Value: < 6.5% NGSP

Lot Number: F2071610F AD

Expiration Date: 7/1/2023

URINALYSIS / 3:14 PM
 Macroscopic

Color YELLOW

Transparency HAZY

Reaction ACIDIC

Specific Gravity 1.020

Protein NEGATIVE

Sugar NEGATIVE

Microscopic

Pus Cells 4-8 /HPF

Red Blood Cells 2-4 /HPF

Epithelial Cells FEW

Bacteria FEW

Am.urates/phosphates

Mucous threads

Crystals

Cast /IPF

OCTOBER 28, 2022/ 5:51 AM

CLINICAL CHEMISTRY
 TEST NORMAL VALUE RESULT

Glucose (FBS) 3.33-6.1 mmol/L

BUN 2.5- 7.7 mmol/L

Creatinine 53.124 umol/L

Uric Acid (Male) 214-458 umol/L

Uric Acid (Femalr) 149-405 umol/L

SGOT/ AST up to 38 U/L

SGPT/ALT up to 40 U/L

Na+ (Sodium) 136-146 mmol/L 135

K+ ( Potassium) 3.5-5.1 mmol/L 3.29

CT (Chloride) 98-106 mmol/L 99.9

HbAlc <6.5 % NGSP

Calcium 2.1-2.6 mmol/L

Alkaline Phosphatase 26-117 U/L

COMPLETE BLOOD COUNT/ 5: 32 AM

PARAMETERS RESULT NORMAL VALUE UNIT

Hemoglobin 128 120-140 g/Dl

Hematocrit L 35.80 36-42 g

 White Blood Cells H 11.7 5.0-10.0 x10^9/L

Red Blood Cells 4.33 4.2-5.4 x10^12/L

DIFFERENTIAL COUNT

Neutrophil 67.20 55-70 g

Lymphocytes 26.60 20-40 g

Monocytes 4.40 0-6 g

Eosinophils 1.50 1-5 g

Basophils 0.30 0-1 g

Platelet Count 175 150-350 x10^9/uL

MCV 82.7 80-100 fL

MCH 29.6 28-32 pg

MCHC H 358 310-350 g/dL

OCTOBER 31, 2022 / 5:24 AM

COMPLETE BLOOD COUNT

PARAMETERS RESULT NORMAL VALUE UNIT

Hemoglobin 135 120-140 g/Dl

Hematocrit 38.30 36-42 g

 White Blood Cells 8.5 5.0-10.0 x10^9/L

Red Blood Cells 4.64 4.2-5.4 x10^12/L

DIFFERENTIAL COUNT

Neutrophil 67.60 55-70 g

Lymphocytes 24.50 20-40 g

Monocytes 4.40 0-6 g

Eosinophils 3.00 1-5 g

Basophils 0.50 0-1 g

Platelet Count 238 150-350 x10^9/uL

MCV 82.5 80-100 fL

MCH 29.1 28-32 pg

MCHC H 352 310-350 g/dL

CLINICAL CHEMISTRY / 6:31 AM

TEST NORMAL VALUE RESULT

Glucose (FBS) 3.33-6.1 mmol/L

BUN 2.5- 7.7 mmol/L

Creatinine 53.124 umol/L

 Uric Acid (Male) 214-458 umol/L

Uric Acid (Femalr) 149-405 umol/L

SGOT/ AST up to 38 U/L

SGPT/ALT up to 40 U/L

Na+ (Sodium) 136-146 mmol/L 136.1

K+ ( Potassium) 3.5-5.1 mmol/L 3.37

CT (Chloride) 98-106 mmol/L 103.3

HbAlc <6.5 % NGSP

Calcium 2.1-2.6 mmol/L

Alkaline Phosphatase 26-117 U/L

COMPLETE BLOOD COUNT/ 6:44 PM

PARAMETERS RESULT NORMAL VALUE UNIT

Hemoglobin 139 120-140 g/Dl

Hematocrit 38.70 36-42 g

White Blood Cells H 21.4 5.0-10.0 x10^9/L

Red Blood Cells 4.73 4.2-5.4 x10^12/L

DIFFERENTIAL COUNT
 Neutrophil H 92.50 55-70 g

Lymphocytes L 3.40 20-40 g

Monocytes 3.60 0-6 g

Eosinophils L 0.00 1-5 g

Basophils 0.50 0-1 g

Platelet Count 235 150-350 x10^9/uL

MCV 81.8 80-100 fL

MCH 29.4 28-32 pg

MCHC H 359 310-350 g/dL

URINALYSIS / 9:52 PM

Macroscopic

Color YELLOW

Transparency HAZY

Reaction ACIDIC

Specific Gravity 1.030

Protein TRACE

Sugar NEGATIVE

Microscopic
 Pus Cells 10-20 /HPF

Red Blood Cells 0-2 /HPF

Epithelial Cells MODERATE

Bacteria MODERATE

Am.urates/phosphates

Mucous threads MODERATE

Crystals

Cast /IPF

NOVEMBER 2, 2022/ 6:20 PM

COMPLETE BLOOD COUNT

PARAMETERS RESULT NORMAL VALUE UNIT

Hemoglobin 124 120-140 g/Dl

Hematocrit L 35.40 36-42 g

White Blood Cells H 16.2 5.0-10.0 x10^9/L

Red Blood Cells 4.23 4.2-5.4 x10^12/L

DIFFERENTIAL COUNT

Neutrophil H 79.00 55-70 g

 Lymphocytes L 14.30 20-40 g

Monocytes 5.10 0-6 g

Eosinophils 1.20 1-5 g

Basophils 0.40 0-1 g

Platelet Count 221 150-350 x10^9/uL

MCV 83.7 80-100 fL

MCH 29.3 28-32 pg

MCHC 350 310-350 g/dL

BRAIN CT-SCAN
Impression…
● No intracranial hemorrhage, acute territorial and focal mass lession.
● Chronic lacunar infarcts in both centrum semiovale, corona radiata,
basal ganglia, right pons, and right cerebellum.
● Small patchy hypodensities in white matter of both frontal and parietal
lobes. Consider small vessel ischemia, demyelination and/or gliosis
● Mild cerebral and cerebellar volume loss
● Atherosclerotic vessel disease

CHEST AP
Impression…
● Pneumonia, right lung
● Magnified cardiac size. Please correlate clinically to rule out true
cardiomegaly
● Atheromatous aorta
Drug Study/Pharmacological Management
Actual Nursing Diagnosis and Care Plan
Potential Nursing Diagnosis and Care Plan
 Discharge Planning
Nutrition

- Educate relatives on how to use the nasogastric tube, ensure that the tube is
located in the stomach and check its patency
- Advice patient to limit cholesterol intake
- Avoid fatty foods and do not take anything that contains caffeine

Medication
- Tell the patient to take all prescribed medication according to time, dose and
route. Make sure that all prescribed medications are taken regularly.
- Notify the physician if the prescribed medication is not available, ask for any
advice for what to do
- Consult the physician if there are any adverse reaction to the medication
- Remind patients of the importance of taking the exact dose prescribed and
using any measuring device that comes with liquid medication

Diet
- Promote taking of vitamins and supplements to strengthen immune system
- Encourage patient to take nutritional foods and drinks and avoid foods that is
rich in sodium and glucose
- Encourage patient should be careful and be aware of what to eat to avoid
further complications
- Eating a variety of foods and consuming less salt,sugars and saturated and
industrially-produced trans-fats are essential for healthy diet
Health education
- Educate the patient about her current illness. Encourage the patient to avoid
risk factors
- Educate the family about the patient's medications according to the right
dose,route and time.
- Educate the family regarding the risk factors that can trigger the patient
condition
- Tell the patient family that it is important to take all prescribe medication
- State the importance of proper hygiene and sanitation during recovery to
prevent further infection.
- Instruct the patient's family member to provide a safe environment
- Instruct the family to keep record of side effects from medication
- Tell the patient’s family to monitor blood glucose level and weight. Document
all results for baseline data and report to the physician for every follow up
check ups.
- Instruct the family/caregiver to provide mouth care frequently to avoid dryness
of the mouth surface

Exercise
- Encourage patient to do minimal exercises of hands and legs and promote
proper range of motion
- Move patient from side to side every 2 hours to avoid bedsores
- Encourage patient to do wrist curls are isolated movements that build forearm
strength, improve range of motion and enhance gripping ability

Environment
- Instruct the patient's family member to provide a safe environment.
- Promote enough ventilation for the patient
- Tell the patient to avoid stressors, and
- Tell the family/ caregiver to avoid indoor noise, such as the neighborhood and
residential area.