LABORATORY AND DIAGNOSTICS RESULTS

Automated Urine Microscopy

Date: March 08, 2023 @ 7:50 AM

PARAMETERS RESULT PARAMETERS RESULT REF

(p/hpf) RANGE
Physical Microscopic
Examination
Color Yellow WBC 0.30 0-5
Transparency Clear RBC 0.20 0-1.14
Chemical Epith. Cells 0.20 0-1.14
Analysis
Ketone Cast 0.20 0-1
Glucose Negative Bacteria 24.10 0-29.55
Protein Trace Mucus Threads 34.70 0-60
pH Acidic
Specific Gravity 1.015

Hematology

Date: March 08, 2023 @ 9:00AM

Examination Result Reference Value

HEMOGLOBIN 126 M: 140- 180
F: 120- 150
HEMATOCRIT 0.42 M: 0.40- 0.50
F: 0.30- 0.40
WBC 7.55 5.0-10.0x 10/L
NEUTROPHILS 0.29 0.30- 0.70
LYMPHOCYTES 0.47 0.20- 0.40
MONOCYTE 0.06 0.02- 0.10
EOSINOPHILS 0.18 0.01- 0.06
PLATELET Adequate 150- 130 x10 9/L
RBC 4.40 Pedia: 3.8- 5.4x 1012/L
Adult: 4.6- 5.0x 1012/L
Clinical Chemistry

Date: March 08, 2023 @ 12:30PM

Result (SI Unit) Reference Value

FBS 5.34 mmol/ L 3.5- 6.3
BUA 0.290 mmol/ L M: 0.200- 0.400
F: 0.140- 0.340
BUN 3.18 mmol/ L 1.7- 8.3
CREATININE 61.3 mmol/ L 35.4- 123.8
CHOLESTEROL 8.14 mmol/ L 3.1- 5.6
TRIGLYCERIDES 1.33 mmol/ L 0.34- 2.28
HDL 1.01 mmol/ L 1.42- 6.42
LDL 6.53 mmol/ L 3.9 Suspicious
4.9 Elevated
SODIUM 138.3 mmol/ L 135- 146
POTASSIUM 3.84 mmol/ L 3.5- 5.5
SGOT 18.6 U/L M: 0-37
F: 0-31
SGPT 16.1 U/L 0- 40
HBA1C 6.4 % 4.5- 7.0

Commuted Tomography Imaging

Date: March 10, 2023

Findings:

Ovoid mixed density subcortical foci with avidly enhancing solid components,
peripheral and areas of necrosis showing smooth external margins and fairly large
perilesional edema in both anterior parietal lobes the one in the right measuring 3.4
x 3.3 x 3.5 cms and 2.0 x 2.0 x 2.5 cms respectively. Faint low density changes are
seen in the periventricular white matter areas.

The ventricles are dilated

The cerebral cortical sulci, both sylvian fissures, cisterns and cereballar folia are
mildly widened.
Midline structures are in place

Brainstem and sella are intact

The ethmoid, sphenod and frontal sinuses including both mastoid air cells are well
pneumatized.

Chest X-ray

Date: March 23, 2023

Nodular density with well defined, slightly lobulated margins in the left upper lobe
measuring 4 x23 cms. Contiguous fibrosis are seen. Pulmonary vascularity is
accentuated.

Streaky densities in both lower lobes. Heart is not enlarged.

Diaphragm and sinuses are intact. Aorta is sclerotic. Thoracic spondylosis is

evident.

IMPRESSION: PULMONARY MASS IN THE LEFT UPPER LOBE.

FIBROSIS ACCENTUATED PULMONARY VASCULARITY. PNEUMONITIS
AND OR INTERSTITIAL EDEMA ATHEROMATOUS AORTA.

Clinical Chemistry

Date: March 23, 2023 @ 7:30PM

Result (SI Unit) Reference Value

CREATININE 95.7 mmol/ L 35.4- 123.8
SODIUM 138.5 mmol/ L 135- 146
POTASSIUM 3.64 mmol/ L 3.5- 5.5
Clinical Chemistry

Date: March 23, 2023 @ 8:30PM

Result (SI Unit) Reference Value

SGPT 40 U/L 0-40

Whole Abdomen Ultrasound

Date: March 24, 2023

Findings:

The liver measures 11.8 cms showing uniform echo texture. The intra-hepatic
ducts and veins are not dilated. CBD is not dilated

The gallbladder measures 1.2 cms in its widest diameter. No filling defect noted.
Walls are not thickened.

The pancreas measures 1.8 x 0.7 x 1.3 cms for its head, body and tail respectively.

The spleen measure 9.5 x 3.0 cms. No mass noted.

The right kidney measures 96 x 4.3 cms with cortical thickness of 1.2 cm while the
left kidney measures 11.4 x 5.4 cms with parenchymal thickness of 1.6 cms.
Central echo complex re preserved. Several 2-3 mm calyceal nephrolithiasis noted
bilaterally. Cystic structure measures 1.7 x 1.8 cm seen in the right.

Hematology
Date: March 27, 2023 @ 1:45PM

Examination Result Reference Value

HEMOGLOBIN 123 M: 140- 180
F: 120- 150
HEMATOCRIT 0.41 M: 0.40- 0.50
F: 0.30- 0.40
WBC 7.94 5.0-10.0x 10/L
NEUTROPHILS 0.38 0.30- 0.70
LYMPHOCYTES 0.49 0.20- 0.40
MONOCYTE 0.06 0.02- 0.10
EOSINOPHILS 0.07 0.01- 0.06
PLATELET 282 150- 130 x10 9/L
RBC 4.21 Pedia: 3.8- 5.4x 1012/L
Adult: 4.6- 5.0x 1012/L

Clinical Chemistry

Date: March 27, 2023 @2:20PM

Result (SI Unit) Reference Value

CREATININE 101.7 mmol/ L 35.4- 123.8
SODIUM 138.2 mmol/ L 135- 146
POTASSIUM 3.85 mmol/ L 3.5- 5.5
 COURSE IN THE WARD

Physicians’ Order
DATE PROGRESS NOTES PHYSICIAN’S ORDER
March 24,  Admit to MAB Isolation
2023 @12:20  DAT
AM  Diagnostics:
 CBC
 Na, K
 FBS
 LP
 UA
 WAB UTZ
Same consent

 IVF: PNSS 1L 120cc/hr

 Therapeutics:
 Ceftriaxone q12
 Paracetamol 30mg PRN for
fever/headache/ pain
 Mannitol 10cc IV q6
 Dexamethasone 4mg IV
.. Infection
March 24,  For specimen gene expert, if enable to
2023 @12:20 expectorate. May use saliva as specimen
AM  Facilitate cranial MRI with contrast
 Follow- up FBS, Lipid profile Hba1c
request
 Monitor VS q6
 Monitor I&O
March 25, BP: 110/70  Enable to expectorate, use saliva as
2023 @08:00 PR: 64 specimen for TB gene expert
PM RR:20  For blood culture x2 samples with ARD
Temp.: 36.0  Monitor VS q4
SpO2: 98%  For transfer to Med Ward 209 infectious
ward
(-) Fever  In service notes ()
(-) Dyspnea
(-) Chest pain
…
 … In service note:
… This is a case of 63 year old female with no
known…
Noted tingling on left hand, no consults done.
Few hours PTA, noted left … body weakness
and was then briefed at ER.

 PE:
 AP
 NRRR
 SOE
 CBS
 AP
 NRRN
 Soft flatly abdomen
 GNE, no edema
 Gos? 15

 Labs:
 Crea: 95.7
 Na: 138.5
 K: 3.65

 Still for cranial MRI

Referred to Dr. …
March 26, Continue present management
2023 @10:00
PM
March 27, BP: 120/90  Repeat CBC, Na, K & Crea today
2023 @08:00 PR: 68  Still for cranial MRI
AM RR:20 Decreased mannitol to 100cc q8
Temp.: 36.8
SpO2: 90%

Ceftrioxone .. 5

March 28, BP: 120/70  Still for cranial MRI

2023 @08:30 PR: 65  Decreased mannitol to 100cc q12
AM RR:20
Temp.: 36.6
SpO2: 95%

 Crea: 101.7
 Na: 138.2
 K: 3.85
 Ceftriaxone day 6
IV Fluids

Date Shift Time IVF Oral BM UO

03/23/23 2:45-7 500 1000 - 1x
03/24/23 7-7 996 1000 - 350
03/24/23 7-7 1000 1000 3x 450
03/25/23 7-3 240 2500 5x 1300
03/25/23 4-7 240 500 - -
03/26/23 PM 400 900 1x 2x
03/26/23 AM 940 1500 2x 450
03/26/23 PM 960 300 - 2x
03/27/23 AM 960 900 2x 350
03/27/23 PM 960 300 - 2x
03/28/23 AM 960 - - -

NVS

Date Time BP CR RR Temp SpO2

2:45 110/80 57 20 36. 99%
03/23/23 4 110/80 60 20 36.5 99%
8 120/80 62 20 36.0 98%
03/24/23 12 140/80 51 20 36.0 99%
4 110/70 56 20 36.2 99%
8 120/80 62 20 36.3 98%
03/24/23 12 110/80 60 20 36.4 98%
4 110/70 64 20 36.0 98%
8 110/70 62 20 36.1 97%
03/25/23 12 120/80 74 20 36.4 99%
4 120/80 91 20 37.0 96%
8 120/70 60 20 36.9 95%
03/25/23 12 120/70 60 20 36.5 96%
4 120/70 68 20 36.4 96%
8 130/80 68 20 36.0 96%
03/26/23
12 1300/80 74 20 36.0 96%
4 130/80 74 20 30.6 96%
8 110/70 61 20 36.9 96%
03/26/23 12 120/90 68 20 36.6 97%
4 120/90 68 20 36.8 96%
8 120/80 96 20 36.0 93%
03/27/23 12 120/80 59 20 36.0 93%
4 120/80 60 20 36.0 96%
8 120/70 57 20 36.9 96%
03/27/23 12 120/70 60 20 36.6 95%
4 120/80 55 20 36.6 95%