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.

CTSCAN
WHOLE ABDOMEN C.T. SCAN CONTRAST

Patient:

T,M

Datetime Performed: 01/13/2012 10:19 AM Requesting Doctor: P, SD M.D. Age: 56 yrs. 8 mon

Ward/Rm. No.: 327 File No.: CT-1832

RESULT
CT SCAN OF THE WHOLE ABDOMEN
Axial CT scan of the whole abdomen with oral and I.V contrast reveals irregular wall thickening of middle segment of the ascending colon with luminal narrowing. It has a maximal wall thickness of cm. Pericolic fat stranding and nodularities are observed. The more proximal segments of bowel are dilated. Mucosal irregularities are detected in the posterior body of the stomach. The rest of gastrointestinal system is not unusual. the 3.4 not the

The liver is not enlarged. The common hepatic and common bile duct are prominent. The gallbladder is not visualized. The pancreas and spleen are not unusual. A 0.5 cm exophytic focus is seen arising from the inferior pole of the right kidney. The adrenal glands and left kidney are grosstly intact. The kidneys show good excretion of contrast. The bilateral pelveocalyceal system and ureters are not dilated. The urinary bladder, uterus, and adnexae are not unusual. No ascites is detected. There are no enlarged retroperitoneal or pelvic lymph nodes. The rest of the visualized soft tissues and osseous structures are unremarkable.

IMPRESSION
Ascending colon mass with pericolic fat infiltration and lymphadenopathy; a malignant process is primarily considered. Mucosal irregularities in the posterior body of the stomach, may be from gastritis or ulcers Prominent common hepatic and common bile ducts with nonvisualized gallbladder, probably post cholecystectomy changes Right renal nodule, probably a cyst

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. 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, FRIABLE COVERED WITH NECROTIC PURELENT MATERIAL WITH BLOOD CLOTS THE REST OF VISUALIZED COLONIC MUCOSA IS SMOOTH, PINK AND SHINY WITH GOOD VASCULAR PATTERN THE HEMORRHOIDAL VESSELS ABOVE THE DENTATE LINE ARE INTACT. ANEMIA AND ABDOMINAL PAIN CT SCAN RESULT SHOWS MASS AT ASCENDING COLON MIDAZOLAM 2MG, FENTANYL 50MCG, PROPOFOL 30MG

PATIENT TOLRATED THE PROCEDURE WHICH LASTED FOR 15 MINUTSWITH WITHDRAWAL TIME OF 11 MINUTES

DIAGNOSIS: COLONIC MASS, ASCENDING COLON T/C MALIGNANT RECOMMENDATIONS: REFER TO SURGERY

X-RAY
CHEST PA VIEW

Patient:

T,M

Datetime Performed: 01/1/2012 06:39 PM Requesting Doctor: P, SD M.D. Age: 56 yrs. 8 mon.

Ward/Rm. No.: 327 File No.: X-34454

RESULT
FINDINGS:

Lungs are clear and normoaerated with normovascular pattern Heart, great vessels, diaphragms, cosdophrenic sinuses and underlying osseous structures are intact. Atheromatous aorta noted.

IMPRESSION ATHEROMATOUS AORTA, OTHERWISE, NORMAL CHEST FINDINGS

CLINICAL CHEMISTRY
PATIENT NAME: AGE: 50 T, 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. mg/dL HIGH 234. mg/dL 117. mg/dL 23. mg/dL 48. mg/dL HIGH 162. mg/dL

REF RANGE 74. 106. 0. 200. 0. 150. 0. 40. 40. 60. 0. 150.

SI RESULT 5.49 mmol/L 6.08 mmol/L 1.29 mmol/L 0.6 mmol/L 1.25 mmol/L 4.21 mmol/L

REF RANGE 4.14 5.94 0. 5.2 0. 1.65 0. 1.03 1.03 1.55 0. 3.9

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.

CLINICAL CHEMISTRY
PATIENT NAME: AGE: 50 T, 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. mg/dL 0.65 mg/dL 14. U/L

REF RANGE 7. 17. 0.52 1.04 9. 52.

SI RESULT 6.43 mmol/L 57.46 umol/L 14. U/L

REF RANGE 2.5 6.1 46. 92. 9. 52.

* Analysis
High Blood Urea Nitrogen indicates that kidneys are not working properly. It can also be due to urinary tract obstruction, congestive heart failure, gastrointestinal bleeding, dehydration, shock, burns, fever and certain medications, such as corticosteroids and high protein diet.

SURGICAL PATHOLOGY
Patient Name: T, M Birth Date 5/10/1953 Age: 58 yrs. 8 mo. Sex: Female Civil Status: Married Ward/Room: 327 Examination Desired: BIOPSY: _____________ Operation Performed: Gastroscopy for gastric polyp, gastritis Requesting/Attending Doctor: SARAH D. PREZA, M.D. Specimen: Gastric polyp distal body Sp. No. BJ12-090 Date Requested: 1/13/2012 Date Received: 1/13/2012 Date Released: 1/17/2012 Encoded by: MELVIN JOY M. CERDENA

PATHOLOGIC DIAGNOSIS: FUNDIC GLAND POLYP. STOMA CH. GROSS/MICROSCOPIC RESULT: Consists of 2 white, soft, irregular tissue fragments 0.1x0.1x0.1cm. SECTIONS disclose a polyp composed of fundic gland, some cystic. No H. pylori seen.