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II.

Demographic Data

Personal History Patient XXX is 39 years old, married, and a Filipino citizen. He is residing at Magsaysay Guagua Pampanga and a Roman Catholic. Socio-economic and cultural factors Upon interviewing Patient XXX he mentioned that he works as a laborer, and that is their source of income.

Family Health Illness History Patient XXX reveals that in her mother side, there is a history of hypertension

History of Present illness Two weeks prior to admission the patient XXX developed cough and experienced difficulty in breathing accompanied by fever.

V.

Laboratory and Diagnostic Procedures Indications or Purpose Date Ordered Normal Values Analysis and Interpretation

Diagnostic/ Laboratory Procedure

Results

Hemoglobin

Measures the total amount 1/06/12 of Hemoglobin in the blood. It is used as a rapid indications measurement 1/13/12 of RBC count.

120 120-170 g/L

The hemoglobin that is present in the blood is below the normal level. hgb may indicate anemia.

100

Hematocrit

It measures the volume of the whole blood that is composed of RBC.

0.36 1/06/12 0.40 0.52/L

The hematocrit that is present in the blood is below the normal level. hct may also indicate anemia.

1/13/12

0.30

Platelet count

A test to measure how many platelets you have in your blood. Platelets help the blood clot. They are smaller than red or white blood cells.

1/06/13

270x 109/liter

150-450 x 109/liter

Number of platelet in the blood exceed beyond the normal range

1/13/12

312x 109/liter

Erythrocytes

A decrease in RBC indicates inadequate oxygen supply of the blood. An increase in leukocyte or WBC result indicates that there is an infection in the body.

01/06/12 1/13/12

4.2 3.5

4.0-5.0 x1012/liter

in RBC result may indicate anemia.

Leukocytes

1/06/12

6.7 5-10 x109/liter in WBC result means that there is an infection.

1/13/12/

12.4

Diagnostic/ Laboratory Procedure

Indications or Purpose

Date Ordered 1/13/12

Results

Normal Values

Analysis and Interpretation

0.90 0.50-0.70 The presence of segmenters in the blood exceed the normal range

Segmenters

Lymphocytes

Determine if there is enough cell that

1/13/12

0.60

0.20-0.40

The presence of lymphocytes in

produces antibodies and other chemicals responsible for destroying microorganisms; contributes to allergic reactions, graft rejection, tumor control, and regulation of the immune system

the blood below the normal range

Diagnostic/ Laboratory Procedure FBS

Indications or Purpose Use to test the level of blood sugar in the body

Date Ordered

Results

Normal Values 70105mg/dl

Analysis and Interpretation

Conventional unit

1.47 1/09/12

S.I unit

8.16

3.8-5.83

Diagnostic/ Laboratory Procedure

Indications or Purpose

Date Ordered

Results

Normal Values

Analysis and Interpretation

Clinical chemistry Used to determine if there is malfunctioning in the kidneys Used to determine if there is damage in the liver cells

The results are in normal range

Creatinine

1.0 1/09/12 88.4

0.61.4mg/dl

53124um/l

The results is in the normal range

SGPT-ALT

BUN

Used to determine the urea level in the blood

1/07/12

10

7-18

The results is in the normal range

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