DIAGNOSTIC AND LABORATORY PROCEDURES

PROCEDURES INDICATIONS RESULTS NORMAL VALUES IMPLICATIONS NURSING

REPONSIBILITIES
Coagulation Test To measure your PROTHROMBINE TIME 13.2 – 16.2 1. Explain test
blood’s ability to Patient : 15.4secs procedure.
clot and the  % Activity: 79.0% 2. Encourage to avoid
amount of time it  INR : 1.14 stress if possible
takes to do so. Control : 13.9sec because altered
 Control % Act: 97.6% physiologic status
 Control INR :1.008 influence and
changes normal
hematologic values.
3. Apply no pressures
and dressings over
puncture site on
removal of
4. Monitor puncture
for oozing hematoma
formation.
 PROCEDURES INDICATIONS RESULTS NORMAL VALUES IMPLICATIONS NURSING
REPONSIBILITIES
CLINICAL MICROSCOPY
URINALYSIS
 Color YELLOW
 Tranparency CLEAR
 Specific gravity 1.020
 pH 6.0
 Glucose NEGATIVE
 Protein NEGATIVE
 RBC 0-1/hpf
 WBC 0-1/hpf
MISCELLANEOUS
STRUCTURES
 Squamous E. cells RARE/lpf
 Bacteria RARE/lpf
 Mucus threads RARE/lpf

HEMATOLOGY SECTION
Sedimentation Rate 57mm/hr 0-10

IMMUNOLOY SECTION
CRP 54.34mg/L - <5.0
 CLINICAL CHEMISTRY

PROCEDURES INDICATIONS RESULTS NORMAL VALUES IMPLICATIONS NURSING

REPONSIBILITIES
Creatinine 1.28mg/dL 0.9 - 1.3

Electrolytes
Sodium 134.6mmol/L 135 – 148
Potassium 3.82mmol/L 3.50 – 5.30
Chloride 104.0mmol/L 98 – 107
Ionized Calcium 1.12mmol/L 1.13 – 1.32

SGPT 57.7 U/L 0.0 – 41.0

81.4 U/L
TEST DONE TWICE
Bilirubin
Total Bilirubin 0.77mg/dL 0.2 – 1.0
Direct Bilirubin 0.33mg/dL - <0.2
Indirect Bilirubin 0.4mg/Dl -

Albumin 3.99g/dL 3.5 – 5.0

 HEMATOLOGY SECTION

PROCEDURES INDICATIONS RESULTS NORMAL VALUES IMPLICATIONS NURSING

REPONSIBILITIES
CBC To evaluate accurate - Increased WBC - Explain test
 WBC Count health and detect 10.56 10^9/L 4.5 – 11.5 indicates infection. procedure.
 Hemoglobin wide range of 126 g/L 140 – 180 - Decreased - Encourage to avoid
 Hematocrit disorder. 0.38 L/L 0.40 – 0.54 haemoglobin may stress if possible
 MCV 85.30 fl 80 – 100 indicate anemia because altered
 MCH 28.10 pg 26 – 32 - Decreased RBC physiologic status
 RBC Count 4.49 10^12/L 4.6 – 6.0 may indicate influence and
 MCHC 329 g/L 320 – 360 anemia. changes normal
 RDW 14.70% 11.5 – 14.5 hematologic values.
 MPV 9.50 fl 7.2 – 11.1 - Apply no pressures
 Platelet count 359.00 10^9/L 150 – 450 and dressings over
DIFFERENTIAL COUNT puncture site
 Neutrophil 62.00 50 – 70 - Monitor puncture
 Lymphocyte 23.10 18 – 42 for oozing
 Monocyte 7.70 2 – 11 hematoma
 Eosinophil 6.70 1–3 formation.
 Basophil 0.50 0–2 - Instruct to usual
 Stab 0 0–5 normal activities
 Atypical lymphocyte 0 - and dressing.
 Metamyelocytes 0 -
 Myelocytes 0 -
 blast 0 -
 MEDICAL IMAGING REPORT

Multislide CT scan (256 slices) of the CERVICAL and THORACIC SPINE (PLAIN)
There is osteolytic bone destruction of T1, T2 and T3 vertebral bodies with severe compression deformity
of T1 vertebral body, with paravetebral abscess formation (C7-T3 level) with intraspinal extension and significant C7-T2 spinal canal
stenosis with cord compression. There is an area of consolidation at the upper lobe with air bronchograms and small nodular
calcifications. There are pulmonary nodules (up to 1.4 cm) at both upper lungs. There are slightly enlarged bilateral supraclavicular
(up to 1.3 cm), paratracheal and ateropulmonary (up o 1.5 cm) lymph nodes. The rest of the cervical and thoracic vertebras are
intact.

IMPRESSION:

1. Osteolytic bone destruction of T1, T2, and T3 vertebral bodies with severe compression deformity of T1 vertebral body, associated
paravertebral abscess formation (C7-T3 level) with intraspinal extension and significant C7-T2 spinal canal stonsis with cord
compression. Consider Tuberculous spondylitis (Pott’s disease). Metastasis less likely. Please correlate clinically.

2. Area of consolidation at the left upper lobe with air bronchograms and small nodular calcifications. Consider tuberculoma/PTB.
Rule out pulmonary malignancy.

3. Pulmonary nodules (up to 1.4cm) at both upper lungs

4. Slightly enlarged bilateral supraclavicular (up to 1.3 cm), paratracheal and aortopulmonary (up to 1.5 cm) lymph nodes.
 CT-SCAN REPORT
EXAMINATION: SPINE-LUMBAR

CLINICAL DATA

==== [IMPRESSION] ====

Partial Destruction involving the vertebral bodies of T1, T2, and T3 with an accompanying soft tissue mass extending from the lower
endplate of C6 to the lower endplate of T3. This measures approximately 5.6 x 8.3 x 6.9 cm. The findings are compatible with a Pott’s
disease with a large paravertebral soft tissue abscess, with insinuation of the soft tissue mass into the spinal canal of T1, T2, and T3.
There is apparent extrinsic compression of the spinal cord along its ventrolevolateral aspect.

Airspace consolidation in the left upper lobe. There are tree-in-bud nodular opacities and noncalcified nodules scattered in the left
lung and in the right upper lobe. These are compatible with a chronic infection such as tuberculosis with multiple enlarged lymph
nodes in the mediastinum and left hilum.

Small liver cysts.

Small calcified granuloma in the right lobe of the liver.