DIAGNOSTIC TESTS Hospital: Adventist Medical Center Iligan January 31, 2014 (on admission) CBC with platelet

et Blood Component Normal Values RBC 4-6 10 12/L Hematocrit 0.37-0.47 110-180 g/L 5-10 10 9/L 0.50-0.65 0.25-0.35 0.05-0.10 0.03-0.07 0.01-0.03 0.01 140-450 10 9/L

Result 4.30 0.34

Interpretation Normal Decreased

Significance May suggests anemia, hemodilution due to fluid retention

Hemoglobin WBC Segmenters

125.0 8.22 0.81

Normal Normal Increased

Viral and some bacterial infections, hepatitis. Decrease count occur in aplastic anemia, AIDS and bone marrow suppression Infection

Lymphocytes

0.15

Decreased

Stabs Monocytes Eosinophils Basophils Platelet Creatinine Normal Value (53-100 umol/L)

0 0.02 0.02 0 248

Normal Decreased Normal Normal Normal

Result 120.16

Interpretation Increased

Significance Impaired renal function or may suggest damage to the kidneys

February 2, 2014 HBSAG (for screening purposes) Normal Value Result nonreactive nonreactive Potassium Normal Value 3.5-5.3 mmol/L

Interpretation normal

Significance

Result 2.86

Interpretation Decreased

Significance Hypokalemia may results to vomiting or edema or ascites

February 3, 2014 Prothrombin time Result Patient: 12.3s Control: 13.1s Activity: 100% INR: 1.00

Interpretation normal

Significance

Bilirubin Normal Values Bilirubin (1.7-20.5 umol/L) B1 or indirect (1.7-17.1 umol/L) B2 or direct (0-5.1 umol/L)

Results 7.37 4.92 2.45

Interpretation Normal Normal Normal

Significance

 Albumin Normal Values 35-54 g/L

Results 23.56

Interpretation Decreased

Significance Hypoalbuminemia may indicate acute liver failure

Liver Enzymes Normal Values Alanine aminotransferase or SGOT (8-40 Iu/L) Aspartate aminotransferase or SGPT (5-35 u/L)

Results 23.92 11.77

Interpretation Normal Normal

Significance

Whole Abdomen Ultrasound Normal Result Results A normal scan Impression: o Minimal hepatic reveals no parenchymal fatty change abnormalities in the o Cholelithiasis with chronic size, shape, or cholecystitis density of the organs scanned. o Normal sized kidneys with minimal parenchymal changes (no urolithiasis nor signs of ureteral obstruction) o Sonologically normal biliary ducts, pancreas, spleen, urinary bladder, uterus and adnexae o Minimal bilateral pleural effusion (165cc on the right and 187cc on the left) o Minimal ascites

Interpretation Abnormal result

Significance Chronic Cholecystitis Ascites (minimal) Pleural Effusion (Bilateral)

February 5, 2014 Creatinine Normal Value 53-100 umol/L

Result 107.10

Interpretation Increased

Significance Impaired renal function or may suggest damage to the kidneys

February 6, 2014 2D echo Normal Result A normal echocardiogram shows a normal heart structure and the normal flow of blood through the heart chambers and heart valves. Albumin Normal Values 35-54 g/L

Result Normal sized left ventricle with good wall motion and contractility, preserved overall systolic function.

Interpretation normal

Significance

Results 28.89

Interpretation Decreased

Significance Hypoalbuminemia may indicate acute liver failure

Thyroid-stimulating Hormone Normal Values Results (FT4) Free T4 (9-20pmol/L) 15.16 TSH (0.47-5.01 ulU/ml) 3.24

Interpretation Normal Normal

Significance

February 7, 2014 Upper Abdomen Ultrasound Normal Result Result A normal scan reveals o Follow-up Sonographic Evaluation no abnormalities in the showed the normal sized liver with size, shape, or density minimal fatty infiltration. of the organs scanned. o No focal parenchymal mass lesion seen. The gland outline is smooth. o The portal vein, intrahepatic and common bile duct are dilated. CBD = 4mm, normal caliber. o The gallbladder was partially contracted with minimal thickened wall. o The 3cm cholelithiasis was again noted. o The pancreas and the spleen are normal in size and configuration. o The abdominal aorta is normal in caliber with no abnormal focal dilatation. o Normal sized kidneys with minimal parenchymal changes. o Persistent minimal ascites with no significant interval change. o Persistent bilateral pleural effusion (219cc on the right and 195cc on the left). No significant interval regression.

Significance Cholecystitis Minimal Ascites Bilateral Pleural Effusion

Alkaline Phosphatase Normal Values Results 53-141 U/L 67.91 February 8, 2014

Interpretation Normal

Significance

Upper Gastrointestinal Endoscopy Normal Result Result The endoscopy o Esophagus: Unremarkable should reveal normal o Stomach: Some amount of food debris seen. function and Patchy areas of hyperemia and edematous appearance of the mucosa noted. No definite mass nor ulcer area being examined. seen in the visualized mucosa. Biopsy taken for rapid urease test. o Duodenum: 1st and 2nd portion: Unremarkable o H.pylori: Positive

Significance Gastritis with H.Pylori infection

Hemoglucotest (HGT) Monitoring Date Jan 31, 2014 Feb 1, 2014 Time 11PM 5AM 11AM 5PM 65 193 HGT Result 119

Normal Value: 60 110mg/dL Intervention

11PM Feb 2, 2014 5AM 11AM 5PM 11PM Feb 3, 2014 5AM 11AM 5PM Feb 4, 2014 5AM 11AM 5PM 11PM Feb 5, 2014 5AM 11AM 11PM Feb 6, 2014 5AM 11AM 5PM 11PM Feb 7, 2014 5AM 5PM 11PM Feb 8, 2014 5AM 11AM 8PM 11PM Feb 9, 2014 5AM 11PM

113 120 82 123 64 118 169 173 71 144 162 94 79 171 155 153 87 90 106 107 253 212 148 196 174 187 174 133 Humulin 70/30 10units pre-supper D50 W Humulin 70/30 20units prebreakfast

Hospital: Dr. Uy Hospital January 28, 2014 admission CBC with platelet Blood Component RBC Hematocrit Normal Values 4-4.5 10 12/L 0.37-0.45 120-140 g/L 5-10 10 9/L 0.55-0.70 0.25-0.40 0.01-0.08 140-440 10 9/L Result 3.5 0.31 Interpretation Decreased Decreased Significance May suggest anemia May suggests anemia, hemodilution due to fluid retention May indicate anemia or hemodilution due to fluid retention

Hemoglobin

104

Decreased

WBC Segmenters Lymphocytes Monocytes Platelet Creatinine Normal Values 0.50-1.20mg/dL or 53100 umol/L

8.9 0.66 0.29 0.05 240

Normal Normal Normal Normal Normal

Results 1.7 or 150.20 mmol/L

Interpretation Increased

Significance Impaired renal function or may suggest damage to the kidneys

Sodium Normal Values 135-148.0 mmol/L Potassium Normal Values 3.5-5.3 mmol/L

Results 143.0

Interpretation Normal

Significance

Results 2.97

Interpretation Decreased

Significance Hypokalemia may results to vomiting or edema or ascites

Chest X-ray PA view Normal Result Results A normal chest x Impression: o Minimal ray will show Cardiomegaly normal structures for the age and medical history of the patient.

Interpretation Abnormal result

Significance Cardiomegaly (minimal)

Whole Abdomen Ultrasound: Normal Result Results A normal scan Impression: reveals no o Minimal Hepatic Parenchymal Fatty Change o 3cm Cholelithiasis. No evidence of biliary abnormalities in the size, shape, or obstruction. density of the o Normal Sonographic Evaluation of the biliary organs scanned. ducts, pancreas, spleen, both kidneys, urinary bladder and uterus

Significance Cholelithiasis

January 29, 2014 Urine Analysis: Normal Values

Specific gravity Ph Protein Glucose Ketone Bilirubin Blood Nitrite Leukocyte Urobilinogen Micro RBCs WBCs RBC casts 1.002-1.030 5-7 negativetrace negative negative negative negative negative negative 0.2-1.0 Ehr U/dL 0-2/HPF 0-2/HPF 0/HPF

o o o o o o o o o

Results Color: Yellow pH: 7.0 Specific Gravity: 1.010 Sugar: +4 Albumin: +3 RBC: 7-10/HPF Epithelial Cells: Abundant Amorphous subs. : Few Bacteria: Moderate

Interpretation Presence of sugar, albumin with moderate bacteria

Significance Albuminuria, Glycosuria, possible UTI

January 30, 2014 Albumin Normal Values 38-51 g/L

Results 23.3

Interpretation Decreased

Significance Hypoalbuminemia may indicate acute liver failure

Potassium Normal Values 3.5-5.3 mmol/L

Results 2.81

Interpretation Decreased

Significance Hypokalemia may results to vomiting or edema or ascites

Hemoglucotest (HGT) Monitoring Date January 28, 2014 Time On admission 5PM January 29, 2014 5AM 5PM January 30, 2014 5AM 5PM January 31, 2014 5AM

Normal Value: 60 110mg/dL HGT Result 164.0 153.0 85 217.0 164.0 148.0 95 Intervention

Procedures and Nursing Interventions LABORATORY TESTS Albumin, Alkaline Phosphatase, Complete Blood Count (with Platelet Count), Creatinine, Hemoglucotest, Prothrombin Time, Serum Sodium and Potassium, SGOT, SGPT, TSH (TSH AND FREE T4).

PRETEST: Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Obtain a history of the patients complaints, including a list of known allergens, especially allergies or sensitivities to latex. Obtain a history of the patients gastrointestinal, genitourinary, and hepatobiliary systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. Obtain a list of the patients current medications including herbs, nutritional supplements, and nutraceuticals. Explain the procedure. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture. Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. There are no food, fluid, or medication restrictions unless by medical direction.

INTRATEST: If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Observe standard precautions. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Perform a venipuncture. Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. Promptly transport the specimen to the laboratory for processing and analysis.

POST-TEST: A written report of the results will be sent to the requesting health care provider (HCP), who will discuss the results with the patient. Instruct patient to resume any medications stopped before the test

SPECIAL CONSIDERATION: Creatinine Instruct patient to restrict activities 8 hours prior to the test Alkaline Phosphatase Instruct the patient to fast for at least 8 hours before the test because fat intake stimulates intestinal alkaline phosphatase (ALP) secretion Thyroid-stimulating Hormone venipuncture should be performed between 6 a.m. and 8 a.m.

URINANALYSIS

PRETEST: Explain that this analysis helps to diagnose renal or urinary tract disease and to evaluate overall body function. Inform the patient that there is no food or fluid restriction Notify the laboratory and physician of drugs the patient is taking that may affect laboratory results

INTRATEST: Collect a random urine specimen (a midstream-catch) of at least 15ml. obtain a firstvoided morning specimen if possible Label the specimen (name, date, time, physician) and submit to the laboratory within 30mins

POST-TEST: Inform the patient that she may resume her usual diet and medication

CHEST XRAY PRETEST: Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Inform the patient that the procedure assesses cardiopulmonary status. Explain that the patient will be asked to take a deep breath and hold it momentarily during the XRAY Explain that the test takes less than 5minutes Any metals should be remove from the patients body during the test

INTRATEST: The patient is instructed to stand or sit in front of a stationary radiography machine

POST-TEST: Assist the patients needs (e.g. changing of clothes) Instruct to resume activities and diet

UPPER AND WHOLE ABDOMEN ULTRASONOGRAPHY PRETEST: Make sure the patient or responsible party has signed a consent form Note and report all allergies Provide a fat-free meal in the evening before the procedure Tell the patient that he must fast for 8-12hours before the procedure Instruct the patient to remain still as possible during the procedure and to hold her breath when requested

INTRATEST: Assist the patient into a supine position

Coat the target area with a water-soluble jelly. The transducer is used to scan the area, projecting the images on the oscilloscope screen. The image on the screen is photographed for subsequent examination

POST-TEST: Remove the lubricating jelly from the patients skin Have the patient resume her normal diet

UPPER G.I. ENDOSCOPY PRETEST: Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. Inform the patient that the procedure assesses the esophagus and upper GI tract. Obtain a history of the patients complaints, including a list of known allergens, especially allergies or sensitivities to latex, iodine, seafood, anesthetics, or contrast mediums. Obtain a history of the patients GI system, symptoms and results of previously performed laboratory tests and diagnostic and surgical procedures. Note any recent barium or other radiological contrast procedures ordered. Ensure that barium studies are performed after this study. Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women. Obtain a list of the patients current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals. Note the last time and dose of medication taken. Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort, but that the throat will be anesthetized with a spray or swab. Inform the patient that he or she will not be able to speak during the procedure, but that breathing will not be affected. Inform the patient that the procedure is performed in a GI lab or radiology department, usually by a health care provider (HCP) and support staff, and takes approximately 30 to 60 min. Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. Explain that an IV line may be started to allow for the infusion of a sedative or IV fluids. Inform the patient that a laxative and cleansing enema may be needed the day before the procedure, with cleansing enemas on the morning of the procedure, depending on the institutions policy. Inform the patient that dentures and eyewear will be removed before the test. Instruct the patient to remove jewelry and other metallic objects from the area to be examined. Instruct the patient to fast and restrict fluids for 8 hours prior to the procedure. Protocols may vary from facility to facility. Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

INTRATEST: Ensure the patient has complied with dietary and medication restrictions and pretesting preparations for at least 8 hr prior to the procedure. Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.

Assess for completion of bowel preparation according to the institutions procedure. Have emergency equipment readily available. Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided. Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results. Observe standard precautions. Positively identify the patient, and label the appropriate collection container with the corresponding patient demographics, date, and time of collection. Obtain and record baseline vital signs. Start an IV line and administer ordered sedation. Spray or swab the oropharynx with a topical local anesthetic. Provide an emesis basin for the increased saliva and encourage the patient to spit out the saliva because the gag reflex may be impaired. Place the patient on an examination table in the left lateral decubitus position with the neck slightly flexed forward. The endoscope is passed through the mouth with a dental suction device in place to drain secretions. A side- viewing flexible, fiberoptic endoscope is advanced, and visualization of the GI tract is started. Air is insufflated to distend the upper GI tract, as needed. Biopsy specimens are obtained and/or endoscopic surgery is performed. Promptly transport the specimens to the laboratory for processing and analysis. At the end of the procedure, excess air and secretions are aspirated through the scope and the endoscope is removed. Remove the needle or catheter and apply a pressure dressing over the puncture site.

POST-TEST: A report of the examination will be sent to the requesting HCP, who will discuss the results with the patient. Observe the patient for indications of esophageal perforation (i.e., painful swallowing with neck movement, substernal pain with respiration, shoulder pain or dyspnea, abdominal or back pain, cyanosis, or fever). Do not allow the patient to eat or drink until the gag reflex returns; then allow the patient to eat lightly for 12 to 24 hr. Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered by the HCP. Take temperature every 4 hr for 24 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary from facility to facility. Instruct the patient to resume usual activity and diet in 24 hr or as tolerated after the examination, as directed by the HCP. Inform the patient that he or she may experience some throat soreness and hoarseness. Instruct patient to treat throat discomfort with lozenges and warm gargles when the gag reflex returns. Inform the patient that any belching, bloating, or flatulence is the result of air insufflation and is temporary. Instruct the patient that any severe pain, fever, difficulty breathing, or expectoration of blood must be immediately reported to the HCP. Recognize anxiety related to test results, and offer support. Discuss the implications of abnormal test results on the patients lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.

2D ECHO PRETEST: Tell the patient that she may be asked to breathe in and out slowly, to hold her breath or to inhale a gas with a slightly sweet odor (amyl nitrite) while changes in heart function are recorded Warn about the possible adverse effects of amyl nitrite (dizziness, flushing, and tachycardia), but reassure that such effects quickly subsides Stress the need to remain still during the test because movement may distort results Explain that the test takes 15 to 30 minutes

INTRATEST: The patient is placed into the supine position and conductive gel is applied to the third or fourth intercostal space to the left of the sternum. The transducer is placed directly over it. The transducer is systematically angled to direct ultrasonic waves at specific parts of the patients heart. During the test, the oscilloscope screen is observed; significant findings are recorded on a strip chart recorder or on a videotape recorder For left lateral view, patient is placed on her left side Doppler echocardiography may also be used: color flow simulates RBC flow through the heart valves. The sound of blood flow may also be used to assess heart sounds and murmurs as they relate to cardiac hemodynamics

POST-TEST: Remove the conductive gel from the patients skin