LABORATORY AND DIAGNOSTIC PROCEDURE

CBC results: May, 28,2018

parameters results Normal Analysis

WBC 11.20g/L 5.0-10.0x10 increase

RBC 4.08 4.5-5.5x10 decrease

HGB 144.00g/L 140-170 normal

HCT 0.41 0.40-0.54 normal

Platelet 374 150-400x10 normal

CBC results: June 1,2018

parameters results Normal Analysis

WBC 13.92 5.0-10.0x10 increase

RBC 4.08 4.5-5.5x10 decrease

HGB 139.0g/L 140-170 decrease

HCT 0.42 0.40-0.54 normal

Platelet 305 150-400x10 normal

CLINICAL CHEMISTRY: May 29, 2018

parameters results Normal Analysis

FBS 5.17 mmol/L 3.9 - 6:4 normal

BUN 1.50 mmol/L 2.9-8.2 Low

Creatinine 44.2 umol/L 53 - 115 Low

URIC ACID 0.41 mmol/L 0.15 - 0.43 normal

Cholesterol 5.68 mmol/L 1.55 - 5.16 High

TRIGLYCERIDES 1.70 mmol/L up to 1.70 normal

CLINICAL CHEMISTRY: May 28, 2018

parameters results Normal Analysis

HGT 6.27mmol/L Below 11.1 normal

(114.0mgs%) mmol/l Below 200
mg/dl
TROP T below 50 0-100 normal
 Urinalysis: May 28, 2018

parameters results Normal Analysis

Quantity 10

Specific Gravity 1.025

Color straw
Reaction acidic
Transparency slightly turbid

Albumin negative
Sugar negative
Red Blood Cells 1-2
Pus Cells 2-4
Squamous Epithelial Rare
Cells
Bacteria Rare
Amorphous Urates Rare
Mucus Threads few

Chest X-ray AP/PA: May 28, 2018

INTERPRETATION
The ribs are intact. The heart is not enlarged. There is prominence of the aortic knob. No
pneumothorax: or pleural effusion is demonstrated. The lung fields are essentially clear. The diaphragm
is normal.

IMPRESSION:
Atherosclerosis. The lung fields are essentially dear.

CRANIAL CT-SCAN: May 28, 2018

Findings:
Plain head scan shows hyperdense focus in the pons measuring 1.2cm x 1.1cm x 2.0 cm. (about 1.3cc).
The basal ganglia, midbrain, cerebellum and medulla are unremarkable.
The ventricles are symmetrical and unenlarged.
The ventrcles are symmetrical and unenlarged.
The C-P angles and cisterns are clear.
The pestromastoids, visualized sinuses and bony calvarium are intact.

IMPRESSIONS:
Parenchymal hemorrhage, pons.
CRANIAL CT-SCAN: May 31, 2018

Findings:
Multiple axial images of the head were obtained without intravenous contrast. Reference was made
with previous CT study dated 5/28/18.
There is no interval change in the pontine hemorrhage still measuring 1.2 x 1.1 x 2.0 cm
(APWH). The ventricles, cisterns and sulci are normal in size and shape. There is no midline shift, mass or
mass effect. The parenchymal gray-white pattern is intact.
The mastoids and sinuses are well-aerated and intact. The visualized osseous structures are normal

IMPRESSION:
Subacute pontine hemorrhage, stable in size.

CRANIAL CT-SCAN: June 5, 2018

Multiple axial images of the head were obtained without intravenous contrast. Reference was made
with previous CT study dated 5/31/18.
There is interval regression of the right side of the pons now measuring 0.8 x 1.0 x 1.0 cm (APWH). The
ventricles, cistens and sulci are normal in size and shape there is no midline shift, mass or mass effect.
The parenchymal gray-white pattern is intact.
The mastoids and sinuses are well-aerated and intact. The visualized osseous structures are normal.

IMPRESSION:
Subacute pontine hemorrhage with interval regression.

ECG: June 5, 2018

IMPRESSION:
Sinus Tachycardia(107)
Left axis deviation
 INTAKE AND OUTPUT MONITORING
May 28,2018
Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total

6-2 250 300 550 350 350
2-10 50 960 1010 500 500
10-6 - 480 480 1500 1500
Total: 2040 Total: 2350

May 29,2018
Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total

6-2 - 700 700 500 350
2-10 150 1000 1150 900 500
10-6 - 480 480 1300 1300
Total: 2330 Total: 2700
May 30,2018
Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total

6-2 150 1180 1330 1400 1400
2-10 - 630 630 1000 1000
10-6 - 1190 1190 800 800
Total: 3150 Total: 3200
May 31,2018
Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total

6-2 - 1000 1000 1200 1200
2-10 - 700 700 1600 1600
10-6 30 750 780 400 400
Total: 2480 Total: 3200
June 1,2018
Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total

6-2 100 660 760 1200 1200
 2-10 250 650 900 800 800
10-6 100 800 900 800 80
Total: 2480 Total: 2800
June 2,2018
Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total

6-2 250 600 850 1200 700
2-10 250 500 750 1600 600
10-6 100 750 850 400 800
Total: 2450 Total: 2100