HEMATOLOGY:

Test

6/25/13

6/29/136

Normal

analysis

Hemoglobin

100

111

120-150

Clients Hgb is below the normal range. Analysis: Hemoglobin is a protein in red blood cells that carries oxygen. A blood test can tell how much hemoglobin you have in your blood. The hemoglobin test is almost always done as part of a complete blood count (CBC). (Medicinenet.com

Hematocrit

0.32

O.34

0.37-O.47

Analysis: The value of the hematocrit is dependent upon the number of RBC's. If the Hct is abnormal, then the RBCcount is possibly abnormal. Shock, hemorrhage, dehydration, or excessive IV fluid administration can reduce the Hct. However, this is still a good baseline lab test for the patient. It helps the physician to diagnose and to treat the patient with any disease which will lower or raise the Hct levels. (Brunner et. al., 1999)

Wbc

32.4

19.37

5.0 - 10.0

The test showed a significant increase in the patients WBC. Analysis :

Neutrophils

0.95

0.92

.30-.70

Interpretation: The clients neutrophils are above the normal. Analysis: They are the body's primary defense against bacterial infection and physiologic stress. An increased need for neutrophils, as with an acute bacterial infection, will cause an increase in both the total number of mature neutrophils and the less mature bands or stabs to respond to the infection. In addition to bacterial infections, neutrophil counts are increased in many inflammatory processes, during physical stress, or with tissue necrosis that might occur after a severe burn or a myocardial infarction. Neutrophils are also increased in granulocytic leukemia. (Kennedy, 2011).

Lymphocytes

0.05

0.08

0.20-0.40

Platelet MCH MCV RBW

113 21 68 0.159

1.38

150 - 350 x 109/L 5-0.145

6/25/13 11:30pm Cell morphology: smear shows normocytic, slight hypochronic with few microcytic RBCs platelets are decrease.

URINALYSIS:

Result

Normal

Analysis

Color Transparency Specific gravity Reaction CHON Glucose Microscopic: RBC WBC EC CAST BACT SRC

Light yellow Slightly turbid 1.015 Acidic +4 negative

198.1 25.10 41.6 5.6 39.3 28

June 26 2013 SGOT SGPT

Result 34 28

6/25/13 4:40pm 5:30pm For E CS Ampicillin sulbactam 1.5g IV Note: IE ,cervix 6cms BP 160/100 POST OP ORDERS: NPO Admit to OB ward Dr.Santos/Abad Santos NPO Dx. Test CBc U/A stat IVF D5LR 1L x 30 gtts/min D5W 500cc+ 4amps iso x uprive Dexamethasone 6mg 1M now then q12 x 4 doses CBR w/ ARDS Monitor VS q1 WOF bleeding and uterine contraction Refer prn

To RR till fully stable/ awaked hooked to monitor Flat on bed on 8 hours Encourage deep breathing Connect urine bag to bedside Continue ampicillin 500mg IV q 6hrs. Present IVF with 10 u oxy x 30 gtt IVF to follow D5LR 1L x 30gtt/min

10:00pm Incidental appendectomy 7:00pm NPO until further orders Note: 7cm x 1cm with fecaltin

9:25pm Magnesium sulfate 4g SIVP then 5g IM 6/26/13 8:00am May have sips of clear liquid now then general liquids this 1 week Soft diet once with flatus, DAT IVF to follow D5LR 1L x 40gtt/min Ambulate Increase fluid intake Start oral meds once on soft diet Co-amoxiclav 625mg BIDx7day Mefenamic acid 500mg TID PC Ferumarate 1 tab BID x 1 month Daily wound perineal care VS q4 6/27/13 1pm COD D/C IE done Still to transfuse PRBC 2 u

6/28/13 2:40pm For report CBC 6 houre post BT and relay results Continue oral meds Daily wound care 6/29/13 2pm For qualitative TORCH screening OPD Follow up at OPD on july 6, 2013 Well adviced Note: adequate U/O, Well contracted uterus, minimal vaginal bleeding.