ST.

LUKES BEDSIDE ULTRASOUND OF GALLBLADDER AND LIVER February 17, 2014 Findings: GALLBLADDER: The gallbladder was partially contracted with associated wall thickening. There is a subcentimeter intraluminal non-shadowing echogenicity probably representing a polyp. Suggests additional scanning after 3 days of fat-free diet for further evaluation. Common bile duct is dilated measuring 1.0 cm in widest diameter. LIVER: The liver is slightly enlarged with a span of 17 cm. There is slightly coarsened parenchymal echogenicity with areas of increased echogenicity suggestive of patchy fatty infiltration. An irregular solid hypoechoic focus is appreciated at segment V of the right lobe extending to the periportal region measuring 5.1 x 4.4 x 2.9 cm. There is dilation of the intrahepatic ducts in both lobes. Portal vein is not dilated measuring 0.7 cm in diameter with evidence of good vascular flow on color interrogation. No evidence of thrombosis noted. Impression: Slight hepatomegaly with slightly coarsened parenchymal echogenicity with areas of increased echogenicity suggestive of patchy fatty infiltration. Irregular solid hypoechoic focus, as described dilated intrahepatic ducts, both lobes.

Interpretation: Based on the laboratory result, there was a slight hepatomegaly and with some patchy fatty infiltration seen at the liver, while there was also a polyp growth seen at the gall bladder area of the patient. These implied that the carcinomas of the pancreas of the patient has metastasized and therefore invade the other adjacent structures nearby. In addition, there was a noted dilation of the intrahepatic ducts in both lobes of the liver of the patient. This proved that there is an obstruction in the biliary ducts which leads to an increase bilirubin level of the patient.

LAGUNA HOLY FAMILY HOSPITAL CLINICAL CHEMISTRY Parameters Random (RBS) BUN Creatinine ALP 1/6/2014 255 (High) 13 0.7 (High) 195 (High) 40 34 7.5 3.5 4.0 (High) 0.88 (Low) 137.1 3.46 14.1 (High) Reference Range 75-115 mg/dL 9-20 mg/dL 0.66-1.25 mg/dL 38-126 u/L Interpretation Elevated random blood sugar can be a sign of diabetes that increases the risk in developing pancreatic cancer. Normal level Elevated creatinine level indicates that the patient has no proper excretion of waste products in the body related to its renal insufficiency. Elevated alkaline phosphatase indicates an underlying liver damage. This was evidenced by the enlarged liver of the patient and increased bilirubin level of the patient. Normal level Normal level Normal level Normal level Elevated globulin level in blood indicates an underlying liver and renal diasease. Low A/G Ratio indicates an underlying liver and renal diasease. Normal level Normal level Elevated bilirubin level in the blood indicates blockage of bile ducts. This was evidenced by the dilation of the hepatic ducts due to the obstruction. As a tumor grows, the bile ducts become blocked. When the duct becomes obstructed the bile backs up into the liver and enters the bloodstream. This leads to a visible yellowing of the eyes and the skin that was present to our patient. Elevated direct bilirubin level due to the obstruction in the intrahepatic ducts as evidenced by the clients skin jaundice that further indicates liver damage.

SGPT (ALT) SGOT (AST) Protein Albumin Globulin A/G Ratio Sodium Potassium Bilirubin

21-72 u/L 17-59 u/L 6.6-8.3 g/L 3.5-5.0 g/dL 1.2-3.0 g/L 1.5-2.5 135-148 mmol/L 3.5-5.4 mmol/L 0.2-1.3 mg/dL

Direct Bilirubin (BC)

11.4 (High)

0.0-0.3 mg/dL

Indirect Bilirubin (BU)

2.7 (High)

0.0-1.1 mg/dL

Elevated indirect bilirubin level indicates liver damage.

LAGUNA HOLY FAMILY HOSPITAL FECALYSIS January 27, 2014 Parameters Appearance Consistency Pus cells Red Blood Cells Result Light brown Soft 1-2 0-1

Interpretation: Based on the laboratory result, the stool of the patient appeared to be light brown in color, soft, with some presence of pus cells and red blood cells. The light color of the stool of the patient was primarily due to the increased level of bilirubin that backs up into the liver that later on enters the bloodstream. The bile does not reach the digestive system leading to a light colored stool of the patient. In addition, pus cells and red blood cells are abnormally seen in stools. Presence of these indicates that there is an infection and a slight bleeding that can be due to the obstruction on the intrahepatic ducts of the patient.

FEU-NRMF HEMATOLOGY (Complete Blood Count) Parameters 2/19/2014 4:45 PM 17.51 x 10^9 L (High) 0.937 (High) 2/22/14 5:50 AM 17.15 x 10^9 L (High) 0.927 (High) Reference Range Interpretation

White Blood Cell (WBC) Neutrophils

5.00 10.00 x 10^9 L 0.550 0.650

Lymphocytes Monocytes Eosinophils

0.032 0.023 0.007 (Low) 0.001 3.70 x 10^12/L (Low)

0.034 0.034 0.004 (Low) 0.001 2.28 x 10^12/L (Low)

0.250 0.350 0.020 0.060 0.030 0.650

WBC primarily Neutrophils are the most abundant and one of the first line of defense in response to an inflammatory process. In the case of our patient, this immunity response is primarily due to intrahepatic and biliary duct obstruction and some polyp growth at the adjacent structures of the pancreas. Normal level Normal level Eosinophils were low since it mostly responds to parasitic infections. Normal level Low levels of red blood cells were due to renal insufficiency. There was a decreased functioning level of the kidneys leading to low production of hormones that lead to decreased production of RBCs. As a result, more bilirubin circulates in the system of the patient.

Basophils Red Blood Cell (RBC)

0.000 0.010 5.50 6.50 x 10^12/L

Hemoglobin (HGB) Hematocrit (HCT) Mean Corpuscular Hemoglobin Concentration (MCHC) RDW-SD Platelets

117 g/L (Low) 0.320 (Low) 365 g/L (High)

76 g/L (Low) 0.194 (Low) 392 g/L (High)

140 160 g/L 0.420 0.520 320 - 360

59.0 fL (High) 434 x 10^9/L (High)

60.7 fL (High) 286 x 10^9/L

35.0 - 56.0 160 - 380 x 10^9/L

Parameters pH

ARTERIAL BLOOD GAS (Radiometer ABL500) February 22, 2014 Time of Examination: 3:27 AM Result Interpretation 7.307 Low; Acidic

Reference Range 7.35-7.45

pCO2 pO2 HCO3 Oxygen Saturation FiO2

25.8 102.4 12.5 mmol/L 97.4% 21%

Low; Basic High Low; Acidic Adequate

35-45 mmHg 80-100 mmHg 22-26 mEq/L 95-100%

Interpretation: Based on the laboratory result, the patient was experiencing metabolic acidosis.

Parameters pH pCO2 pO2 HCO3 Oxygen Saturation FiO2

ARTERIAL BLOOD GAS (Radiometer ABL500) February 23, 2014 Time of Examination: 7:39 PM Result Interpretation 7.287 Low; Acidic 36.1 Normal 120.1 High 16.7 mmol/L Low; Acidic 98.1% Adequate 32%

Reference Range 7.35-7.45 35-45 mmHg 80-100 mmHg 22-26 mEq/L 95-100%

Interpretation: Based on the laboratory result, the patient was experiencing uncompensated metabolic acidosis.