DIAGNOSTIC EXAMINATION

Test Done: CT Scan Report

Dated:
September 17, 2016
Findings:
Multiple plain CT images of the head were obtained
There is a parenchymal bleed in the pons measures 1.3 x 3.5 x 2.3 cm. with
approximate volume of 5.4 cc. The cerebral and cerebellar parenchyma show
normal attenuation with no evidence of acute or chronic infarcts and bleed
noted. No mass or abscess noted. The gray-white matter interface is
maintained
The sulci and gyri are normal
The midline structures are not displaced
The ventricles are normal in size, shape and location
No extra-axial fluid or bleed noted
Impression:
Pontine bleed
Test Done: Blood Chemistry
Dated:
September 17, 2016
Results:
Parameters
Normal Values
Troponin I
Sodium
136-144 mmol/L
Potassium
3.6-5.1 mmol/L
Creatinine
53-97 mmol/L

Test Done: Urinalysis

Date:
September 17, 2016
Results:
Macroscopic
Normal Values
Color
Yellow
Transparency
Clear
Reaction (pH)
4.8-7.8
Microscopic
Pus cells
RBC (0-5)
Amorp. Urates
Bacteria
Mucus threads
Epithelial cells
Qualitative Test
Spec. Grav.
1.015-1.025
Sugar
Negative

Actual Results
negative
137.8
3.55
316

Actual Results
Light Yellow
Hazy
6
6-8/hpf
8-12/hpf
Moderate
Moderate
Moderate
Few
1.020
Negative

Interpretation

Indicator for
impaired kidney
function or kidney
disease.

Interpretation

Albumin
Remarks:
Hyaline casts
Fine granular casts :
Coarse granular casts
Test Done:
Dated:
Results:

+3
:
0-2/lpf
0-2/lpf
:
0-2/lpf

Complete Blood Count

September 17, 2016

Hemoglobin
Hematocrit
RBC count
WBC count
Platelet count

Normal Values
140.00-170.00
0.41-0.51
4.60-5.20
4.50-11.00
142,000424,000 U/L

Actual Results
95
0.28
3.26
12.11
428,000

Red Blood Cells Indices

MCV
83.00-101.00 fL

82.1 fL

MCH
MCHC

27.00-32.00 pg
315.00-345.00
g/L
39.00-46.00 fL

30.1 pg
366 g/L

0.55-0.70
0.20-0.35
0.0-0.05
0.03-0.05

0.41
0.51
0.03
0.04
0.01

RDW
Differential Count
Neutrophil
Lymphocyte
Eosinophil
Monocytes
Basophil

38.8 fL

Interpretation
Indicator for anemia
Same as hemoglobin
Same as hemoglobin
Indicator for infection
Indicator for
thrombocytosis/thrombocyt
hemia
Indicator for microcytic
anemia
Indicator for macrocytic
anemia
Same as MCHC
Indicator for neutropenia
Indicator for infection

Test Done: CT Scan Report

Dated:
September 18, 2016
Findings:
Hemorrhagic foci are again seen in the pontine region with a combined
computed volume of 5.5 ml. (previously 5.4 ml.). Perimetric edema is noted.
The rest of the brain parenchyma appears normal
The ventricles are not dilated. There is no midline shift.
The paranasal sinuses, orbits and bony calvarium are intact
Impression:
Pontine hemorrhage, stable since the previous study
No new focus of hemorrhage or infarction identified
No hydrocephalus detected at this time

Test Done: ABG

Dated:
September 18, 2016
Results:
FiO2 :
80%
Parameters
Normal Values
pH
7.35-7.45
PCO2
35-45
PO2
80-100 mmHg
HCO3
22-26 mEq/L
BE/BD
(+/-)2-2 mEq/L
O2 Sat
95-98%
Interpretation:

Fully compensated metabolic acidosis

Test Done: Blood Chemistry

Dated:
September 18, 2016
Results:
Parameters
Normal Values
Urea Nitrogen
2.85-7.20 mmol/L
Sodium
Potassium
Creatinine

Test Done:
Dated:
Results:

Actual Results
12.59

136-145 mmol/L

134

3.6-5.1 mmol/L
53-97 mmol/L

4.4
272.49

Interpretation
Indicator for heart
failure
Indicator for
hyponatremia
Indicator for
impaired kidney
function or kidney
disease.

Lipid Profile
September 18, 2016

Fasting Glucose
(FBG)
Total Cholesterol
Triglycerides
HDL cholesterol
LDL cholesterol
ALT/SGPT
AST/SGOT

Actual Results
7.37
35
218
20.2
-4.4
100%

Normal Values
70-115 mg/dL

Actual Results
152.73 mg/dL

< 200 mg/dL

213.85 mg/dL

50.00-150.00
mg/dL
25.77-62.69 mg/dL

175.45 mg/dL

65.40-130.00
mg/dL
0.00-33.00 U/L
0.00-32.00 U/L

157.69 mg/dL

22.31 mg/dL

9.00 U/L
22.90 U/L

Interpretation
Indicator for
diabetes
High risk for heart
diseases
High risk for heart
diseases
High risk for heart
diseases
High risk for heart
diseases

Test Done: Complete Blood Count

Dated:
September 18, 2016
Results:
Prothrombine Time
Control
13.4 seconds
Normal Values
Actual Results
Patient
12.00-15.00 sec
14.2 sec
Activity
70.00-120.00 sec
93.1 sec
INR
1.05
Activated Partial Thromboplastin Time
Control
28.3 sec
Patient
25.1
Test Done: CT Scan Report
Dated:
September 19, 2016
Findings:
There is no significant interval change in the extent and amount of the
pontine bleed now with a computed volume of 5.6 ml (previously 5.5 ml.).
Same degree of surrounding edematous changes are seen
The rest of the brain parenchyma remains normal
As before, the ventricles remain intact with no dilatation noted. There is no
midline shift
The paranasal sinuses, orbits and bony calvarium remains unremarkable
Impression:
Pontine hemorrhage with no significant change in volume or extent
As before, no new focus of hemorrhage or infarction identified
No ventricular dilatation detected at the time of this examination
Test Done: ETA
Dated:
September 19, 2016
Gram Stain Results:
Epithelial cells
:
few
Pus cells
:
>50/hpf
Gram(+) Cocci (Singly/In pairs) :
3+
Gram (-) Bacilli
:
few
No other microorganisms seen
Test Done: ABG
Dated:
September 19, 2016
Results:
FiO2 :
40%
Temp :
37.8C
Parameters
Normal Values
pH
7.35-7.45
PCO2
35-45

Actual Results
7.38
32

PO2
HCO3
BE/BD
O2 Sat

80-100 mmHg
22-26 mEq/L
(+/-)2-2 mEq/L
95-98%

Interpretation:

Fully compensated metabolic acidosis

Test Done: ABG

Dated:
September 20, 2016
Results:
FiO2 :
35%
TV
:
400
Parameters
Normal Values
pH
7.35-7.45
PCO2
35-45
PO2
80-100 mmHg
HCO3
22-26 mEq/L
BE/BD
(+/-)2-2 mEq/L
O2 Sat
95-98%
Interpretation:

Actual Results
7.27
28
65
12.9
-12.6
89%

Fully compensated metabolic acidosis

Test Done: Blood Chemistry

Dated:
September 20, 2016
Results:
Parameters
Normal Values
Urea Nitrogen
2.85-7.20 mmol/L
Sodium

74
18.8
-5.2
94%

Actual Results
17.04

136-145 mmol/L

130.00

Potassium

3.6-5.1 mmol/L

2.90

Creatinine

53-97 mmol/L

570.62

Test Done:
Dated:
Results:

Interpretation
Indicator for heart
failure
Indicator for
hyponatremia
Indicator for
hypokalemia
Indicator for
impaired kidney
function or kidney
disease.

Complete Blood Count

September 20, 2016

Hemoglobin

Normal Values
140.00-170.00

Actual Results
80

Hematocrit

0.41-0.51

0.25

RBC count

4.60-5.20

2.77

WBC count

4.50-11.00

24.2

Interpretation
Indicator for
anemia
Same as
hemoglobin
Same as
hemoglobin
Indicator for
infection

Platelet count
200.00-400.00
Red Blood Cells Indices
MCV
83.00-101.00 fL
MCH
27.00-32.00 pg
MCHC
315.00-345.00 g/L
RDW
39.00-46.00 fL

333
88.8 fL
28.9 pg
325 g/L
53.9 fL

Differential Count
Segmenters

0.55-0.65

0.93

Lymphocytes

0.25-0.35

0.07

Indicator for
macrocytic anemia
Indicator for
infection
Indicator for
infection

Test Done: CT Scan Report

Dated:
September 21, 2016
Impression/Findings:
There is a stability in the area of the formerly seen pontine hemorrhage. No
progression noted.
Ventricles are not dilated. No intraventricular hemorrhagic extension detected
Cerebral atrophy is demonstrated
The internal carotid arteries are segmentally calcified
No midline shift
The orbits, paranasal sinuses, mastoids and sella turcica are intact
NGT is partially visualized
Test Done: Chest X-Ray
Dated:
September 21, 2016
Roentgenological Findings:
Dense hilar shadows
Enlarged cardiac outline
Sclerotic thoracic aorta
The left sulcus is not well defined
IJ catheter is seen
NGT is partially visualized
EDT tip is about 2-3 cm from the carina
Impression:
Hilar congestive changes
Cardiomegaly
Atheromatous aorta
Minimal pleural effusion, left is not ruled out
Test Done: Blood Chemistry
Dated:
September 23, 2016
Results:
Parameters
Normal Values
Urea Nitrogen
2.85-7.20 mmol/L

Actual Results
10.50

Interpretation
Indicator for heart
failure

Sodium
Potassium
Creatinine

136-145 mmol/L
3.6-5.1 mmol/L
53-97 mmol/L

Test Done:
Dated:
Results:

Complete Blood Count

September 23, 2016

140.00
4.2
305.09

Hemoglobin

Normal Values
140.00-170.00

Actual Results
106

Hematocrit

0.41-0.51

0.33

RBC count

4.60-5.20

3.65

WBC count

4.50-11.00

18.2

Platelet count
200.00-400.00
Red Blood Cells Indices
MCV
83.00-101.00 fL
MCH
27.00-32.00 pg
MCHC
315.00-345.00 g/L
RDW
39.00-46.00 fL

Indicator for
impaired kidney
function or kidney
disease.

Interpretation
Indicator for
anemia
Same as
hemoglobin
Same as
hemoglobin
Indicator for
infection

290
91.0 fL
29.0 pg
319 g/L
55.4 fL

Differential Count
Segmenters

0.55-0.65

0.85

Lymphocytes

0.25-0.35

0.12

Eosinophil
Monocyte

0.02-0.05
0.02-0.08

0.01
0.02

Indicator for
macrocytic anemia
Indicator for
infection
Indicator for
infection