PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

Gen. Luna Muralla St. Intramuros, Manila

College of Nursing

In Partial Fulfilment of the Requirements of Related Learning Experience

Surgery Ward

BSN 3-1

Submitted by:

Ansherina S. Awatin

2016-02630

Submitted to:

Prof. Lady Anne O. De Jesus, RN

Clinical Instructor

August 23, 2017

 TABLE OF CONTENTS

I. Introduction Of the Case

II. General Objectives

III. Specific Objectives

IV. Demographic Data

V. Chief Complaint

VI. History of Present Illness

VII. Past Medical History

VIII. Psychological History

IX. Family History

X. Social History

XI. Physical Assessment

XII. Review of Systems

XIII. Gordon’s Functional Health Pattern

XIV. Anatomy and Physiology

XV. Pathophysiology

XVI. Laboratory Results and Analysis

XVII. Nursing Care Plan

I. INTRODUCTION

“Diabetes" is derived from the Greek word siphon (a tube bent in two through which liquid flows)

and the Latin word mellitus (sweet as honey). This is a condition in which the pancreas no longer produces

enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot

be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and

hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of

insulin.

Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed. In the

United States, approximately 800,000 new cases of diabetes are diagnosed yearly (Mokdad et al., 2000).

Diabetes is especially prevalent in the elderly, with up to 50% of people older than 65 suffering some degree

of glucose intolerance. Among adults in the United States, diagnosed cases of diabetes increased 49%

from 1990 to 2000, and similar increases are expected to continue (Centers for Disease Control and

Prevention [CDC], 2002).

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset

diabetes, and this form of diabetes occurs most often in people who are overweight and who do not

exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing

over the course of several years) and because it usually can be controlled with diet and oral medication.

The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as

those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat

misleading. Many people with Type II diabetes can control the condition with diet and oral medications,

however, insulin injections are sometimes necessary if treatment with diet and oral medication is not

working.

The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic

factors passed on in families) and environmental factors involved. Research has shown that some people

who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the body’s
defense system against infection, is believed to be triggered by a virus or another microorganism that

destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of

diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have become

resistant to the insulin produced and it may not work as effectively. Symptoms of Type II diabetes can begin

so gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and

frequent urination. Other symptoms may include sudden weight loss, slow wound healing, urinary tract

infections, gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while a patient

is seeing a doctor about another health concern that is actually being caused by the yet undiagnosed

diabetes.

This case study presents the case of a 61 year old Filipino male patient that has been admitted to

in the Surgery Ward of Ospital ng Maynila Medical Center at 1:39 am on August 10, 2017 with a chief

complaint of surgical site infection on left foot. Patient D was recently diagnosed with Diabetes Mellitus

Type II and had undergo a surgical procedure that involves amputation of big toe on left foot due to presence

of fibrin deposits over the subcutaneous and muscular layer and necrotic areas over the edges of the left

foot. Few weeks later after the surgical procedure, Patient D went for a follow-up care visit at OMMC. Upon

consultation, abscess was observed in the surgical site. Patient was directly admitted to surgery ward for

further management.
II. GENERAL OBJECTIVES

This study aims to determine, understand and gain extensive knowledge on the general health

problems and needs experienced by a client who is diagnosed with Diabetes Mellitus and had developed

a surgical infection after few weeks post-operation of left foot. Moreover, this study also intends to help

patient promote health and medical understanding of such condition through the application of the nursing

skills and theoretical knowledge.

III. Specific Objectives

 To build rapport with the patient and significant others for an effective nurse-patient interaction.

 To gather meaningful information about the patient’s health history for an accurate health

assessment.

 To thoroughly assess the clinical manifestations of patient with Diabetes Mellitus based on the

patient’s history.

 To develop insight about the diagnosis of the patient and set considerations and priorities about

the patient’s condition

 To perform physical assessment to the patient

 To be able to familiarize with the medications administered to the patient knowing its mechanism

of action, frequency, dosages, indication, contraindications and the nursing responsibilities to

consider.

 To formulate a workable nursing care plan based on the subjective and objective cues gathered,

make diagnosis and provide necessary nursing management and interventions.

 To formulate appropriate health teaching for continuity of care and patient’s fast recovery and

prevention of possible complications.

IV. DEMOGRAPHIC DATA

Patient: Patient D

Sex: Male

Address: Paco, Manila

Age: 61

Date of Birth: September 6, 1955

Place of Birth: Negros Occidental

Occupation: Security guard of a convent

Educational Attainment: College year level

Marital Status: Married

Number of Children: 6 (2B & 4G)

Nationality: Filipino

Religion: Roman Catholic

Date and Time of Admission: August 10, 2017 1:39 AM

V. CHIEF COMPLAINT: Surgical site infection

Admitting diagnosis: Surgical site infection S/P Ray Amputation 1st digit foot left

Final diagnosis: Surgical site infection S/P Ray Amputation 1st digit foot left

Other diagnosis: S/P disarticulation; 1st metatarsal; wound debridement

Type of Procedure done: Revision of flap

VI. HISTORY OF PRESENT ILLNESS

3 months PTC, patient felt pain on his big toe on his left foot and noticed it became reddish. But he just

ignore it. Until days passed, it started to develop into a wound. The patient just applied amoxicillin directly

into the wound twice a day as treatment.

2 months PTC, the patient experienced difficulty in walking because of the wound, he went for consultation.

He was then diagnosed with Diabetes Mellitus Type II. They discovered abscess in the wound. The doctors

scrapped the abscess and cleaned the wound. They prescribed him with Tramadol for pain and Metformin

for his high blood sugar levels. Patient didn’t take insulin at home due to financial constraints, however

patient uses herbal treatment such as ampalaya capsules and malunggay powder.

1 month PTC, The patient undergo a surgery which involves amputation of his big toe on his left foot due

to worsening of his condition. Patient was sent home two days after.

On day of admission, the patient was scheduled for a follow up care. Upon consultation, abscess was

observed in the surgical site. Patient was directly admitted to surgery ward.

VII. PAST MEDICAL HISTORY

- The patient had a bike accident last 2012 which resulted to a clavicle fracture that needed surgery.

- He also experienced a mild stroke for two times (2014, 2016) but recovered from unilateral paresis

which resulted from stroke.

- Diagnosed with hypertension on 2014.

- No known allergies to any food or medications.

VIII. PSYCHOLOGICAL HISTORY

The patient was not able to finish college, since after his second year in college he went home to

his province in Negros Occidental and helped in their farm. Usually the main stressors according to the

patient is his children. Patient copes with problems by thinking positive of the circumstances and focus on

ways to resolve the problem. He was able to communicate with appropriate emotions. There was no

manifestations of altered thought process.

IX. FAMILY HEALTH AND ILLNESS HISTORY

X. SOCIAL HISTORY

Patient D is a 61 year - old, Roman Catholic Male who is married and have six children (G38, G36,

G34, B31, G29 and B27). He is currently living in Paco, Manila with wife and his 3rd and 6th child together

with their own children. They are 8 in the house. Their house is made of wood and has two floors. The

patient used to work as a security guard of a convent on weekdays and on weekends he goes biking with

his friends as a stress reliever. Usually they bike to far places such as Antipolo, Baguio, Tagaytay.

According to him, he usually only sleeps for 3-4 hours, he explained that it is because he is aging. The

patient admitted that he is fond of eating sweet and salty foods, before he was diagnosed with DM. He is

not fond of fruits. He doesn’t smoke nor use any illicit drugs. He drinks alcohol occasionally but stopped a

year ago.
XI. PHYSICAL ASSESSMENT

General The patient was conscious, coherent and cooperative. He was oriented to person,

Survey place and time. He is properly groomed and there is no noted body odor. Facial

grimace noted due to pain of surgical site. The patient’s weight is 55kg and height is

160cm.

V/S:

BP: 140/80 mmHg Temp: 36.5 C PR: 81 bpm RR: 19 cpm

Integumentary The skin of the patient is not dry, good skin turgor noted. No presence of primary

lesions nor edema. Patient has dark brown non-elevated marks on right arm due to

previous IV insertion and on lower extremities due to biking accidents experienced.

Hair is thin and gray; no presence of lesions on scalp nor signs of lice

manifestation/dandruff. Patient’s nails have smooth texture, with a blanch test of < 3

seconds.

HEENT The facial features and movements are symmetrical. Patient’s head is normocephalic

and is proportionate with her body. No tenderness noted upon palpation. No

involuntary muscle movements. Pupils equally round reactive to light and

accommodation. Both eyes coordinated, move in unison with parallel alignment.

No tenderness in the ears upon palpation. The nares of the patient are patent. There

are no swelling, bleeding, and no lesions are noted. No discharge observed. There is

no tenderness during palpation of the frontal, ethmoidal, sphenoidal and maxillary

sinuses.
 Lips are moist and color pink with no lesions. Gums is color pink, moist and has a

firm texture. Patient has only 18 teeth at present. No retraction, swelling and bleeding

observed. No halitosis. No dentures.

The patient is able to move in full range of motion without complain of pain and

discomfort. No lesions observed. No masses palpated. Lymph nodes are not

inflamed. The patient’s thyroid gland is not enlarged and not tender upon palpation.

Thorax The patient’s collar bone is not equal on left side to the right side. The patient has a

regular and normal breathing pattern; quiet effortless and regular respirations. No

presence of lesions or tenderness during palpations of the abdomen.

Extremities The patient’s radial and brachial pulses were regular. Good range of motion was

noted in extremities except in lower left foot where surgical site infection is located.

No hand tremors noted. No edema observed.

Genitourinary Patient reports no pain in urinating or defecating. No presence of constipation nor

diarrhea.

XII. REVIEW OF SYSTEMS

General Survey

The patient is oriented to the three spheres (person, place and time). He is attentive and coherent

on the questions that are being asked to him and comprehensive in verbalizing his needs and problems.

Integumentary

“Masakit yung sugat ko, minsan naging 8/10” as verbalized by the patient.
HEENT

“Okay lang naman ang paningin ko, hindi naman ako nagsalamin,” as verbalized by the patient.

Patient also reported no hearing loss experienced and that he knows when he is hungry whenever he hears

a tingling-like sound. He also denies any complaint particularly pain and or tenderness and other

manifestations in his ears.

“Wala naman akong sipon o ubo”, as verbalized by the patient. The patient did not report any

serious problems and manifestations on his nose specifically pain and tenderness from his sinuses. The

patient has no pain and tenderness on his throat. Also, he reports that there were no experiences of difficulty

in swallowing and stiffness of his neck.

Central Nervous System

“Dalawang beses po ako na stroke, noong 2014 at 2016,” as verbalized by the patient. The patient

experienced unilateral paresis as a result of his mild stroke, but was able to regain strength on affected side

(right side). The patient manifested no signs of mental alteration. And he is fully aware of the following

questions and is conscious upon the interview.

Respiratory System

“Hindi naman ako nahihirapan huminga tsaka hindi naman sumisikip ‘yung dibdib ko,” as verbalized

by the patient. The patient doesn’t manifest any signs of respiratory distress or problem.

Cardiovascular System

“Nalaman ko na may high blood ako noong 2014 dahil nastroke po ako,” as verbalized by the client.

The patient reported that in his familial history, hypertension and heart diseases are common.

Gastrointestinal System

“Hindi naman ako nahihirapan dumumi araw-araw”, as verbalized by the patient. The patient did

not complain of any abnormalities in stool or epigastric pain.

Genitourinary System

“Okay naman ‘yung pag-ihi ko, wala namang sumasakit kapag umiihi ako”, as stated by the patient.

The patient denied having difficulty of urine elimination. The patient also reported that he always urinate a

big amount of urine (usually 1 cup/urination). No other abnormalities observed by patient.

Hematological System

The patient denies any history of easy bruising, anemia or eczema.

Musculoskeletal System

“Mahilig ako magbibike kasama mga friends ko, minsan pumupunta kami sa malalayong lugar

katulad ng Baguio. Pero sa ngayon, hindi ako makalakad dahil sa sugat ko,” as verbalized by the patient.

Patient is able to perform ROM on other extremities except on left foot.

XIII. GORDON’S 11 FUNCTIONAL PATTERN

Gordon’s Before Admission During Admission Interpretation

Functional

Pattern

How do you describe your health?

1. Pattern of “Kapag walang masakit sayo tsaka “Hindi na ako healthy kasi The patient was based

Health pag malakas ang katawan,” as masakit sugat ko,” as health on presence of

Perception verbalized by the patient. verbalized by the patient. discomfort/diseases.

and Health
How do you improve or maintain your health?
Management
“Palagi po ako nagbibike tuwing “Ngayon sinusunod ko lang The patient does

Linggo para mapanatilihing malakas yung utos ng doctor para what’s best for him to

mabilis po yung recovery

yung katawan ko," as verbalized by ko,” as verbalized by the maintain and improve

the patient. patient. his current health.

How do you link lifestyle choices and health?

Dati, mahilig ako kumain ng mga “Ngayon hindi na kasi may Based on the patient’s

pagkain na maalat tsaka matamis” as diabetes tsaka high blood condition, he has

verbalized by the patient. na po ako,” as verbalized improved her lifestyle

by the patient. choice.

How big is the problem in financing health care for you?

“Libre naman ang pagpapacheck-up “Medyo maraming gastusin Based on the patient’s

sa OPD kaso yung ibang meds ay ngayon pero hindi siya economic situation,

gastos namin. Hindi po ako nag ganun kalaking problema”, the patient decides on

insulin sa bahay, uminom lang ng as verbalized by the alternatives to lessen

mga herbal meds para bawas patient. cost regarding health

gastos,” As verbalized by the patient. care.

Can you name Medications you are taking and their purpose?

“Umiimon ako ng ampalaya capsules “Piptazo at Vancomycin Based on the patient’s

tsaka malunggay para sa diabetes para sa sugat; Tramadol at condition, he intakes

ko,” as verbalized by the patient. Paracetamol para sa sakit; more medicines than

tsaka Amlodipine and before.

Cloridine para sa high

blood,” as verbalized by the

patient.

What is your usual diet?

 “Mahilig po ako sa adobo tsaka “Ngayon naka-diabetic diet Patient has some

maalat na pagkain,” as verbalized by ako, bawal ako sa matamis restrictions in regard to

the patient. tsaka maalat,” as his food intake due to

verbalized by the patient. restrictions.

2. Nutritional

Metabolic How’s your appetite?

Pattern
“Malakas akong kumain dati,” as “Ngayon, careful na po ako Due to condition,

verbalized by the patient. sa kinakain ko, gusto ko patient is more aware

nang gumaling,” as and knowledgeable in

verbalized by the patient. the food he intakes.

3. Pattern of Usual bowel pattern? Frequency? Color?

Elimination
“Kadalasan, isang beses sa isang “Naiilang kasi ako dumumi Based on the patient’s

araw, minsan dalawa. Hindi ko dito tsaka hindi ako condition, the patient’s

pinansin yung kulay minsan, pero makalakad, kailangan ako bowel pattern has

wala naman problema sa dumi ko,” nang kasama,” as changed due to being

as verbalized by the patient. verbalized by the patient. uncomfortable

Do you experience any discomforts: pain, burning, and difficulty voiding? How do you

manage it?

“Hindi naman,” as verbalized by the “Hindi parin,” as verbalized No discomfort or

patient. by the patient. abnormalities

experienced.

Do you experience any discomforts diarrhea, constipation, bleeding?

“Hindi naman,” as verbalized by the “Hindi naman minsan lang The patient has no

patient. ako dumudumi ngayon na difficulty in defecating.

 nasa Ospital ako,” as

verbalized by the patient.

Do you perspire heavily, in what occasions/ conditions?

“Opo, kahit wala akong ginagawa, “Ganun pa rin” as Based on the patient’s

pinapawisan parin ako,” as verbalized by the patient. condition, he perspires

verbalized by the patient. when he’s not doing

any activities and this

did not changed.

How do you describe your weekly pattern of activity and leisure, exercise and recreation?

4. Pattern of “Nagbibike po kami tuwing Linggo,” “Ngayon hindi muna dahil Based on the patient’s

Activity and as verbalized by the patient. sa sugat ko, pero kapag condition, the patient

Exercise gumaling na ako, babalik pattern of activity

ako sa biking activities decreased due to

naming,” as verbalized by restrictions in moving.

the patient.

Do you have any disease that affects cardio-respiratory system or musculo-skeletal system?

“Dati wala naman” as verbalized by “Recently ko lang po Patient was not aware

the patient. nalaman na may Diabetes before of his health

tsaka high blood po ako,” condition of DM and

as verbalized by the HPN.

patient.

Do you experience fatigue/weakness, pain after the activity?

 “Hindi naman, nanghihina ako kapag “Hindi parin, nakakamiss na The patient’s activity

wala akong ginagawa kaya palagi nga magbibike,” as lessen because of his

ako naghahanap ng gagawin katulad verbalized by the patient. recent condition.

ng pagbibike” as verbalized by the

patient.

5. Cognitive Do you have sensory deficits (sight, smell, auditory, taste and vision)? Are they Corrected?

– Perceptual
“Sa pagkakaalam ko wala e,” as “Ganun parin,” as The patient’s is not
pattern
verbalized by the patient. verbalized by the patient. aware of any sensory

deficits.

Do you experience pain? How do you manage it?

“Noong una kong nakita na may “Minamasahe ko yung Patient manages pain

sugat ako sa paa ko, nilagyan ko bahaging itaas ng sugat ko by using relaxation

lang ng amoxicillin,” as verbalized by para mabawasan yung techniques such as

the patient. sakit na nararamdaman ko. cutaneous stimulation.

Tapos binibigyan naman

ako ng gamot para sa

sakit,” as verbalized by the

patient.

6. Pattern of Describe your sleep pattern?

sleep and
“Three hours lang tulog ko araw- “Madali akong magising, Based on the patient’s
rest
araw, siguro dahil tumatanda ako,” kapag sumakit yung sugat condition, sometimes

as verbalized by the patient. ko, minsan dalawang beses his sleep-wake cycle is

ako nagising,” as disturbed due to pain.

verbalized by the patient.

Do you feel tire upon waking up?

 “Hindi naman, malakas naman,” as “Hindi naman masyado,” as Patient doesn’t feel

verbalized by the patient. verbalized by the patient. tired after waking up.

7.Pattern of Do you think that there is anything unusual about your appearance and self?

self-
“Wala naman,” as verbalized by the “Hindi ko iniisip yan, iniisip Patient focuses on
perception
patient. ko lang na dapat gumaling getting well.
and self
ako para sa pamilya ko,” as
concept
verbalized by the patient.

Are you comfortable with your appearance?

“Ok naman,” as verbalized by the “Okay naman kahit Patient’s appearance

patient. naputulan po ako ng isang doesn’t upset patient

daliri sa paa, ipagpatuloy and his activities.

ko parin ang pagbibike pag

gumaling na ako,” as

verbalized by the patient.

How are you feeling?

“Ayos naman ako,” as verbalized by ”Okay naman ako ngayon, The patient feels okay

the patient. kumalma na po yung sakit since pain is at a low

dahil sa gamut,” as instensity.

verbalized by the patient.

What are your traits that you’re proud of?

“Mapagmahal sa pamilya tsaka sa “Positibo parin ako kahit The patient retained

mga kaibigan” as verbalized by the ganito nangyari sakin,” as, her good personality

patient. verbalized by the patient. and gained

confidence.
8. Role- How do you describe various roles in life?

Relationship
“Ako po yung bread winner ng family “Yung mga anak ko may Based on the patient’s
pattern
naming, lalo na noong maliit pa mga trabaho na, nagbibigay condition, His role as a

bata naming,” as verbalized by the naman sila ng pera pag breadwinner has been

patient. meron sila para sa gamut changed and now he

ko,” as verbalized by the is dependent on her

patient. family

Which relationship is most important to you?

“Pamilya ko po,” as verbalized by the “Ganun parin po, gusto nila Patient values his

patient. gumaling ako kaya gusto family and use this as

ko rin,” as verbalized by the his motivation to get

patient. recover.

9. Sexuality- Are you in a relationship? How many children do you wish/have?

Reproductive
“May asawa na po ako at meron “Ganun parin po,” as Has not changed.
pattern
kaming anim na anak,” as verbalized verbalized by the patient.

by the patient.

Can you say that you are sexually active?

“Hindi na kasi busy po sa trabaho “Hindi, kasi nasa ospital Because of the

tsaka matanda na po kami, iba yung eh,” as verbalized by the patient’s condition, his

priorities naming,” as verbalized by patient. sexual activity diminish

the patient.

Have you experience any discomforts in life? What condition brought it?
 “Normal naman magkaroon ng “Opo, dahil sa sugat ko, pero The patient views

problema, pero lahat ng hindi po ako nawalan nang pag- discomfort as a normal

problema may solusyon,” as asa, gagaling din ako,” as stressor in life.

verbalized by the patient. verbalized by the patient.

How do you usually cope with problems?

10. Pattern

of coping “Lahat ng problema may “Positibo lang sa buhay,” as Patient shows to have

and stress solusyon,” as verbalized by the verbalized by the patient. a positive outlook in

tolerance patient. life.

To whom would you go if you have problems?

“Sa pamilya tsaka mga kaibigan “Ganun pa rin,” as verbalized by Has not changed

ko po,” as verbalized by the the patient.

patient.

11. Values- What principle in life did you learn as a child? Do you think it’s important?

Belief pattern
“Siguro sa pagiging mabait at “Ganun parin, naniniwala ako na Has not changed

makadiyos. Opo, mahalaga po gagaling ako sa tulong ng Diyos.

ang pagiging mabait sa kapwa Wag tayo mawalan ng pag-asa,”

tsaka makadiyos,” as verbalized as verbalized by the patient.

by the patient.

What support systems do you have?

“Yung asawa ko tsaka mga “Sila parin,” as verbalized by the Has not changed

anak namin,” as verbalized by patient.

the patient.
XIV. ANATOMY AND PHYSIOLOGY

Anatomy & Physiology of the Pancreas

The pancreas is an organ that stretches partway across the abdomen, just below the stomach. Because its

main functions are to aid digestion and produce hormones that control blood glucose levels, the pancreas

is a focal point for understanding diabetes.

In addition to secreting certain enzymes that help you properly digest food, the pancreas manufactures

hormones that regulate blood glucose - the fuel that provides the body's cells with energy. Scattered

throughout the pancreas are tiny nests of cells known as islets of Langerhans; the majority of the cells are

beta cells that produce and store the hormone insulin until needed. Also located in the islets are alpha cells,

which make and store glucagon, a hormone that counteracts the effects of insulin.

After a meal, carbohydrates in foods are converted into glucose in the intestine and liver and enter the

bloodstream. Beta cells sense the rising blood glucose levels and secrete insulin into the blood. Once in

the bloodstream, insulin helps glucose enter the body's cells, where it can be "burned" by the liver and

muscles for energy. Liver and muscles can also convert glucose to glycogen, a type of reserve form of

energy that is stored there for future needs. When the body is working as it should, blood glucose levels

quickly return to normal, and insulin secretion decreases.

A drop in blood glucose levels - for example, when one hasn't eaten for several hours - stimulates an

opposite effect: alpha cells secrete glucagon into the blood, which converts stored glycogen back into

energy-producing glucose.

Normally, the secretion of these hormones by the pancreas is perfectly balanced: Beta and alpha cells

continuously monitor blood glucose levels and release insulin or glucagon as needed. In diabetes, this

balance is thrown off because beta cells produce little or no insulin or the body's cells are resistant to insulin

action - or often both. Glucose then fails to enter cells effectively and the fuel for energy remains stuck in

the bloodstream. The result is persistently high blood glucose levels (hyperglycemia). Without treatment,

hyperglycemia can lead to serious long-term complications, such as eye, kidney, and heart disease and

damage to nerves.

XV. PATHOPHYSIOLOGY

DISEASE PROCESS AND ITS EFFECTS

XVI. LABORATORY RESULTS AND ANALYSIS

RADIOLOGICAL REPORT

Requested procedure: CHEST PA, FOOT AP/O

 CALCIFIED PEDAL BLOOD VESSEL

 S/P RESECTION LEFT 1ST MID TARSAL BONE

 OLD FRACTURE, LEFT CLAVICLE

 DEXTROSCOLIOSIS

 TORTUOUS ATHEROMATOUS AORTA

HbA1C

SPECIMEN: BLOOD

TEST RESULT NORMAL VALUE INTERPRETATION

HbA1C 7.7 4.3 – 6.4 % Indicates Diabetes Mellitus

(2X DONE)

COMPLETE BLOOD COUNT

Test Reference Result Analysis

Angle September and Interpretation

15, 2016 (AM)

WBC 5.2-12.4 11.3 Normal

Neutrophils 40-74 84.1 Above Normal.

According to Lab Tests Online, it is known as

neutrophilia. Examples causes of a high count

 may be acute bacterial infections, inflammation,

trauma, heart attack, or burns, stress, rigorous

exercise, certain leukemias (e.g., chronic myeloid

leukemia) and cushing syndrome

Lymphocytes 19-48 10.8 Below Normal

Increase risk of infection

Monocytes 3.4-9 5.1 Above Normal

Usually not significant

Neutrophils 40-74 84.1 Above Normal

Indicates a bacterial infection

RBC 4.2-6.1 3.70 Below Normal

May indicate anemia

HGB 12-18 10.7 Below Normal

May indicate anemia

HCT 37-42 32.3 Below Normal.

According to Lab Tests Online, it usually mirrors

RBC results which known as anemia. Example

causes of a low count may be acute or chronic

bleeding, RBC destruction (e.g., hemolytic

anemia, etc.), nutritional deficiency (e.g., iron

deficiency, vitamin B12 or folate deficiency), bone

marrow disorders or damage, chronic

inflammatory disease and chronic kidney

disease.

MCV 73-85 87.3 Above Normal.

 According to Lab Tests Online, it indicates RBCs

are larger than normal (macrocytic), for example

in anemia caused by vitamin B12 or folate

deficiency, myelodysplasia, liver

disease, hypothyroidism

MCH 27-31 29.0 Normal

MCHC 32-36 33.2 Normal

RDW 11.5-14.5 12.8 Normal

Platelet 150-450 391 Normal

BLOOD CHEMISTRY

Test Results Unit Reference Flag

BUN 6.16 mmol/L 1.70 – 8.30 Normal

Creatinine 108.5 mmol/L 69.0 - 104.0 Above Normal

According to Newport Natural

Health, the kidneys process this

waste product, so elevations could

indicate a problem with kidney

function.