URINALYSIS

Date performed: May 11, 2019

TEST NORMAL PATIENT’S INTERPRETATION

VALUES RESULT
RBC 0-11 1.3
WBC 0-11 4.4
Epithelial cells 0-17 13.5
Bacteria 0-111 116.7 H Presence of bacterial
infection
Mucus Thread 0-1 0.4
Color Light yellow/Clear Light yellow
Transparency Clear Clear
pH 5-8 6.5
Specific Gravity 1.002-1.030 1.015
Protein Negative Negative
Glucose Negative Negative

HEMATOLOGY

Date performed: May 11, 2019

TEST NORMAL PATIENT’S INTERPRETATION

VALUES RESULT
WBC 4-15 9.0
RBC 3.8-5.9 4.0
Hemoglobin 113-130 117
Hematocrit 0.35-0.40 0.36
MCV 80-100 88.9
MCH 27-31 29.1
MCHC 31-36 32.7
RDW 0.115-0.150 0.126
Platelet 150-450 446
Segmenters 0.40-0.48 0.82 H Presence of bacteria
Lymphocytes 0.40-0.48 0.12 L Lymphocytopenia
Monocytes 0.05-0.10 0.04 L Monocytopenia
Eosinophils 0.02-0.05 0.02
Basophils 0.00-0.001 0.00

X-RAY FINDINGS

Shows hazy densities both lower lung fields

The heart is not enlarged
Both hemidiaphragms are sharp and distinct
The trachea lies in the midline
The visualize osseous and soft tissue structures are unremarkable

Impression:
Pneumonia; both lower lung fields
 DISCHARGE PLAN

MEDICATIONS:
Give the following prescribed medications at the right time, dose, frequency and route.

ENVIRONMENT:
Encouraged to maintain a safe home free from any hazards such as sharp objects, chemicals and
matches
Encouraged to maintain cleanliness of the house and surroundings
Encouraged to provide a well ventilated area

TREATMENT:
Encourage to have a good sleeping time and adequate nutrition
Reminded to always assess patient needs
Reminded to have a follow up check-up at attending physician’s clinic one week after discharge

HEALTH TEACHINGS:
Instructed to observe proper hygiene such as bathing the daily to keep from infection
Instructed to keep the patient always clean and dry
Instructed to do hand washing before and after contact with patient
Instructed not to take the patient to crowded places to prevent risk of having infection
Instructed to give medications at the right route, dose and time

OBSERVABLE SIGNS AND SYMPTOMS:
 Fever
 Chills
 Cough
 Unusually rapid breathing
 Breathing with grunting or wheezing sounds
 Labored breathing that makes a child’s rib muscles retract 
 Vomiting
 Chest pain
 Decreased activity
 Loss of appetite (in older children) or poor feeding (in infants)in
extreme cases, bluish or gray color of the lips and fingernails

DIETS:
Encouraged to follow diet prescribed by the doctor
Encouraged increased oral fluid intake
Encouraged to eat green leafy vegetables such as “malunggay”, “kangkong”, and “petchay”
DIAGNOSTIC AND LABORATORY
RESULT