CHEST AP PORT (Sitting)

November 13, 2010 @ 11 pm

REPORT NURSING CONSIDERATIONS

 Diffuse hazy infiltrates seen all over Pretest:

both lungs, more on the left,
homogenous densities likewise • Make s sure the patient has
demonstrated in both basolateral
hemothothorax the signed an appropriate
 Showed bilateral pulmonary
densities with progression of the consent form
hemothorax. Homogenous density
was noted with progression of the • Explain the procedure that
left lower hemithorax. However,
the left upper zones showed air the patient will ask to deep
bronchospasm pattern.
 The trachea was slightly shifted to breath
the left. Ribbon like homogenous
density seen at the periphery of the • Explain the procedure is
right lung. The heart was
persistently obscured including the taken less than 5 minutes
diaphragm. The bony thorax is
normal. Implementation:

• The patient is instructed to

IMPRESSION:
stand in the front of the
BILATERAL DIFFUSE PTB with
BILATERAL SMALL PLEURAL
stationary radiography
FLUID more on the LEFT
board or machine

• Check that no tube have

been dislodge during the

procedure or positioning

• Place an lead apron over the

patient to avoid radiation

• Provide privacy to the client

 X-RAY
November 14, 2010 @ 2:10 pm

REPORT:

 Scans of both hemithoraces shows bilateral small pleural fluid, more on the left.
Estimated fluid collection on the right hemothorax is about 300-330cc and about
350-370cc on the left.
 Thick septations demonstrated on the left
 The underlying lungs are partially collapsed with no definite pulmonary mass
lesions.
 Diaphragm is high set
 No other significant findings

IMPRESSION:

BILATERAL SMALL PLEURAL FLUID, MORE with SEPTATIONS on the

LEFT

November 19, 2010 @ 11 pm

IMPRESSION:

 Diffuse PTB
 Opacified Hemothorax, suggesting left pleural effusion at the base . However,
parenchymal consolidation was noted at the left upper lobe suggestive for
consolidative pneumonia, left upper lobe.
 Minimal pleural fluid , pleural thickening, right

CHEST ULTRASOUND
November 20. 2010 @ 3:30 pm

- Follow-up sonographic evaluation showed very small amount of right pleural fluid seen
at the posterior costophrenic, <500cc, with adjacent pleural thickening. This suggest
regression of the right pleural fluid.

- The left pleural space showed pleural fluid collection with thick septations and pleural
thickening with estimated total volume of 400cc. The largest fluid compartment seen at
the postero-basal area, measures 800cc. Very minimal progression of the located left
pleural effusion (from initial of 370cc to 400cc total volume of the compartments).

- The adjacent lower lung is heterogeneously atelectic but no parenchymal mass seen.
Suggestive consolidation of the upper lobe.

- Negative for pericardial effusion

- Both hemodiaphragms are intact. The spleen is at the upper limits of normal size.
However, the liver was enlarged with increased parenchymal echogenecity, suggesting
difduse parenchymal disease. Presence of moderate amount of ascites.
 ULTRASOUND (WHOLE ABDOMEN)
August 9, 2010 @ Northern Mindanao Medical Center, CDO
Requested by: Dr. Magsayo

Findings:

The liver is normal in size but with granular echogernic parenchyma. No mass or
calcification seen. The liver margin is smooth. Intrahepatic bile ducts and common bile
duct are non-dilated. Gallbladder is normal in size. Its wall is thickened to 4.0mm. no
intraluminal mass or lithiasis seen.

Pancreas and spleen are unremarkable. No focal mass lesion seen. Abdominal
aorta is unremarkable. No stone mass nor caliectasis noted. Urinary bladder empty

The uterus measure 5.4cmx3.4cmx3.0cm with endometrial thickness of 4.0mm.

myometrium is homogenous. No mass seen. Cervix is unremarkable.

Right and left ovaries measure 3.1cmx 1.8cm and 2.6cmx2.0cm. atleast 4 follicles are
seen in the right and 2 follicles are seen in the left. The largest follicle in both ovaries
measure 1.0cmx1.0cm.

Small non-sepated fluid collections are seen in perihepatic parisplenic hepatorenal and
splenorenal spaces. Massive fluid c thin septations is seen in the lower abdomen and
pelvic cavity. Fluid seen in right basal hemithorax.

DIAGNOSIS:

• Diffuse liver parenchymal disease. Cannot rule out early liver cirrhosis.
• Massive ascites with thin septations at the lower abdomen and pelvic cavity
• Thickened gallbladder wall likely reactive cholecystitis
• Non-remarkable ultrasound findings in the pancreas, spleen, abdominal aorta,
kidneys, uterus and ovaries
• Empty urinary bladder
• Pleural effusion, right

NURSING CONSIDERATIONS

Preparation:
- Make sure the patient or SO has signed an appropriate consent form
- Note and report any allergies
-Let patient eat a light fat free meal at dinner
- Instruct patient to NPO after midnight

Patient Care:
- let patient resume his usual diet after the test
 ULTRASOUND (PELVIC)
August 2, 2010 @ Amai Pakpak Medical Center, Marawi City

FINDINGS:

Uterus is anteverted and measures 4.03cmx3.73cmx4.58cm (LxAPxW).

Myometrium is homogenous. Endometrium is distinct and echogenic and measures
0.50cm. no mass or calcification.

Massive fluid is seen throughout the abdominal cavity

Incidental note of contracted liver with course echogenic parenchyma

IMPRESSION:

• Sonographically normal uterus

• Massive ascites
• Incidental note of contracted liver

NURSING CONSIDERATIONS

Preparation:
- Make sure the patient or SO has signed an appropriate consent form
- Note and report any allergies
- Instruct the patient to drink fluids and avoid urinating before the test because pelvic
sonography requires a full bladder as a landmark to define pelvic organs

Patient Care:
- Allow the patient to void right after the test