II.

PATIENT PROFILE

Ward: Manila Health Center
Date of Admission: 22
nd
of May 2014
Pt. Name (Initials): J.C.
Address: 2728 Lamayan St. Sta. Ana, Manila
Age: 27 years old
Gender: Female
Date of Birth: November 20, 1987
Educational Status: High School Graduate
Religion: Catholic
Nationality: Filipino
Civil Status: Married
Occupation: Helper
Health Care Financing: N/A
Informant: Self
Reliability: 100%

Admission Data

1. Chief Complaint: Neck mass
2. Initially Diagnosis: Non-toxic goiter
3. Final Diagnosis: Non-toxic goiter
4. Attending Physician:



















IX. DIAGNOSTIC PROCEDURES / LABORATORY RESULTS

Complete Blood Count (CBC)
The most commonly performed blood test is the complete blood count, which is a
basic component of cellular components of blood (RBC, WBC, and platelets).
Automated machine perform this test in less than one minute on a small drop of blood.
The CBC is supplemented in most instances by examination of blood cells under a
microscope.
The CBC determines the number of red blood cells and the amount of
hemoglobin in the blood. In addition, the size of red blood cells is usually assessed and
can alert laboratory workers to the presence of abnormally shaped red blood cells
(which may then be further characterized by microscopic examination). Abnormal red
blood cells may be fragmented or shaped like tear drops, crescents needles, or a
variety of other forms. Knowing the specific shape or size of red blood cells can help a
doctor diagnosed a particular cause of anemia. For example, sickle shaped cells are
characteristic of sickle cell disease, small cells containing insufficient amount of
hemoglobin may signal iron deficiency anemia and large oval cell suggest anemia due
to folic acid or vitamin B12 deficiency (pernicious anemia).
After putting together the information about number, size, and shape of red blood
cells, a doctor might order additional tests to evaluate the cause of an anemia. These
include tests for increased red blood cell fragility, abnormal types of hemoglobin, and
the quantities of certain other substances contain within red blood cells.
The CBC also determines the numbers of white blood cells. The specific type of
white blood cell can be counted (differential white blood cell count) when a doctor needs
more detailed information on a persons condition. If the total number of white blood
cells or the number of one of the specific types of white blood cells is above or below
normal, the doctor can examine these cells under a microscope. The microscopic
examination can identify features that are characteristic of certain diseases. For
example, large number of white blood cells that have a very immature appearance
(blasts) may suggest leukemia (cancer of the white blood cells).
Platelets are usually counted as a part of CBC. The number of platelets is an important
measure of the bloods protective mechanism for stopping (clotting). A high number of
platelets (thrombocytosis or thrombocypenia) can lead to blood clots in small blood
vessels, especially those in the heart or brain.
Reference:
The Merck Manual of Medical Information by Mark H. Beers M.D., 2
nd
Home Edition pp.
888-889

PARAMETERS RESULT NORMAL
VALUES
Interpretation Analysis
Hemoglobin
- To detect
anemia in a
client with
bleeding after
trauma or
surgery
124 gm/L 120-180 Normal -hemoglobin is
within a
normal level
provides
proper
oxygenation of
the cell
Hematocrit
- Measures the
percentage of
red blood cell
in the total
blood volume
.376 0.370-0.540 Normal -the
percentage of
red blood cells
in a total blood
volume is
within a
normal range
Leukocyte
- Determines
5.8x10
9
/L 4.6-10.0 Normal -the number of
leukocyte
the number of
circulating
WBCs per
cubic
millimeter of
whole blood
count is within
a normal
range for
defense to
microorganism
DIFFERENTIAL
COUNT
Segmenter
- type of mature
white blood
cell






Lymphocytes
-A small white blood
cell (leukocyte) that
plays a large role in
defending the body
against disease,
responsible for
immune responses.



Platelet Count
- Important

.62








.35










306x10
9
/L

.60-.70








.20-.40










150-450

Normal








Normal










Normal

-0.62 means
that they
made up 62%
of the WBCs
you had in
your system
when you
were tested.

-indicates no
presence of
viral
infections.







-no active
bleeding and
can prevent
hemorrhage.
measure of
the bloods
protective
mechanism for
stopping
bleeding
(clotting)









-


URINALYSIS
Urinalysis can be used to detect and measure the level of variety of substances
in the urine, including protein, glucose, ketones, blood and other substances. This test
use a thin strip of plastic (dipstick) impregnated with chemicals that react with
substances in the urine and change color. Sometimes the test results are confirmed
with more sophisticated and accurate laboratory analysis of the urine. The urine is
examined under a microscope to check for the presence of the red and white blood
cells. Crystals, casts.
Protein: Protein in the urine (proteinuria) can usually be detected with dipstick. Protein
may appear constantly or only intermittently on the urine, depending on the cause.
Proteinuria is usually a sign of kidney disorders, but it may occur normally after
strenuous exercise such as marathon running.
Glucose: Glucose in the urine (glucosuria) can be accurately detected by dipstick. The
most common cause of glucose in the urine is diabetes mellitus. If glucose continues to
appear in the urine while glucose levels in the blood are normal, impaired reabsorption
of glucose by the kidney tubules (renal glucosuria) is the cause of glucosuria.
Ketones: Ketones in the urine (ketonuria) can be detected by dipstick. Ketones are
formed when body breaks down fat. Starvation, uncontrolled diabetes mellitus, and
occasionally alcohol intoxication can produce ketones in the urine.
Blood: Blood in the urine are (hematuria) is detectable by dipstick and confirmed by
viewing urine with a microscope and other tests. Sometimes the urine contains enough
blood to be visible, making the urine appear red or brown.
Nitrates: Nitrates in the urine are (nitrituria) is detectable by dipstick and confirmed by
viewing urine with a microscope and other tests. Sometimes the urine contains enough
blood to be visible, making the urine appear red or brown.
Leukocyte Esterase: Leukocyte esterase (an enzyme found in certain white blood
cells). In the urine can be detected by dipstick. Leukocyte esterase is a sign of
inflammation, which is most commonly caused by UT.
Acidity: The acidity of urine is measured by dipstick. Certain foods and metabolic
disorders may change the acidity of the urine.
Concentration: The concentration of the urine (also called the osmolality or specific
gravity) may be important in diagnosing abnormal kidney function. The kidneys lose
their capacity to concentrate urine at an early stage of a disorder that leads to kidney
failure. In one special test, a person drinks no water or other fluids for 12-14 hours; in
other, a person receives an injection of antidiuretic hormone. Afterward, urine
concentration is measured. Normally, either test should make the urine highly
concentrated. However, in certain kidney disorders (such as nephrogenic diabetes
insipidus) the urine cannot be concentrated even though other kidney functions are
normal.
Sediment: Sediment in urine can be examined under a microscope to provide
information about a possible kidney or urinary tract disorder. Normally, urine contains a
small number of cells and other debris shed from inside of the urinary tract. A person
who has kidney or urinary tract disorder usually sheds more cells, which form a
sediment if the urine is centrifuge or allowed to settle.
Urine cultures: Urine cultures, in which bacteria are grown in a urine sample in a
laboratory, are perform to diagnose a urinary tract infection. The sample of urine must
be obtained by the clean-catch method. Other methods to obtain an uncontaminated
urine sample include passing a catheter through the urethra into the bladder or inserting
a needle through the abdominal wall into the bladder (suprapubic needle aspiration).

URINALYSIS CELLS CHEMICAL TEST

Color: Yellow
Transparency: Clear
Reaction: 5.0
Specific Gravity: 1.020

RBC: 0-1/hpf
Pus Cells: 0-1 hpf
Squamous Cells: few
Bacteria: (-)


Albumin: negative
Sugar: Negative


RADIOLOGY
Ultrasound (Sonogram)
Ultrasound uses high-frequency sound waves to look at organs and structures
inside the body. Health care professionals use them to view the heart, blood vessels,
kidneys, liver and other organs. During pregnancy, doctors use ultrasound tests to
examine the fetus. Unlike x-rays, ultrasound does not involve exposure to radiation.
During an ultrasound test, a special technician or doctor moves a device called a
transducer over part of your body. The transducer sends out sound waves, which
bounce off the tissues inside your body. The transducer also captures the waves that
bounce back. Images are created from these sound waves.
Xray
X-rays are a form of electromagnetic radiation, just like visible light. In a health care
setting, a machines sends are individual x-ray particles, called photons. These particles
pass through the body. A computer or special film is used to record the images that are
created.
Structures that are dense (such as bone) will block most of the x-ray particles, and will
appear white. Metal and contrast media (special dye used to highlight areas of the
body) will also appear white. Structures containing air will be black, and muscle, fat, and
fluid will appear as shades of gray.

Examination Thyroid
Right Lobe 4.5x1.1 x1.9 cm
Isthmus 0.1 cm
Left Lobe 4x1.0x1.8 cm

Both lobes and isthmus are normal in size with smooth contour and homogenous
parenchyma.

Three lesions are noted in the right lobe:
a) Two small thin walled cystic, anechoic lesion are noted in the mid aspect of
the right lobe with transverse diameter of 0.4 cm
b) Complex mass in the right inferior pole, predominantly cystic with a 0.60 cm-
echogenic focus in its superior aspect. The lesion measure
0.67x0.74x0.61cm.
No focal/diffuse solid or cystic lesions in the left lobe and isthmus.


Impression:
- Normal sized Thyroid Gland
- Cystic and complex nodules, RIGHT



IMMUNULOGY-SEROLOGY-ENDOCRINE REPORT

TSH test
The TSH test is often the test of choice for evaluating thyroid function and/or symptoms
of hyper- or hypothyroidism. It is frequently ordered along with or preceding a T4 test.
Other thyroid tests that may be ordered include a T3 test and thyroid antibodies (if
autoimmune-related thyroid disease is suspected).
TSH testing is used to:
diagnose a thyroid disorder in a person with symptoms,
screen newborns for an underactive thyroid,
monitor thyroid replacement therapy in people with hypothyroidism
diagnose and monitor female infertility problems,
help evaluate the function of the pituitary gland (occasionally), and
screen adults for thyroid disorders, although expert opinions vary on who can
benefit from screening and at what age to begin.

Examination Result Normal Values Interpretation
TSH 1.89 0.27-4.20 Normal
Free T3 3.47 2.02-4.43 Normal
Free T4 1.21 0.93-1.71 Normal






X. COURSE IN THE WARD
5/22/14

Left Neck R/o Goiter, non-toxic
Patient for Lab work
Paracetamol
TCB with results

5/22/14

26 years old
BP = 100/70
T = 37.00

Bukol sa leeg (Left side 1 year)
Medecine taken biogesic
CMD: 5/21/14

5/26/14
Goiter, non-toxic
Patient referto PGH-OPD endocrinology for possible biopsy
26 years old
BP = 90/60
T = 36.5
For follow up (-) Fever
Lab resulot






XIV DISCHARGE PLANNING
M (MEDICATION)

Advise patient to take the prescribed medications continuously at home
Always check the expiration date of the medicine before taking
Teach the patient on how to take the medicine in the right time, right dose and right route
as prescribed by the physician.

E (EXERCISE & ACTIVITY)

Promote a calm and clean environment
Encourage the relative to promote good ventilation and free from pollution
environment
Avoid crowded areas, especially during cold and flu season
Avoid strenuous activities
Light exercise such as walking, deep breathing and coughing exercise are
recommended

T (TREATMENT)

Eating a healty diet (eating more fruits, vegetables, and low fat dairy products,
less saturated and total fat
Reducing the amount of sodium in your diet to 2300 milligrams (about 1
teaspoon of salt) a day or less
Advise the patient to avoid smoking area and avoid alcohol beverages intake.

H (HEALTH TEACHING)

Instruct patient to comply with the take home medications that would be given by
her physician. Remind her to complete the full course of the antibiotic treatment.
Encourage patient to do the recommended light exercises such as walking. Avoid
doing strenuous activities
Encourage him to comply with the dietary modifications; moderate the intake of
iodine rich food
Explain to patient to refer for unusual signs and symptoms of any untoward
feelings immediately regarding to her condition

O (OUT PATIENT FOLLOW UP)

Advise the patient to have a monthly check-up to a physician.
Encourage the patient for the compliance of her take home medications.
Encourage the patient to maintain her healthy condition.


D (DIET)

Advise the patient to eat foods rich in iodine, like sea foods & nutritious foods that will
make her healthy.
Advise the client to have a proper diet and adequate fluid intake.

S (SPIRITUALITY)

Provides emotional support coming from family. Encouraged the patient to participate in
the community services to promote social supportive relationship.
Provide safety by keeping things in the right place specially those which can injured.
-Encourage the relatives to be sensitive enough about the things that can harm the
patient.
-Be careful all the time.