Diagnostic Significance/Purpose of the

Description of the Procedure Findings &Implications

Procedure Procedure

Chest X-ray An X-ray is an imaging test that It is used to determine the severity of Follow-up study of the chest taken since 03-07-19, There is
uses small amounts of radiation to the patient’s pneumothorax and to minimal progression of the right sided pleural effusion with
produce pictures of the organs, determine the progress of his medical interfissural extension, Stationary findings of the previously
tissues, and bones of the body. and surgical management. noted edema with probable pneumonia in both lungs, The
When focused on the chest, it can cardiac size is not properly assessed due to overlying opacity,
help spot abnormalities or diseases Aortic arch is atherosclerotic, Pulmonary vascular markings are
of the airways, blood vessels, prominent and cephalized, The left costophrenic sulcus is now
bones, heart, and lungs. Chest X- blunted which may represent minimal pleural effusion.
rays can also determine if you have
fluid in your lungs, or fluid or air Comparative of the chest since 03-09-19, there is partial
surrounding your lungs. diminution of the right sided pleural effusion, Partial clearing of
the previously noted edema and/or pneumonia in both lungs,
The heart appears enlarged, aortic arch is atherosclerotic,
Pulmonary vascular markings are less prominent, The left
hemidiaphragm and costophrenic sulcus are intact, No other
significant chest findings noted.

Comparative of the chest since 03-13-19, stationary findings of

the previously noted edema and/or pneumonia in both lungs, No
interval change in the right sided pleural effusion, the heart still
appears enlarged, aortic arch is atherosclerotic, Pulmonary
vascular markings ar less prominent, The left hemidiagphragm
and costophrenic sulcus is intact, No other significant chest
findings noted.

Comparative of the chest since 03-16-19, there is no significant

change in previously noted edema and/or pneumonia in both
 lungs, No interval change in the right sided pleural effusion,
Thick linear density in the right middle lobe which may suggest
thickened minor fissure, the heart still appears enlarged, Aortic
arch is atherosclerotic, Pulmonary vascular markings remain
perminent.

Chest Ultrasound A Chest ultrasound is a noninvasive Chest Ultrasound is used to detect Follow-up study of the hemothrorax taken on the same day
diagnostic exam that produces small amount of pleural locular fluid. shows free fluid collection in the left pleural cavity with an
images, which used to assess the approximate volume of +/- 340cc with secondary right lower
organs and structures within the lobe atelectasis, Trace of fluid collection is also noted in the
chest, such as the lungs, right pleural cavity.
mediastinum and pleural space.

Diagnostic procedure and Description of procedure Significance/ Purpose of the Significant findings Nursing Implications
date done procedure

Complete Blood Count A CBC may be ordered when a To determine general health status, Hemoglobin A low hemoglobin
person has any number of signs and screen, diagnose, or monitor any indicates that the patient
March 9, 2019 symptoms that may be related to one of a variety of diseases and Normal Range: has an anemia
disorders that affect blood cells. conditions that affect blood cells,
140-180 g/L
When an individual has an infection, such as anemia, infection,
inflammation, bruising, or bleeding, inflammation, bleeding disorder or Result:
a doctor may order a CBC to help cancer.
diagnose the cause and/or determine 111g/L - Low
its severity.
Hematrocrit A low hematrocrit indicates
that the patient has an
Normal Range: anemia
0.40-0.54 L/L

Result:

0.34 L/L - Low

Leucocyte (WBC) Within the normal range.

Normal Range:

55.0-10.0

Result:

6.58 - Normal

Neutrophils Indicates that the body has

infection.
Normal Range:

50-70 %

Result:

73 - High

Lymphocytes Indicates that the body has

infection.
Normal Range:

20-40%

Result:
14 - Low

Basophils Within the normal range.

Normal Range:

0-1%

Result:

1 - Normal

Monocytes Indicates that there is an

infection.
Normal Range:

0-10%

Result:

11 - High

Eosinophils Within the normal range.

Normal Range:

0-7%

Result:

1 - Normal

RBC Count A low RBC count

indicates that the patient
Normal Range:
 4.69-6.13 10^12/L has an anemia

Result:

4.18 - Low

Platelet count Within the normal range.

Normal Range:

150-400x10^9/L

Result:

331- Normal

Arterial Blood Gas An arterial blood gas test measures Used to check how well your lungs pH Indicates that the blood is
the amounts of arterial gases, such as are able to move oxygen into the more Alkalotic
March 10, 2019 oxygen and carbon dioxide. blood and remove carbon dioxide Normal Range:
from the blood.
7.35-7.45

Result:

7.53 - High

PCO2 Indicates that there is

respiratory acidosis
Normal Range:

35-45 mmHg

Result:
 28.1 mmHg - Low

HCO3 Within the normal range.

Normal Range:

22-26 mmol/L

Result:

23.1 mmol/ L -
Normal

Urinalysis Urinalysis can reveal diseases that Urinalysis or urine testing is used Color
have gone unnoticed because they to look for abnormalities such as an
March 09, 2019 do not produce striking signs or excess amount of protein, blood, Light Yellow
symptoms. Examples include pus, bacteria or sugar. A urine test Appearance
diabetes mellitus, various forms of can help detect a variety of kidney
glomerulonephritis, and chronic and urinary tract disorders, Slightly Turbid
urinary tract infections. including chronic kidney disease,
diabetes, bladder infections and Specific Gravity Indicates Hyposthenuric
kidney stones.
Normal Range:

1.010-1.035

Result:

1.009- Low

pH Within the normal range.

Normal Range:
4.5-8.0

Result:

7.5

Leukocyte esterase

Negative

Nitrites

Negative

Protein

Negative

Glucose

Negative

Ketones

Negative

Urobilinogen

Normal

Bilirubin

Negative
 Erythrocyte

Negative

Pus cells Indicates inflammation

1-3/hpf

Bacteria

Rare/hpf

Epithelial cells

None/hpf

Routine Chemistry Clinical chemistry (also known Routine chemistry is used to Blood Urea Indicates that the kidneys
as chemical pathology, clinical confirm or reject a diagnosis, Nitrogen are not able to remove the
March 09, 2019 biochemistry or medical provide guidelines in patient urea from the blood.
biochemistry) is the area management, establish a prognosis, Normal Range:
of chemistry that is generally detect disease through case finding
2.8-7.2 mmoll/L
concerned with analysis of bodily or screening and to monitor follow-
fluids for diagnostic and therapeutic up therapy Result:
purpose
28.7 mmol/L - High

Creatinine Within the normal range.

Normal Range:

64-104 umol/L
Result:

4498.12 umol/L -
Normal

SGOT/AST Indicates that the liver or

another organ that produces
Normal Range: enzyme is damaged
< 50 U/L

Result:

468.70 U/L - High

SGPT/ALT Indicates that the liver may

be injured or irritated
Normal Range:

< 50 U/L

Result:

92.02 U/L - High

Sodium Within the normal range.

Normal Range:

136-145 mmol/L

Result:
 137.5 mmol/L -
Normal

Potassium Within the normal range.

Normal Range:

3.5-5.1 mmol/L

Result:

3.97 mmol/L -
Normal

Prothrombin Time / Prothrombin Time: Prothrombin Time: Patient: Fast blood clotting
Partial
A prothrombin time (PT) test Prothrombin test is used by doctors Normal Range:
Thromboplastin measures the amount of time it takes to help them diagnose a patient
for your blood plasma to clot. with blood disorder. 12.2-14 seconds
March 13, 2019 Prothrombin, also known as factor
Result:
II, is just one of many plasma
proteins involved in the clotting 14.30- High
process.
Control: Within the normal range.

Normal Range:

11.5-15.5 seconds

Result:

14.40- Normal
Partial Thromboplastin: Prothrombin Time: Patient: Within the normal range.

The partial thromboplastin time (PT Prothrombin test is used by doctors Normal Range:

T) test is a blood test that is done to i to help them diagnose a patient
nvestigate bleeding disorders and to  with blood disorder. 2.5.8-34.8 seconds
monitorpatients taking an anticlottin
Result:
g drug (heparin).
3.90- Normal

Control: Within the normal range.

Normal Range:

24-32 seconds

Result:

31.50- Normal