TANCHULING COLLEGE, INC.

College of Nursing
Imperial Court Subdivision, Phase II,
Legazpi City 4500 Philippines
Tel. # (052) 480-6106/(052) 742-0098
http://www.tanchuling.edu.ph

CASE PRESENTATION

GROUP 2

Members:
Alipin, Mary Salvi A.
Ferrer, Danella Mae S.
Magcalas, Adriana
Nato, Charm O.
Riňon, Alliyah Mae E.
BSN 2E

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 CASE PRESENTATION

PART 1 Introduction

PART II The Profile- Present and Past History

Patient’s profile
1. Identification Data:
Client name: Nudo, Kim Bryan
23 YRS OLD/MALE
Father/Spouse Name (OPTIONAL)
Hospital Registration number 0576
Ward Medical Ward
Bed No 320
Address P1 Calucay STO. Domingo Albay
Education N/A
Occupation N/A
Marital Status Single
Religion Roman Catholic
Date of Admission Feb 23, 2025
Date of Discharge
Diagnosis: R/O Nasal Fracture/R/O Maxillofacial Fracture
2 To VA Fracture
Surgery (if any) Nasal And Endoscope
Date of Surgery

II. History of Illness

Chief complaints Difficulty in swallowing, Chewing and breathing

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 Present medical history complaints
of dyspnea (complaints of
dyspnoea, low blood pressure and
cold and clammy skin.

Present surgical history (complaints

of backache, low blood pressure,
fever, etc

Past medical history: history of any

hypertension, Diabetes mellitus,
asthma, COPD or other
disease.

Past surgical history: history of any

surgery in the past.

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PART III. FAMILY HISTORY

No. Family Members Age/Sex Occupation Relation to Health Status Eductational

Patient Attainment
C.D 21Yrs Student Partner Healthy Undergraduate
old/
Female

Note: Please use initial for confidentiality

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PERSONAL HISTORY
Dietary Habits (vegetarian/ non vegetarian) Non Vegetarian

Addiction: history of smoking, drug addiction,

alcohol consumption, etc. There is a history of smoking and drinking alcohol

Socio-economic status:
AVERAGE

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DISEASE CONDITION: (NASAL FRACTURE)
Definition:
A broken nose, also called a nasal fracture, is a break or crack in a bone in your nose often the bone over the bridge of your nose.
Common causes of a broken nose include contact sports, physical fights, falls and motor vehicle accidents that result in injuries to the face.
A broken nose can cause pain, and it is common to get a nosebleed. You may have swelling and bruising around your nose and under your eyes.
Your nose may look crooked, and you may have trouble breathing through it.
Causes:
Common causes of a broken nose include:
● Injury from contact sports, such as football or hockey
● Physical fights
● Motor vehicle accidents
● Falls
Sign and Symptoms:
● Pain or tenderness, especially when touching your nose
● Swelling of your nose and surrounding areas
● Bleeding from your nose
● Bruising around your nose or eyes
● Crooked or misshapen nose
● Difficulty breathing through your nose
● Discharge of mucus from your nose
● Feeling that one or both of your nasal passages are blocked

ANATOMY AND PHYSIOLOGY

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ORGANS INVOLVED IN THIS CONDITION
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1. Radiz Nasi: The nasal root is the part of the nose that connects with forehead. The apex, at the "bottom" of the nose, is where the
openings of the nostrils (nares) are located. The outside of the nose is made up of the nasal bone, firm, flexible cartilage, and fatty
tissue.
2. Nasal Ridge: The midline prominence of the nose, extending from the nasal root to the tip (also called the dorsum of the nose).
3. Ala of the nose (ala nasi, "wing of the nose"; plural alae) is the lower lateral surface of the external nose, shaped by the alar
cartilage and covered in dense connective tissue.
4. Nostrils (nares): Your nostrils are holes that lead to your nasal cavities.
5. Lateral nasal cartilage: Fuses with the septum to provide support within the nasal cavities. With a collapse of the lateral nasal
cartilage, the inner nasal valve could become obstructed and prevent the movement of airflow throughout.
6. Accessory cartilages: Are small nasal cartilages between the lateral crus and piriform aperture of the nose bilaterally. These
cartilages are among the supporting structures of the nasal tip.
7. Major alar cartilage(greater alar cartilage) (lower lateral cartilage): is a thin, flexible plate, situated immediately below the lateral
nasal cartilage, and bent upon itself in such a manner as to form the medial wall and lateral wall of the nostril of its own side.
8. Minor alar cartilage: Associated within the ala of the nose, these small structures are contained within the most dorsal part of the
ala.
9. Nasal septum cartilage: is a hyaline cartilage that provides structural support to the nasal cavity and midface.
10. Minor alar cartilage: Associated within the ala of the nose, these small structures are contained within the most dorsal part of the
ala.
11. Fibrofatty Tissue: These layers help in smoothing the surfaces and the margins of the bodies of the lower lateral cartilages.
12. Nasal septum: is the central structure of the nasal cavity and is formed by the quadrangular cartilage anteriorly, and the
perpendicular plate of the ethmoid bone and vomer posteriorly.
13. Pars cartilaginea (Cartilaginous part): The cartilage lies in a groove between the petrous part of the temporal and the great wing
of the sphenoid; this groove ends opposite the middle of the medial pterygoid plate.
14. Pars ossea (Bony part): is mainly found in the posterior part and this part forms the vomer with the lamina perpendicularis of the
os ethmoidale.
15. Nasal cavity: is a large, air-filled space above and behind the nose in the middle of the face.
16. Hard palate:plays a significant role as it separates the oral cavity from the nasal cavity while also aiding swallowing and speaking
17. Oral cavity: or mouth, is the first step of the digestive system but can be used as a secondary source to bring air into the body.
18. Pharynx (throat): is a muscular tube in the middle of your neck. It helps you to breathe and digest food. Many medical issues can
affect your pharynx, from a common cold to cancer.
19. Limen nasi: is a mucous ridge between the nasal cavity proper and the nasal vestibule.
20. Nasal vestibule: is the first area encountered as you move posteriorly through the anterior nares, also known as the nostrils or
external nasal valve. The first half of the vestibule has a covering of keratinized stratified squamous epithelium that contains
coarse hairs called vibrissae.
21. Olfactory:system is at the roof of the nasal cavity at the cribriform plate - a perforated portion of the ethmoid bone separating the
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 frontal lobe of the cerebrum from the nasal cavity. Odorant molecules within the nasal passages first encounter receptors on the
primary cilia of olfactory sensory neurons.
22. Olfactory bulb: (Latin: bulbus olfactorius) is a neural structure of the vertebrate forebrain involved in olfaction, the sense of
smell. It sends olfactory information to be further processed in the amygdala, the orbitofrontal cortex (OFC) and the
hippocampus where it plays a role in emotion, memory and learning.
23. Olfactory tract: connects the olfactory bulb to the remainder of the cerebral cortex. This creates a direct connection between the
sensory output from the olfactory neurons and the olfactory cortex
24. Olfactory nerve: is the first cranial nerve (CN I). This nerve enables your olfactory system and sense of smell. Cranial nerve 1 is
the shortest sensory nerve. It starts in your brain and ends in the upper, inside part of your nose.
25. Superior turbinate: is also part of the ethmoid bone and has a similar thin, curved shape. The superior turbinate is covered by
mucosa thinner than the inferior and middle turbinates.
26. Superior meatus: located beneath the superior turbinate, provides drainage for the posterior ethmoidal sinuses.
27. Middle turbinate:is that part of the lateral mass of the ethmoid bone which projects from the external wall of the nasal cavity,
continuous anteriorly with the lateral mass and separated from its posterior portion by a space known as the inferior ethmoidal
fissure.
28. Middle meatus: drains the frontal, anterior ethmoid, and maxillary sinuses.
29. Inferior turbinate: is the largest and is located in the lower part of the lateral nasal wall. The inferior turbinate is a separate bone
that articulates with the maxillary, palatine, and ethmoid bones.
30. Inferior meatus: contains the orifice of the nasolacrimal duct
31. Sphenoethmoidal recess: is a small space in the nasal cavity. It lies posterior and superior to the superior concha into which the
sphenoidal sinus opens.
32. Frontal sinus: is a highly variable air-filled anatomical structure located superior to the orbit and within the frontal bone.
33. Ethmoidal sinus: A type of paranasal sinus (a hollow space in the bones around the nose). Ethmoid sinuses are found in the spongy
ethmoid bone in the upper part of the nose between the eyes. They are lined with cells that make mucus to keep the nose from
drying out.
34. Sphenoid sinus: There are two large sphenoid sinuses in the sphenoid bone, which is behind the nose between the eyes. The
sphenoid sinuses are lined with cells that make mucus to keep the nose from drying out.
35. Maxillary sinus: there are two large maxillary sinuses, one in each of the maxillary bones, which are in the cheek area next to the
nose. The maxillary sinuses are lined with cells that make mucus to keep the nose from drying out.

PATHOPHYSIOLOGY

Etiology
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 Nasal Fracture

Soft Tissue
Injury

Epistaxis

Nasal
Hematoma

Nasal Obstruction

Infection

ETIOLOGY
Motor vehicle accident.

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NASAL FRACTURE
Nasal fracture (broken nose) occurs when trauma to the nose results in a fracture of the nasal bones. Develop trauma causes blood vessel to
rupture.
SOFT TISSUE INJURY
The body reacts with inflammation, swelling, and hemorrhage. Rupture of blood vessels in the nasal tissues may result in bruising or a nasal
hematoma, which is a collection of blood between the cartilage and its lining. If left untreated, this can obstruct blood flow, resulting in tissue
injury or cartilage destruction, which may lead to abnormalities such as a saddle nose. Damage to surrounding muscles and tissues can cause
stiffness and discomfort when moving the jaw.
EPISTAXIS
A nosebleed, resulting from the burst of blood vessels in the nasal mucosa owing to factors such as dryness, trauma, or allergies.
NASAL HEMATOMA
If blood accumulates within the nasal septum rather than flowing out, it may result in a nasal hematoma. Damaged blood vessels may continue
to pass blood into the space between the nasal septum and its lining when a nosebleed occurs, particularly following trauma.
NASAL OBSTRUCTION
Nasal obstruction indicates an ongoing blockage of the nasal passageways, hindering nasal respiration. It may result from anatomical defects,
inflammation, or chronic illnesses impacting the nasal airway. A fractured nose can block normal breathing through the nose, forcing a person to
breathe through the mouth, which can make swallowing uncomfortable.
COMPLICATIONS IF LEFT UNTREATED
Untreated nasal fractures may result in significant implications that impact respiration and appearances. Certain issues may manifest
immediately, while others might appear weeks or months later.
INFECTION
An infection of a nasal fracture arises when bacteria enter the damaged nasal tissues, resulting in irritation and possible consequences.

NURSING CARE PLAN

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Patient’s Nursing Diagnosis: Nasal Fracture
Age: 23
Date of Admission: February 23, 2025

Assessment Nursing Goals Interventions Implementation Rationale Evaluation

Diagnosis
Subjective: Impaired  The patient  Monitor the patient’s  Administer the  Ensures that any  The patient’s
swallowing will ability to prescribed changes in the ability to swallow
“hindi ako
related to facial demonstrate swallow and any Sinupret Forte patient’s condition will be assessed
makakain ng
trauma (suspected improved discomfort or tablet, Nasoclear are identified for improvement,
maayos dahil
nasal fracture) as swallowing pain during spray, and early, allowing for and will reduce
nahihirapan
evidenced by ability with meals. Hyclens/Bactidol prompt difficulty noted.
ako
difficulty in minimal as ordered by the intervention.
lumunok”
swallowing. discomfort in physician.
48 hours.  Administer  The patient will
prescribed  Sinupret Forte report less
Objective:
medications.  Provide a soft- and Nasoclear discomfort and pain
Difficulty in  The patient Ensure that the food diet and spray help reduce during eating and
swallowing will express patient takes modify the nasal congestion, drinking.
verbally their Sinupret Forte consistency of which can impact
comprehensive Tablet, Naso foods if the patient's
safe eating clear Spray, and necessary to ability to  Nutritional and
practice and Bactidol as ensure easier swallow and fluid intake will
demonstrate prescribed to swallowing. breathe properly. be monitored to
adherence to manage nasal ensure the
these congestion, patient consumes
BP: 120/80 practices. maintain oral  Educate the  Hyclens and adequate
hygiene, and patient on proper Bactidol promote

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 PR: 61 prevent medication oral hygiene, amounts.
infection. administration preventing
SpO2: 98
and the infections and
RR: 19 importance of further
 Encourage the hydration and complications
Temp: 36.4 maintaining
patient to
consume soft good oral
foods and hygiene.
fluids to case
 Soft foods are
the swallowing
easier to swallow
process and  Assess the
and prevent
ensure patient's
choking or
adequate swallowing
aspiration,
nutrition and progress and
ensuring
hydration monitor for any
nutritional intake
signs of
 Instruct the patient to and preventing
aspiration,
use the malnutrition or
choking, or
NasoClear spray dehydration.
further difficulty
directly to
swallowing.
reduce nasal
congestion and  Medication helps
to improve reduce discomfort
 Offer assistance
breathing, which during
with eating or
may help with swallowing,
drinking if the
swallowing. improving the
patient has
patient’s ability to
 Ensure the patient is difficulty,
eat and drink.
positioned ensuring safety
comfortably during meals  Rest and comfort
during meals. measures support
overall recovery
and allow the body

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 to heal from the
trauma.

Assessment Nursing Goal Interventions Implementation Rationale Evaluation

Diagnosis
Subjective:  Impaired  The patient  Administer  Administer  Sinupret Forte and  The patient reports
Dentition will report a prescribed Sinupret Forte Nasoclear spray improved comfort
“nadidipisila
related to reduction in medications as tablet, Nasoclear can help alleviate and a reduction in
n ako mag
maxillofacial difficulty ordered (Sinupret spray, and inflammation in difficulty
nguya”
injury as chewing. Forte, Nasoclear Hyclens/Bactidol the nasal passages chewing.
evidenced by spray, Hyclens, as prescribed, and promote
 The patient  The patient
difficulty in Bactidol) to ensuring the drainage, reducing
Objective: will demonstrates the
chewing. reduce patient follows discomfort during
demonstrate ability to eat soft
Difficulty in inflammation and the treatment chewing.
an improved foods without
Chewing infection risk. regimen.
ability to eat  Hyclens and significant difficulty
and chew  Provide patient  Encourage a Bactidol can within the set
soft foods education on the soft-food diet prevent or manage timeframe.
importance of and assist with any oral infection.
 No signs of
eating soft, meals if
 Eating soft foods infection or
nutritious foods necessary,
minimizes strain further
that are easy to helping the
on the affected complications are
BP: 120/80 chew. patient to avoid
area, reducing pain observed during
foods that are
PR: 61  Perform regular and promoting follow-up
difficult to
oral hygiene to healing. assessments.
chew.
SpO2: 98 prevent
 Monitoring for
complications and  Monitor the
RR: 19 infection and
promote healing, patient's
providing oral
Temp: 36.4 using gentle progress by
hygiene are
techniques. observing their
essential to
ability to chew
prevent
and swallow,
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 adjusting complications
interventions if from the injury.
needed.

 Offer education
about
medication
schedules,
dietary
changes, and
the importance
of oral hygiene
to promote
healing and
prevent
infection.

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Assessment Nursing Goals Interventions Implementation Rationale Evaluation
Diagnosis
Subjective:  Ineffective  The patient will  Administer  Administer  Sinupret Forte  The patient
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 Airway demonstrate prescribed Sinupret Forte and Nasoclear reports improved
Clearance improved medications as and Nasoclear spray are ability to breathe
“Nahihirapan
related to nasal airway ordered (Sinupret spray according intended to through the nose
ako
fractures as clearance as Forte, Nasoclear to the reduce nasal and experiences
huminga”
evidenced by evidenced by spray) to reduce physician’s inflammation reduced
difficulty the ability to nasal swelling and orders. and promote congestion.
breathing due breathe through promote drainage. drainage, which
Objective: to nasal the nose. will ease
Can’t breathe passage and  Ensure the breathing  No signs of
properly due swollen.  Encourage the patient is difficulties. airway
to nasal  The patient will patient to use positioned with obstruction or
passage and verbalize the Nasoclear spray the head elevated severe breathing
swollen reduction of as directed to to promote easier  Monitoring, difficulty are
nasal congestion relieve nasal breathing and to respiratory status observed on
and improved congestion and reduce facial ensures early follow-up
breathing. facilitate easier swelling. detection of assessments.
breathing. complications,
like airway
 Assist the patient obstruction or  The patient
 Monitor the in using worsened demonstrates an
BP: 120/80 patient’s Nasoclear spray congestion. understanding of
PR: 61 respiratory status, if they need help, how to use
oxygen saturation, ensuring they medications and
SpO2: 98 breathe sounds to follow the  Educating the manage
RR: 19 detect any signs correct patient on safe breathing
of worsening technique. nasal care difficulties
Temp: 36.4 difficulty in minimizes the effectively.
 Monitor the
breathing. risk of
patient’s
complications
respiratory status
and empowers
and comfort level,
 Educate the the patient to
adjusting care as
patient on proper manage their
necessary (e.g., if
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 nasal care, breathing symptoms
including using difficulties effectively.
nasal spray. increase, notify
Correctly, the healthcare
avoiding provider).  Deep breathing
excessive blowing exercises
of the noses and improve lung
reporting any  Educate the expansion and
worsening of patient on proper overall
symptoms. medication oxygenation,
usage, including enhancing
the importance respiratory
 Encourage slow of using function.
deep breathing Nasoclear spray
exercise exercises regularly and
to promote lung maintaining
expansion and proper hygiene
case airflow. with
Hyclens/Bactidol
to avoid
infections.

MEDICATION

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Name of Drug Dose/Route Classification Action Side effect Nursing
responsibilities
PLR IVF 1L x8 Isotonic Low Blood Volume - Damage to - Check the
embryos patient vital
signs
especially the
blood
pressure
(BP)
- Assess for
any allergic
reaction

D5LR IVF 1L x 60cc /hr Hypotonic Dehydration - Blurred - Monitor

vision patient for
fluid volume
- Swelling
deficit and
eyelids
other
- Watering of complication
the eye s

- Increased - Instruct the

sensitivity of patients to
eyes to contact if
eyelids they feel
dizzy or
- eye redness unwell
or discomfor

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Tetanus Toxoid 40 i.u IM Prophylactic Stop the spread of - nausea - Keep the
disease or infection patient in a
- diarrhea
quiet, dark
- headache room

- fatigue - Change the

patient
- Insomia position
- Stomach every 3 to 4
Pain hours

HTIG 250 i.u Anaphylactic Allergic Reaction - Increased - Assess the

anxiety patient
breathing
- Lead to post
rate ang
traumstic
pattern
stress
completely
- Monitor the
oxygenation
status
Keterolac 1amp IV Q4 Nonsteroidal anti- Treat severe pain - Dizziness - Monitor
inflammatory drugs patients
- Drowsiness
( NSAID’s) closely for
- Headache seizures,
serotonin,
- Constipation syndrome,
- Diarrhea sedation, and
respiratory
- Difficulty depression
swallowing

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 Ceftriaxone 2g IV OD Cephalosporin Preventing bacterial - Hives - Ensure
Antibiotics form building their adequate
- Nausea
cell walls hydration
- Stomach
- Monitor
pain
insertion site
- Fever for
extravasatio
- Wheezing n
- Swelling
- Tiredness
Tranexamic Acid 500 IV Antifibrinolytic Inhibiting the - Headache - Assess blood
process that pressure
- Muscle
dissolves clots,
cramps - Report low
thereby reducing
blood
bleeding - Changes
pressure
Vision
- Seizures
- Confusion
Sinupret Forte tab TIB N/A To provide relief for - Nausea - Patient with
stuffy or congested sensitive
- Stomach
nose stomach are
ache
advised to
take
medicine
after meals
- Instruct
patient to
report

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 difficulty
breathing or
nausea
Clindamycin 600mg IV Q12 Lincomycin Slowing or stopping - Decrease in - Ensuring
Antibiotics the growth of the amount patient safety
bacteria of urine
- Monitoring
- Difficulty adverse
with reactions
swallowing
- Check for
- Heartburn allergies
- Sore throat
Co-amoxicial 1.2g IV as LD Penicillins and Stops bacteria from - Skin rash - Observe for
Beta-Lactamasen breaking down respiratory
- Bloating
Inhibitors amoxicillin status
- Dark urine
- Ensure that
- Vomiting the patient
has adequate
- Breathing fluid intake
Problems during any
diarrhoea
attack
- Report
haematuria
or oliguria as
high doses
can be
nephrotoxic
Nasoclear puffs TID 2-3 puff Inhalant Rinsing and - Mild nasal - Ensure the

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 Moisturizing the irritation or patient uses
nostril stinging the spray
correctly
- Sneezing
- Monitor for
- Headache
any adverse
- Runny nose reactions like
irritation or
bleeding
- Educate the
patient on
proper usage
and dosage

LAB INVESTIGATION
Complete Blood Count

Investigation Name Patient Result Normal Range Unit Clinical significant

indicators

HCT 43.4 43.5-53.7 N/A The normal hematocrit

is lower than the normal
range.bIt can cause the
body to not get enough
oxygen, which can lead
to fatigue and weakness

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 HGB 153.0 141-181 g/L Hemoglobin is in the
normal range

WBC 13.87 4.6-10.2 10^3/uL This is higher range

than normal range, and
can indicate infections,
inflammation, or certain
medications
PLT 355 150.0-450.0 10^3/uL Platelet count is within
the normal range

RBC 5.18 4.7-6.1 10^6/uL Red Blood Cells is

within the nornal range

RDW-SD 5.18 fL N/A N/A

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 WBC Differential Count

Investigation Name Patient Result Normal Range Unit Clinical significant

indicators

NEUT% 85.2 37.0-80.0 N/A This is higher than the

normal range. It can
indicate infection,
inflammation, or other
condition

LYMPH% 9.1 10.0-50.0 N/A The lymphocytes is

lower and can increase
your risk of infections
and other health issues

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 MONO% 5.6 10.0-50.0 N/A Monocytes are within
lower range. It can make
more susceptible to
infections

EO% 0.0 0.0-14.0 N/A Eosinophils are within

the normal range

BASO% 0.1 0.0-1.5 N/A Basophils are within the

normal range

IG% 0.1 N/A N/A N/A

Blood Indices

Investigation Name Patient Result Normal Range Unit Clinical significant

indicators

MCV 83.8 80.0-97.0 fL Mean Corpuscular

Volume (MCV) are
within the normal
range

MCH 29.5 27.0-31.2 pg Mean Corpuscular

Moglobin (MCH) are in
the normal range

MCHC 35.3 31.8-35.4 g/L Mean Corpuscular

Hemoglobin

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 Concentration (MCHC)
are within the normal
range

MPV 9.2 7.0-12.0 fL Mean Platelet Volume

(MPV) are within the
normal range

PDW 10.1 9.0-17.0 fL Platelet Distribution

Width (PDW) are
within the normal
range

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