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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: SUMAWAY, Felicidad Age/Sex: 83/F Address: 2943 Rd.3 BO. Obrero, Pandacan, Manila Date of Admission: March 28, 2008 Admitting Diagnosis: CAP, moderate risk IHD, lateral wall ischemia, AF with MVR, II-B HCVD, LVH r/o ACS Residents in charge: Drs. Gutierrez/Dimaandal/Areja Clerks in charge: Florentino/Ingles

Hospital No: 1621442

Laboratory Summary CBC + Diff. Count Normal Values WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils RBC Hgb Hct MCV MCH MCHC RDW Platelet ESR 4.8-10.8 x 109 /L 55-57 20-30% 0-7% 0-3% 0-1% 4.0-20 x 1012 /L 12-16g/dl 37-47 % 80-90 fL 27-31 32-36 11.5-15.5 150-400 x 10^9/L 0-10 mm/hr 03/28 9.27 59.9 26.8 7.2 4.4 1.7 3.97 11.4 33.7 84.9 28.6 33.8 14.7 356 4/04/08 6.0 62.1 26.1 6.8 4.7 0.3 3.93 11.3 33.2 84.4 28.8 34.1 14.9 295 4/06/08 6.1 61.0 23.8 8.7 6.5 0.0 4.23 11.8 35.7 84.4 27.9 33.0 14.5 335

Clinical Chemistry Test Name HDL Triglycerides Lipase Uric Acid Cholesterol LDL BUN Creatinine Na K Cl AST ALT Glucose Normal Values 0.91-1.56 mmol/L 0.34-1.70 mmol/L 23-300 U/L 0.11-0.43 mmol/L 4.20-5.20 mmol/L 1.10-3.80 mmol/L 2.78-7.64 mmol/L 44-106 umol/L 135-145 mmol/L 3.80-5.50 mmol/L 96-108 mmol/L 3/31/08 4/04/08 1.03 4/09/08 1.31

4.23 8.7 106.58 139 4.3 111

5.33

4.6

Urinalysis

Physical Color Transparency

3/28/08 Yellow Slightly turbid

4/01/08 Straw Clear

Microscopic Epith. Cell Mucus thread Amorph urates Amorph phosphates Pus cells Erythrocytes Cast Chemical Albumin Sugar Sp. Gravity pH

Moderate Few Few

Few Few Few

3-6/hpf 4-6/hpf None Trace Negative 1.015 6.5

1-2/hpf 0-1/hpf

Negative Negative 1.015 7.0

12L ECG 3/27 – Atrial Fibrillation with MVR; Left ventricular hypertrophy; lateral wall ischemia 3/28 – sinus rhythm with premature atrial contraction 3/31 – Left Axis Deviation, Premature Ventricular Depolarization, Left Ventricular Hypertrophy CXR-PA 3/27 – cardiomegaly, pulmonary congestion, AA, Koch’s pneumonia not ruled-out 3/30 – ff-up shows a moderate resolution of the previously seen pulmonary congestion. Other findings are unchanged. 2D-echo 4/9/08 Mild Concentric Left Ventricular Hypertrophy with Mild Global Wall Motion Abnormality and Mild Systolic Dysfunction Aortic Sclerosis with Trivial Aortic Regurgitation Doppler Findings Suggestive of Left Ventricular Relaxation Abnormality Troponin I 04/06/08 0.07 (N 0.00-0.04)


				
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