Labs

CT scan: July 27, 2010

Plain Cranial CT scan
 Multiple sequential axial images of the brain from the base to the vertex:
o (-) No abnormal density changes in the brain parenchyma
o (-) No focal mass lesion seen
o (-) No displacement of midline structures
o (+) slight effacement of the surface sulci & fissures
o (+) symmetrical minimal narrowing of the cerebral ventricles
o (-) No intra-axial nor extra axial fluid collection
o (-) the ventrioles, cortical
o Posterior fossa structures are grossly intact
 Impression: suggestive mild cerebral edema

Radiology (x-ray): skull AP/LAT view

No evidence fracture in the cranial vault

Blood Chemistry: sodium 139.4 mmol/L

Potassium 3.78 mmol/L
Calcium 6.9 mg/dL

Urinalysis:
7-24-10 7-23-10
Color: yellow Dark yellow
Reaction: pH 6.0 pH 5.0
Specific gravity: 1.020 1.020
Pus cells: 8-10/hpf 8-13/hpf
RBC cells: 1-3/hpf 2-4/hpf
Sugar: negative Negative
Albumin: trace Charac: cloudy
Epithelial cell: moderate Bacteria: moderate
Mucous threads: few few
Other yeast cells: moderate

HEMATOLOGY 7-28-10 7-27-10 7-26-10 7-26-10 7-26-10 7-25-10 7-25-10 7-25-10

12nn 6am 6pm 12nn 6am 12mn 6pm 12nn
Hct 0.40-0.48 0.32 0.45 0.40 0.40 0.45 0.44 0.44 0.45
Platelet 140-440 226.0 60.0 80.0 32.0 60.0 50.0 56.0 45.0
Hgb 135-160 143

HEMATOLOGY 7-25-10 7-24-10 7-24-10 7-24-10 7-24-10 7-23-10

6am 12mn 6pm 12nn 6am
Hematocrit 0.43 0.43 0.43 0.43 0.49 0.44
Platelet 42 40.0 42.0 44.0 52.0 72.0
Hemoglobin 143 143 145 150 150
Neutrophil 0.61
0.55-0.65
Lymphocyte 0.37
 0.25-0.40
Monocyte 0.01
0.02-0.06
Eosinophil 0.01
0.01-0.05
Blood type AB+

Hematology
Leukocyte number conc. 9.6
Differential:
Neutrophil 0.44
Lymphocyte 56
Hemoglobin mass conc. 187.0 g/L
Erythrocyte vol. fraction 0.55
Thrombocyte number conc. 72 × 109/L

----inadequate platelet count