Prenatal Health Asssessment-final
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Transcript of Prenatal Health Asssessment-final
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8/4/2019 Prenatal Health Asssessment-final
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I. Demographic Profile
DDL 26 year old female, born December 12, 1984, a Catholic, and is presently living at
Provido Village City Heights, GSC, was assessed last February 02, 2011.
DDL is married. She works as a cashier at a certain department store, and is receiving a
paycheck of 7,000Php per month.
II. Health History
a.) admitting diagnosis/chief complaint
b.) name of obstetrician
A week prior to admission, DDL has been feeling pain during urination, thinking that this
could be harmful to her current pregnancy; she decided to submit herself for admission under
the management of Dr. Ma. Cecilia O. Balbuena.
c.) past illness and surgeries
Accordingly, DDL has always been healthy and she also feels physically well during the
assessment. She never had a history of any serious illness, never been admitted to the hospital,
and she did not undergo any form of operations. However, in some occasions, she does
experience some common illnesses such as influenza, cough, and common cold.
She also has been exposed to chickenpox and mumps when she was still in
elementary.
d.) history of present illness
Last January 28, 2010, DDL consulted Dr. Cecili O. Balbuena for feeling pain duringurination. She was then suggested to have a urinalysis. Thinking that it was just nothing, she
decided not to submit herself for urinalysis.
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Two days prior to admission, she had her consultation, still regarding her condition.
During that time, she had already the symptom of slight left lumbar pain; however, she did not
submit herself for admission.
After 2 days, she felt a moderate pain during urination, with moderate left lumbar pain
and was associated with scanty urination which then prompted her admission.
e.) obstetrical history and immunization
DDL had her last menstrual period last December 19, 2010. Based on the computation,
her expected date of confinement was on September 26, 2011. Her age of gestation during the
assessment was six weeks and four days (6 4/7).
Accordingly, she never was pregnant and never had an abortion prior to her pregnancy
during the assessment.
Leopolds maneuver was not yet applicable during the assessment considering her age
of gestation.
III. Social History
A.) Habits and Patterns
a.) sleeping pattern: DDL sleeps for 8 hours in a day with a nap time of a one hour
during the afternoon.
She sleeps around 10:00 in the evening after her favorite TV series and wakes up
around 6:00 in the morning to prepare breakfast for her husband.
b.) hobbies/activities/exercises: DDL spends her day working at the department store.
Being a cashier, most of the time she was just sitting. Although she makes it a point to do some
form of exercise such as walking during her break-time. When she is at home, she considersdoing the household chores as a form of exercise.
c.) eating pattern: DDL eats at least three times a day; she also has snacks during
afternoon which comprises of bread and juice, or at times, porridge.
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Furthermore, she said she drinks water frequently but at times, when she tends to be
busy, she neglect this very important health practice. In addition, she is fond of drinking colas
and juices. She could consume one 8oz of cola for a day, or sometimes a 2-3 glasses of juice.
B.) Consumption of Alcohol/Drugs: DDL does not drink alcoholic beverages and she does
not used illegal drugs.
C.) Cigarette Smoking: DDL is said to be a non-smoker, though she made mentioned that she
did try to smoke when she was in High-school due to curiosity.
D.) Home Conditions: DDL and her husband are living in a small, yet well ventilated rented
house at Provido Village City Heights. The house is made of concrete and woods. Even though
the house is small, it seems that it was well managed and well kept. The presences of pests like
rats, mosquitoes, and/or cockroaches are not evident in the vicinity of the house.
E. Familial/ Hereditary Disease: DDLs grandparents (on the fathers side) are said to be
hypertensive, while her grandparents (on her mothers side) are known to be both hypertensive
and diabetic. DDL parents are known to be hypertensive. Other than the one mentioned, other
type of diseases that her parents might have are unknown.
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IV. Review of Systems/ Physical Assessment
Her Physical Assessment reveals the following:
General appearance: She was lying on bed, conscious, coherent and oriented to time and
place. She is also responsive to verbal stimulation and is not in any form of distress. She has a
mesomorphic body built. She was wearing a white patients gown. She was well-groomed and
no body odor was noted during the whole assessment. She responds to the questions and
interacts with calmness during the physical assessment.
Vital Signs:
Components Actual Value Normal Value Remarks
Temperature 36.9 C 35.6-37.4 C Normal
Pulse Rate 80 bpm 60-100 bpm Normal
Respiratory Rate 17 cpm 16-22 cpm Normal
Blood Pressure 100/ 80mmHg 110/70-130/90
mmHg
Normal
Cardiac Rate 81 bpm 60-100 bpm Normal
Height: 5 feet and 1 inch (51)
Weight: 52kgs
Integumentary:
a.) Skin: She has a fair complexion. Chloasma or melasma is not noted. Her skin is
moist, smooth and warm to touch.
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Temperature is uniform and falls within normal range both on upper and lower extremities. She
has good skin turgor; skin springs back to previous state when pinched after 1-2 seconds.
Presence of edema and tenderness on skin surfaces were not noted.
b.) Nails: The fingernail plates were colorless, smooth in texture and have a convex
curvature with an angle of about 160. Nail beds are pinkish indicative of good arterial
circulation. Epidermis surrounding the nails is intact. After performing the blanch test, there is a
prompt return of usual color in 2 seconds. Toenail plates were also colorless, smooth in texture,
and have a convex curvature. The nail beds are also pinkish with surrounding epidermis intact.
c.) Hair and Scalp: There is an even distribution of thin, oily and naturally dark black
hair over the scalp. Infections or infestations were not noted upon inspection. Minimal body hair
is noted.
Head and Neck:
a.) Skull: The head configuration is round, normocephalic and symmetrical with frontal,
parietal and occipital prominences. Head circumference is 53.7cm and the size is in proportion
with the body. She has smooth skull contour, uniform consistency and without any nodules and
masses.
She has symmetrical facial features, palpebral fissures equal in size and symmetrical
nasolabial folds.
b.) Face: Hollowness on periorbital region is slightly evident. Facial movements are
symmetrical as the patient was able to elevate and lower the eyebrows, close the eyes tightly,
puff the cheeks and smile.
c.) Eyes and Ears: The eyebrows are thick, evenly distributed and the skin on the area
is intact. It is symmetrically aligned and with equal movement. The eyelashes are equallydistributed and curled slightly outward. The skin on the eyelids is intact with no discharges or
discoloration. The lids close symmetrically. She has 15 involuntary blinks for one whole minute
which moves bilaterally. When lids close, sclera above cornea is not visible. She has
transparent bulbar conjunctiva with no lesions noted. The palpebral conjunctiva is shiny, smooth
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and slightly pale in color and lesions are absent. No edema, tenderness or tearing on the
lacrimal sac and nasolacrimal duct.
The cornea is transparent, shiny, smooth and with visible details of the iris. Her iris
appears to be dark brown while the pupil is black. The pupils are equal in size, with a pupillary
size of 3 mm with a round and smooth border. The pupil constricts in direct response of light
stimulation while the non- illuminated pupil also constricts as a consensual response. This
reaction indicates proper functioning of the oculomotor and trochlear cranial nerves. Pupil
constricts when looking at near objects and dilates when looking at far objects which indicate a
normal pupil reaction and accommodation. She was able to see objects in the periphery while
looking straight ahead. Both of his eyes are coordinated and move in unison with parallel
alignment upon performing the extraocular movements. During the interview, the patient does
not wear any corrective lenses. She also verbalizes that she does not wear corrective glasses.
No other inflammation, discharge, lesion or tenderness was observed.
Ears are bilaterally equal in size upon inspection. Auricles equally align with the outer
canthus of the eye and have the same color as of that the facial skin. The pinna is symmetrical
and the external canals are clean with no foul smelling discharge. Skin around the area is
smooth with no lesions. Canal walls are pink and smooth without nodules. Gross hearing in
each ear is symmetrical .She responds to the questions accurately and is oriented and coherent
to environmental sound stimuli. She can hear normal voice tones as well as ticking of the clock
during the watch tick test.
d.) Nose and Sinuses: The external nose is symmetrical in size; nasal bridge is located
in the midline. External nasal skin is the same with facial color. Nasal mucosa is pink, moist,
lined with enough amount of hair and free from exudates and other unusual discharges. Nasal
septum is set at the midline with intact skin. Both nostrils are symmetrical and patent as air is
able to move freely inside it upon inhalation and exhalation and without unusual discharges and
lesions noted. Nasal hairs were noted in sufficient amount. Tenderness is not felt upon palpationof maxillary and frontal sinuses.
e.) Mouth and Pharynx: The lips have uniform pinkish-reddish in color, with smooth
appearance. Her lip has also a symmetrical contour with no lesions noted and was able to purse
lips. The oral mucosa has a uniform pink color and appears to be hydrated. The gums are pink
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with no ulcerations noted. Incomplete set of teeth was noted. Missing teeth are right second
premolar on the upper jaw and on the second and third molar on the left side of the lower jaw is
missing. The tongue is positioned centrally, pink in color, able to move freely. Tenderness or
palpable nodules were not noted. Tongue base is smooth. The frenulum is at the midline.
Salivary duct openings have no swelling or discolorations noted. The color is the same
with the buccal mucosa and the floor of the mouth. The soft palate is smooth and light pink in
color. The hard palate is lighter pink and more irregular in texture compared to that of the soft
palate. The uvula is positioned at the midline. The tonsils are pink, smooth and are not inflamed.
Discharges are absent. Gag reflex is present.
f.) Neck: The muscles on the neck are equal in size and head is located on the center.
No marked lesions were noted. Head movement is coordinated and smooth with no signs of
discomfort. There is bilaterally equal strength on the sternocleidomastoid and trapezius
muscles.
Lymph nodes are not palpable. Trachea is centrally placed in the midline of the neck.
The thyroid gland is slightly enlarged upon inspection but ascends when asked to swallow. No
bruit heard upon auscultation.
Thorax and Lungs:
a.) Posterior thorax and lungs
The surrounding skin is intact with uniform temperature. The chest wall is intact and no
masses or tenderness noted. Chest expansion is full and symmetric when the client takes a
deep breath and has a respiratory excursion of 2 cm. Vocal fremitus is bilaterally symmetrical
and is heard most clearly at the apex of the lungs. Diaphragmatic excursion is 1.5 cm. No
adventitious sounds noted.
b.) Anterior thorax and lungs
She has a quiet, rhythmic and effortless respiration. There were no significant scars
noted on the anterior thorax. Lateral diameter is larger than the anteroposterior diameter. Vocal
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tactile fremitus is bilaterally symmetrical and is decreased over the heart and breast tissue. No
adventitious sounds noted. Respiratory rate is 17 cpm.
Cardiovascular and Peripheral Vascular System:
No pulsations, lifts or heaves noted on aortic, pulmonic, tricuspid and apical areas noted
upon inspection and palpation. Aortic pulsations are present on the epigastric area. Jugular
distention is absent. Capillary refill time result is 2 seconds. Carotid arteries have symmetric
pulse volumes and full pulsations. No sound heard upon auscultation.
Peripheral pulses have full pulsations with symmetrical pulse volumes. Peripheral leg
veins are symmetric in size. Original color returns in 10 seconds after performing Buergers test.
Cardiac rate is 81 bpm.
Breast and Axilla: Breast was symmetrical and uniform in color. No tenderness masses
and bulges. Darker pigmentation of nipples and areola were noted. Nipples were, symmetrical
with no tenderness, masses and nodules noted. Fullness of breasts and tingling sensation were
noted as per verbalization of the client. Tubercles of Montgomery are slightly enlarged.
Growth of hair in axilla is minimal with no tenderness and masses upon palpation.
Axillary nodes are impalpable.
Abdomen: Flat, nontender abdomen, no linea nigra present. Fundus is not yet palpable.
Abdomens contour is soft and round with no signs of spleen orliver
enlargement
Gastrointestinal:
Reproductive:
Musculoskeltal:
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Neurologic:
CRANIAL NERVES TYPE FUNCTION ASSESMENTOLFACTORY SENSORY Smell -Able to distinguish varying
substances according to their odor
(e.g. alcohol, perfume, vinegar).OPTIC SENSORY Vision and visual
fields-Able to read imprints by the aid ofreading glasses; able to distinguishcounting by fingers
OCULOMOTOR,TROCHLEAR,ABDUCNES
MOTOR EOM; moveseyeballs up and
down, moveseyeballs left and
right
-brisk eye opening-Able to move EB up and down-Able to move EB left and right
TRIGEMINAL SENSORY Sensation of thecornea
-blinks upon stimulation of thecornea
FACIAL MOTOR AND
SENSORY
Facial
expressions
-able to close eyes tightly, puff
cheeks, smile, and elevateeyebrows
AUDITORY SENSORY Equilibrium;hearing
-Able to hear normal voice
GLOSSOPHARYEAL
MOTOR ANDSENSORY
Swallowingability; tongue
movement
-Good swallowing ability-Able to move tongue vertically andlaterally
VAGUS MOTOR ANDSENSORY
Sensation of thepharynx, larynx,swallowing, and
vocal cordmovement
-Intact speech-Symmetrical palate [soft] as patientsays Ah!
SPINALACCESSORY
MOTOR Head movement;shrugging of
shoulders
-Able to move head vertically, andlaterally against resistance-Equal strength upon shrugging theshoulders
HYPOGLOSSAL MOTOR Protrusion oftongue
-Able to move tongue vertically andlaterally
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V. Laboratory Results with significance and interpretation
Diagnostic Exam: Urinalysis
DateTaken
Name ofLaboratory
Procedure
Purpose ofLaboratory
Procedure
Result NormalValue
Clinical Significance
February03, 2010
UrinalysisSpecimen:Urine
A urinalysis parameter commonly used in the evaluation of kidney function andcan aid in the diagnosis of various renal diseases.
a.) color Shows the
degree of
concentration.
Lightyellow
Pale
yellow
to Dark
Amber
-Turbid may be form of hematuria,
spermatozoa, prostatic fluid, & fat
droplets.
-Red-colored urine may indicate presence
of blood pigments.
-Yellow-Brown reveals obstructive
jaundice.
-Orange urine from urinary antiseptic.-Dark brown to black may be due to
malignant melanoma.
b.)transparency
Also shows the
degree of
concentration.
Hazy Clear May indicate presence of bacteria, pus,
RBC, WBC, phosphates in the urine.
c.) reaction As part of the
acid-base
balance, the
kidneys remove
excess
hydrogen ions
from the blood
and excrete
them in the
urine. In
abnormal
physiology, a
urine pH
greater than 6.5indicates the
presence of
bicarbonate in
the urine.
pH 5 4.6-7.5 Decreased:
-Metabolic & Respiratory acidosis
-DM
-Diarrhea
-Starvation
-Renal Failure
Increased:
-Metabolic & Respiratory alkalosis
-Bacteriuria
-Vegetarian Diet
-NGT suctioning
-Prolonged Vomiting
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DateTaken
Name ofLaboratoryProcedure
Purpose of LaboratoryProcedure
Result NormalValue
Significance
d.) albumin The presence of urinaryalbumin is an indicator ofglomerular disease. The
nephritic syndrome producesa great loss of albumin in theurine. The renal loss also maybe associated with systemicdisease that causesglomerular damage
negative negative May indicate nephrotic
syndrome, renal
disorder associated
with hypertension, DM,
systemic lupus
erythematus,
amyloidosis
e.) sugar Glycosuria (glucose in the
urine) is usually an indicator
of significant hyperglycemia &
DM. When a fasting specimen
is obtained, it is highly specific
& accurate in the detection ofglucose in the urine.
negative negative Presence of sugar
indicates DM,
hyperthyroidism &
stress.
d.) specific gravity Measurement of the ability of
the kidneys to concentrate &
excrete urine. Concentrated
urine has a higher specific
gravity because the proportion
of components to water in its
composition is greater. Diluted
urine has a lower specific
gravity because it contains
fewer components in
proportion to the amount of
water.
1.010 1.005-
1.030
Decreased:
-Overhydration
-Diuresis
-Hypotension
-Pyelonephritis
-Glumerulonephritis
-Renal Tubular
Dysfunction
-Severe renal damage
-Diabetes Insipidus
Increased:
-Dehydration
-Fever
-Profuse Sweating
-Vomiting
-Diarrhea
-Glycosuria
-Proteinuria-CHF
-Adrenal Insufficiency
-Altered secretion of
ADH
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DateTaken
Name ofLaboratoryProcedure
Purpose of LaboratoryProcedure
Result NormalValue
Significance
b.) RBC Normal urine may exhibit a fewRBCs without any significantpathologic cause. The
presence of few cells isconsidered acceptable underhigh power field (HPF)microscopic visualization.Significant hematuria isindicated by one episode ofgross hematuria or oneepisode of high-gradehematuria, with an RBC countgreater than 100 cells perHPF.
1-2HPF
Negative Indicates presence of
benign tumor, cancer,
urinary calculi,
glomerulonephritis.
lupus nephritis,
sclerosis, UTI
c.) Pus cells An elevated WBC count in the
urine indicates pyuria (pus in the
urine). The microscopic urinalysis
findings of 5 to 10 WBCs per HPF
is a significant elevation that
indicates the presence of urinary
tract infection.
20-
25HPF
0-2 HPF Indicates presence of
Urinary Tract Infection
d.)Bacteria Fewe.)Urates crystals Few
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Diagnostic Exam: Urinalysis
DateTaken
Name ofLaboratoryProcedure
Purpose ofLaboratoryProcedure
Result NormalValue
Clinical Significance
February
10, 2010
Urinalysis
Specimen:Urine
A urinalysis parameter commonly used in the evaluation of kidney function and
can aid in the diagnosis of various renal diseases.
a.) color Shows the
degree of
concentration.
Lightyellow
Pale
yellow
to Dark
Amber
-Turbid may be form of hematuria,
spermatozoa, prostatic fluid, & fat
droplets.
-Red-colored urine may indicate presence
of blood pigments.
-Yellow-Brown reveals obstructive
jaundice.
-Orange urine from urinary antiseptic.
-Dark brown to black may be due to
malignant melanoma.
b.)transparency
Also shows the
degree of
concentration.
Hazy Clear May indicate presence of bacteria, pus,
RBC, WBC, phosphates in the urine.
c.) reaction As part of the
acid-base
balance, the
kidneys remove
excesshydrogen ions
from the blood
and excrete
them in the
urine. In
abnormal
physiology, a
urine pH
greater than 6.5
indicates the
presence of
bicarbonate in
the urine.
pH 5 4.6-7.5 Decreased:
-Metabolic & Respiratory acidosis
-DM
-Diarrhea
-Starvation-Renal Failure
Increased:
-Metabolic & Respiratory alkalosis
-Bacteriuria
-Vegetarian Diet
-NGT suctioning
-Prolonged Vomiting
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DateTaken
Name ofLaboratoryProcedure
Purpose of LaboratoryProcedure
Result NormalValue
Significance
d.) albumin The presence of urinaryalbumin is an indicator ofglomerular disease. The
nephritic syndrome producesa great loss of albumin in theurine. The renal loss also maybe associated with systemicdisease that causesglomerular damage
negative negative May indicate nephrotic
syndrome, renal
disorder associated
with hypertension, DM,
systemic lupus
erythematus,
amyloidosis
e.) sugar Glycosuria (glucose in the
urine) is usually an indicator
of significant hyperglycemia &
DM. When a fasting specimen
is obtained, it is highly specific
& accurate in the detection ofglucose in the urine.
negative negative Presence of sugar
indicates DM,
hyperthyroidism &
stress.
d.) specific gravity Measurement of the ability of
the kidneys to concentrate &
excrete urine. Concentrated
urine has a higher specific
gravity because the proportion
of components to water in its
composition is greater. Diluted
urine has a lower specific
gravity because it contains
fewer components in
proportion to the amount of
water.
1.005 1.005-
1.030
Decreased:
-Overhydration
-Diuresis
-Hypotension
-Pyelonephritis
-Glumerulonephritis
-Renal Tubular
Dysfunction
-Severe renal damage
-Diabetes Insipidus
Increased:
-Dehydration
-Fever
-Profuse Sweating
-Vomiting
-Diarrhea
-Glycosuria
-Proteinuria-CHF
-Adrenal Insufficiency
-Altered secretion of
ADH
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DateTaken
Name ofLaboratoryProcedure
Purpose of LaboratoryProcedure
Result NormalValue
Significance
b.) RBC Normal urine may exhibit a fewRBCs without any significantpathologic cause. The
presence of few cells isconsidered acceptable underhigh power field (HPF)microscopic visualization.Significant hematuria isindicated by one episode ofgross hematuria or oneepisode of high-gradehematuria, with an RBC countgreater than 100 cells perHPF.
0-1HPF
Negative Indicates presence of
benign tumor, cancer,
urinary calculi,
glomerulonephritis.
lupus nephritis,
sclerosis, UTI
c.) WBC 0-1
HPFd.)Bacteria Few May indicate the
presence of urinarytract infection.
e.)Urates crystals Few
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Diagnostic Exam: Complete Blood Count
Date
Taken
Name of
Laboratory
Procedure
Purpose of Laboratory
Procedure
Result Normal
Values
Clinical Significance
June 02,
2010
Hematology
Hemoglobin Used to measure the severity
of anemia, which is
characterized by a low
hemoglobin value, or
polycythemia, which is
characterized by a high
hemoglobin value. It is also
used to monitor the result ofmedical or nutritional treatment
for the condition.
99g/L 120-160g/L Decreased:
-Anemia
-Cirrhosis
-Hemolysis
-Leukemia
Increased
-Congestive Heart Failure-COPD
-Dehydration
-Erythrocytosis
Hematocrit Used to evaluate blood loss,
anemia, polycythemia &
dehydration. The hematocrit
value is elevated when the # of
RBC increases or when the
volume of plasma is reduced.
On the other hand, hematocrit
value falls when there is
excessive loss of RBC, as in
anemia or after blood loss.
0.37-
0.47
0.315 Decreased:
-Hemorrhage
-Anemia
-Fluid Overload
Increased:
-Congestive Heart Failure
-COPD
-Dehydration
-Erythrocytosis
Leukocyte Constitutes the total # of 5
types of leukocytes present in
1 mm3 of blood. It is a general
indicator of infection, tissue
necrosis, inflammation or bonemarrow activity.
5-10
x8 /L
11.8 x
1012/L
Decreased:
-Leukopenia
-Anemia
-Viral Infection
Increased:
-Leukocytosis
-Abscess
-Acute Infection
-Seizure
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Date
Taken
Name of
Laboratory
Procedure
Purpose of Laboratory
Procedure
Result Normal
Values
Clinical Significance
Neutrophils Neutrophils are the most
active cells & respond to
tissue damage or infection.The two types of neutrophils
are segmented and bands.
They are phagocytes that
provide an early, rapid
removal of cellular debris & a
large # of bacteria. Of all the
leukocytes, neutrophils are
the largest in group.
0.80 0.50-0.70 Increased:
-Bacterial Infection
-Severe burns-Rheumatic fever
-Ketoacidosis
Lymphocytes Consists of the B-cells & T-
cells that are responsible for
the activities of the immune
system.
0.16 0.25-0.40 Decreased:
-Aplastic Anemia
-Renal Failure
-Terminal Cancer
-Immunoglobulin
Deficiencies
Monocytes
Removes debris or foreign
particles from the articulation.
In the work of phagocytosis,
monocytes perform the samework as neutrophils, but their
# is greater & they are
capable of more work.
0.04 0.03-0.08 Increased:
-Acute Infection (bacteria,
viral, mycotic, rickettsial,
protozoan)
-Chronic Myeloid Leukemia-Ulcerative Colitis
Decreased:
-Hairy Cell Leukemia
-Bone Marrow Failure
-Aplastic Anemia
Thrombocyte Used to assess the bone
marrows ability to produce
platelets & to identify the
destruction or loss of
platelets in the circulation. It
is also used to evaluate the
untoward effects of
chemotherapy or radiation
treatment. Platelets function
is to initiate the process of
coagulation.
270 150-350
x109 /L
Decreased:
-Dengue Hemorrhagic fever
-Thrombocytopenia
Increased:
-Thrombocytosis
-Multiple Myeloma
-Iron Deficiency Anemia
-Lymphomas
-Renal Disease infection or
inflammation
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