Exam 1 Review. Cardiopulmonary Symptoms Physical Examination Clinical Laboratory Studies. WBC Count Differential.
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Exam 1 Review
Clinical Laboratory Studies
Gram Stain 2+ gram positive cocci;
1+ pus cells with many epithelial cells
Leukocytosis is present and appears to be the result of an increase in the neutrophils consistent with a bacteria infection (probably pneumonia). The slight increase in immature neutrophils (bands) represents a left shift indicating stress on the bone marrow to release more neutrophils to fight the infection. The relative decrease in the percentage of lymphocytes is caused by the absolute increase in the number of neutrophils and is not an abnormality.
The RBC count is within normal limits; however the decreases in Hb, Hct, MCV, and MCHC are consistent with a microcytic, hypochromic anemia. Further investigation is needed to identify the cause, but iron deficiency anemia is a likely reason.
The Gram stain of the sputum sample indicates that is was heavily contaminated with secretions from the mouth because many epithelial cells were present. The sample should be discarded and another sputum sample obtained.
The increase in WBC suggests leukocytosis and appears to be the result of an increase in the number of circulating neutrophils. This may be in response to a bacterial infection or acute stress. The RBC count, Hb, and Hct are slightly increased, consistent with polycythemia. These RBC differential findings are consistent with secondary polycythemia typical for patient with a chronic lung disease in which the arterial blood oxygen levels are persistently low. The electrolyte values reveal a decreased serum Cl- and increased serum CO2. This probably is related to the COPD and CO2 retention. Due to the increased HCO3- the kidneys excrete more Cl- in an effort to maintain electrical neutrality.
WBC 5.0 4.5-11.5
Sedimentation rate40 (elevated)
The low CD4 count suggest moderate immunocompromise most likely caused by HIV. The elevated sedimentation rate suggests inflammation, which could be caused by TB or other infection. The large area of redness around the skin test site is not significant, but the nodule in this immunocompromised patient indicates a TB infection. This patient’s CBC is normal despite his chronic infection and because TB does not usually cause an elevated WBC count. We anticipate the sputum cultures will be positive in 6 weeks and a PCR test for TB bacilli in the sputum to be positive.
The RBC and indices are all normal. The elevated WBC count suggests possible infection, however the lack of fever and minimal presence of band on the white cell differential suggests otherwise. This is most likely a case of pseudoneutrophilia, where marginated neutrophils are released into circulation as a result of sudden stress. This type of neutrophilia is usually transient and resolves spontaneously in a matter of hours.
List three reasons why patients with emphysema may have diminished breath sounds.
Explain why patients with obstructive lung disease breathe with a prolonged expiratory time.
Explain why atelectasis causes late inspiratory crackles as opposed to early inspiratory crackles.