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I.

Laboratory Examination
Microbiology Date: 6-16-09

Specimen: Pleural Fluid Result: No Pathogenic Organism isolated after 3 days Of intubation. Dr. Noel C. Santos MD FPSP

Histopathology
-Negative for Malignancy, Pleural Fluid ,Cytology

Date: 6-16-09

-Gross/Microscopic descriptions submitted for cytology is a 1L & 40ml dirty yellow fluid. -Micro show reactive mesothelial cells, lymphocytes, occasional polyps. No malignant cell seen. Mennen A. Alsol M.D. Pathologist

Hematology
Hgb - 157 Hematocrit - 0.48 WBC - 15.8 Segmenters - 0.90 Lymphocyctes - 0.07 Monocytes - 0.03

Date: 6-16-09
(120-150g/L) (0.37-0.47) (5.0-10.0x10/L) (0.42-0.75) (0.20-0.51) (0.02-0.09)

Hematology
Hgb - 128 Hematocrit - 0.39 WBC - 11.5 Segmenters - 0.91 Lymphocytes - 0.06 Monocytes - 0.03

Date: 6-23-09
(120-150 gm/L) (0.37-0.47) (5.0-10.0x10/L) (.42-.75) (.20-.51) (.02-.09)

Interpretation: Prior to his last hematology result the patient has infection related to presence of water in his lungs(Pleural effusion). Dr. Anne Paulette C. San Antonio MD

Hematology
Hgb - 128 Hematocrit - 0.39 WBC - 11.5 Segmenters - 0.91 Lymphocytes - 0.06 Monocytes - 0.03 (120-150 gm/L) (0.37-0.47) (5.0-10.0x10/L) (.42-.75) (.20-.51) (.02-.09)

Date: 06-24-09

Interpretation: Prior to his last hematology result the patient has infection related to presence of water in his lungs(Pleural effusion). Interpretation: Polycythemia with infection related to pleural effusion

Sonographic
Chest Ultrasound

Date: 6-30-09

-Pleural Effusion is present in Right hemithorax w/ estimated volume of 1,182 ml respectively. No No loculation or cenoolidation seen. Ma. Clarita D. Espanol MD, FPCR Radiologist Dr. Anne Paulette C. San Antonio MD

Histopathology
Specimen: Vocal cord masses

Date: 6-29-09

Pathologic Dx -Squamous papillomas showing chronic non-specific inflammation, Right and Left vocal cords. Gross/micro description -Specimen consist of grayish white tissue fragments measuring as labeled A. 1x0.6cm and B. 1.1x0.5cm Entire specimen submitted. Microsecretions A and B disclosed tissues lined by thickened stratified squamous epithelium set in a fibrovascular stroma with cocci of chronic inflammation. There is no evidence of malignancy.

Chest AP Sitting

Date: 6-29-09

-Follow-up Chest Film showed increase in previously noted PE in both hemithoraces suggest clinical correlation and follow-up. Dr. Rufely S. Laron MD FRAMS

Chest Ap Sitting

Date: 6-30-09

-Follow-up chest film when compared w/ the one done on June 29, 2009 show decrease in the amount of pleural effusion, bilaterally. There is a right sided chest tube in place w/ its tip at the level of the 8th posterior rib. Tracheostomy tube is again seen in place. There is minimal subcutaneous in the right chest wall.

Chest Ap Sitting

Date: 7-02-09

-Follow-up chest film 6-29-09 when compared to previous film dated 6-30-09 shows resolutions of previously noted right sided pleural effusion. However, no significant interval change in previously noted left sided pleural effusion other finding remain unchanged. Suggest clinical correlation & follow-up.