SURAT RUJUKAN KE HOSPITAL NEGERI
Date: 22.12.2010
Main Complaint:
For further review/ management and testings of HIV and Hep C
Current Problem:
xxx had been found to have thrombocytopenia and leucopenia recently in October 2010 at Hospital XXX. He was further referred to Hospital Ampang to exclude plasma cell dyscracia based on raised protein level / globulin level.
Further tests done at Hospital Ampang noted positive test for HIV screening and Hepatitis C screening (please referred to attaché results). The protein electrophoresis performed at IMR (protein lab) on 19/10/2010 did not detect any paraprotein or Bence Jones protein.
Our further history taking revealed his status of drug abuse. However, he denied the status of sexual promiscuity and there was no history of blood product transfusions.
As the cause of leucopenia and thrombocytopenia and raised globulin could be contributed by HIV/HepC infection, I appreciate your expert care to perform further tests to ascertain his status and to manage accordingly.
In regard to his leucopenia / thrombocytopenia, please refer him to Dr. XXX (Visiting Haematologist) at Hospital XXX Haemotology Clinic if you encounter new issue.
Laboratory:
19/11/2010
Liver Function Tests (LFT)
12:33 Bilirubin, Total 13.00 umol/L (0.00 – 17.00)
12:33 Alkaline Phosphatase 106 U/L (40 – 129)
12:33 Protein, Total 91 g/L ABNORMAL (66 – 87)
12:33 Albumin 30 g/L Abnormal (34 – 48)
12:33 Globulin 61 g/L ABNORMAL (20 – 35)
12:33 Albumin / Glubolin Ratio 0.49
12:33 Alanine Transaminase (SGPT) 72 U/L ABNORMAL (10 – 40)
LUPUS ANTI COAGULANT
12:33 Fibrinogen 2.45 g/L (2.00 – 4.00)
12:33 D-Dimer 0.29 ug/ml (0.00 – 0.50)
12:33 APTT Mixing Test 40.7 sec
12:33 APTT (LA Sensitive) 56.9 sec
12:33 DRVVT Screening 34.1 sec
12:33 DRVVT Confirm 38.5 sec
12:33 Kaolin Clotting Time sec not provided
12:33 Anti Cardiolipin (B2GlyIgG) Negative
12:33 Screen / Confirm Ratio 0.86
12:33 ANA – Immunofluorescence Negative
Comment: Method: Immunofluorescence
Hepatitis B surface Ab (HBs Ab)
12:33 Hepatitis B s Ab (Comment) Non Reactive
< 10 IU/L
Suggest to have Immunization for
Hepatitis B.
Hepatitis B surface Ag (HBs Ag)
12:33 Hepatitis B s Ag (Comment) Non Reactive
12:33 HIV Particle Agglutination Test Reactive
Hepatitis C Virus Ab (HCV Ab)
12:33 Anti HCV (Comment) Reactive
Human Immunodeficiency Virus (HIV)
12:33 HIV Ab (Comment) Reactive
Purpose Of Referral:
For further review / management of HIV / Hep C screening.
CLINICAL HAEMATOLOGY LABORATORY, HOSPITAL AMPANG
Date Received: 22-12-2010
TEST | RESULT | UNIT | PREVIOUS RESULT | |||
FBC | ||||||
RBC | L | 4.21 | 10^6/Ul | L | 3.92 | 19/11/2010 |
HGB | 13.0 | g/dl | L | 12.4 | 19/11/2010 | |
HCT | L | 37.2 | % | L | 35.9 | 19/11/2010 |
MCV | 88.4 | fL | 91.6 | 19/11/2010 | ||
MCH | 30.9 | pg | 31.6 | 19/11/2010 | ||
MCHC | H | 34.9 | g/dl | 34.5 | 19/11/2010 | |
RDW-SD | 48.5 | fL | 50.1 | 19/11/2010 | ||
RDW-CV | H | 15.1 | % | H | 15.0 | 19/11/2010 |
NRBC% | 0.0 | /100WBC | 0.0 | 19/11/2010 | ||
NRBC# | 0.00 | 10^9/L | 0.00 | 19/11/2010 | ||
RET% | 0.82 | % | 0.90 | 19/11/2010 | ||
RET# | L | 0.035 | 10^6/uL | L | 0.035 | 19/11/2010 |
IRF | 2.9 | % | 10.7 | 19/11/2010 | ||
LFR | 97.1 | % | 89.3 | 19/11/2010 | ||
MFR | 2.6 | % | 9.0 | 19/11/2010 | ||
HFR | 0.3 | % | 1.7 | 19/11/2010 | ||
RET-HE | 38.4 | pg | 38.7 | 19/11/2010 | ||
RPI | 0.5 | 0.5 | 19/11/2010 | |||
Hypochromic RBCs | 0.8 | % | 0.7 | 19/11/2010 | ||
Hyperchromic RBCs | 1.4 | % | 1.3 | 19/11/2010 | ||
Microcytes | 2.5 | % | 1.7 | 19/11/2010 | ||
Macrocytes | 7.0 | % | 8.4 | 19/11/2010 | ||
PLT | L | 44 | 10^3/uL | L | 56 | 19/11/2010 |
PDW | - | fL | 18.6 | 19/11/2010 | ||
MPV | - | fL | 12.5 | 19/11/2010 | ||
P-LCR | - | % | 45.8 | 19/11/2010 | ||
PCT | - | % | 0.07 | 19/11/2010 | ||
IPF | 6.5 | % | 11.0 | 19/11/2010 | ||
WBC | L | 2.96 | 10^3/uL | L | 2.67 | 19/11/2010 |
NEUT% | L | 38.8 | % | 61.8 | 19/11/2010 | |
NEUT# | L | 1.15 | 10^3/uL | L | 1.65 | 19/11/2010 |
IG% | 0.0 | % | 0.4 | 19/11/2010 | ||
IG# | 0.00 | 10^3/uL | 0.01 | 19/11/2010 | ||
LYMPH% | H | 49.0 | % | 30.3 | 19/11/2010 | |
LYMPH# | 1.45 | 10^3/uL | L | 0.81 | 19/11/2010 | |
MONO% | 9.5 | % | 6.0 | 19/11/2010 | ||
MONO# | 0.28 | 10^3/uL | L | 0.16 | 19/11/2010 | |
EO% | 2.7 | % | 1.9 | 19/11/2010 | ||
EO# | 0.08 | 10^3/uL | 0.05 | 19/11/2010 | ||
BASO% | 0.0 | % | 0.0 | 19/11/2010 | ||
BASO# | L | 0.00 | 10^3/uL | L | 0.00 | 19/11/2010 |
HFLC% | 0.7 | % | 0.4 | 19/11/2010 | ||
HFLC# | 0.02 | 10^3/uL | 0.01 | 19/11/2010 | ||
IP / RULE MESSAGE
61. Leucocytopenia -> SMEAR!
66. WBC < X-> Inform Doctor or Ward!
AHP: Sila klik sini dan sini untuk maklumat lanjut jika para pengunjung masih baru di blog ini atau rujuk categories “AKU” di blog wallpaper. Terima kasih.
Aku berpendapat keputusan BMA aku tak sepatutnya inadequate, apatah lagi hilang kerana maklumat tersebut sangat penting daripada masalah HIV itu sendiri.
