Systemic Lupous Erythematosus (SLE)

I.
INTRODUCTION
The immune system is a complex system within the body that is designed to fight
infectious agents, such as bacteria and other foreign microbes. One of the ways that the
immune system fights infections is by producing antibodies that bind to the microbes.
Lupus is an autoimmune disease characterized by acute and chronic

inflammation of various tissues of the body; autoimmune diseases, meaning, illnesses
that occur when the body's tissues are attacked by its own immune system. Patients
with lupus produce abnormal antibodies in their blood that target tissues within their own
body rather than foreign infectious agents. Because the antibodies and accompanying
cells of inflammation can affect tissues anywhere in the body, lupus has the potential to
affect a variety of areas. Sometimes lupus can cause disease of the skin, heart, lungs,
kidneys, joints, and/or nervous system.
Systemic Lupus Erythematosus (SLE) is a form of an autoimmune disease that

causes a chronic inflammatory condition in which a person's immune system attacks
several various organs or cells of the body causing damage and dysfunction. This is
called a multisystem disease because it can affect many different tissues and organs in
the body. Women, especially African-American and Asian women, are at highest risk for
developing SLE. Some patients with lupus have a very mild condition, which can be
treated with simple medications, whereas others can have serious, life-threatening
complications.
As for our client, Patient X, she was diagnosed with SLE in September of 2008,
and was recently admitted at XU-Community Health Care Center (XUCHCC), or
German Doctors Hospital on February 10, 2009. She was admitted at the said hospital
under the care of Dr. Gabatan for her 2 nd monthly chemotherapy to go on for 6 months,
which was advised to her by Dr. Saavedra of Cagayan de Oro Medical Center (COMC).
Her stay in the hospital was extended, however, because her chemotherapy had to be
postponed due to cutaneous lesions on her leg, one of which erupted. However, her
wound has shown progress; manifesting decreased swelling and less exudate draining
from the wound; thus, her chemotherapy was pushed through and she was then
discharged on the 23rd of February.
In conclusion, the group aims to present Patient X’s case comprehensively and
discuss the ideal and actual management done to improve the condition of the client,
including the individualized nursing care plan done to relieve the nursing problems
identified by the team in the small span of time that we were able to care for the patient.
In the process, we will be able to enhance our knowledge, skills and attitude and be
more effective with our nursing practice.
A. GENERAL OBJECTIVE
1
At the end of 1 hour of case presentation, we will be able to increase our
knowledge on conducting case studies especially for medical-surgical patients and on
the different concepts applied; enhance our critical thinking skills in formulating and
rationalizing individualized medical & nursing interventions appropriate for the
betterment of the patient and in delivering reports on our patient’s case; and lastly,
develop teamwork and a good attitude when interrelating with our patients, colleagues
and everyone in the health care setting.
B. SPECIFIC OBJECTIVES
At the end of 1 hour, we will be able to:

1. Establish effective communication between our group and the Clinical Instructors.
2. Present and describe the condition of the patient.
3. Present the development of the pathological condition and its clinical
manifestations.
4. Clearly and intelligibly report every part of our case study.
5. Present the various Nursing Care Plans we have devised specifically for the
patient.
6. Maintain confidentiality of the patient’s personal information and background.
7. Evidently show knowledge and confidence in reporting on assigned portions of the
case study.
8. Correctly and efficiently answer all the necessary questions thrown by the Clinical
Instructors after the case presentation.
C. SCOPES AND LIMITATIONS
2
Our case presentation revolves around our 25 year old female client with
Systemic Lupus Erythematosus (SLE). This includes the patient’s assessment gathered
during the Medical Rotation at Community Health Care Center (CHCC) – German
Hospital. The patient was assessed on February 15, 17, 19 and 20, 2009. Only the
present laboratory tests and results were obtained because the patient wasn’t able to
provide us with her past laboratory results pertaining to her condition, especially when
she was diagnosed with the disease in 2008. Also, the information we were able to
gather about her past admissions, such as her medications and laboratory tests, are
only verbalizations from the patient. No actual documents were seen by the group that
could make certain these verbalizations. The patient, also, wasn’t able to recall all the
drugs that were prescribed to her after her diagnosis of SLE. Further assessment of the
patient wasn’t possible for the group because she was discharged on February 23,
2009.
The study is limited only to the case of patient X. All the information gathered
about the patient was obtained from the patient herself, her husband, and her chart. The
general management presented in this study is the actual management given and done
to the patient as advised by her attending physician. The nursing management, on the
other hand, is formulated by the group to appropriately care for the patient, with basis
on the information obtained upon assessment and from the chart. This study also
covers the pathophysiology of SLE, as manifested specifically by the patient. Moreover,
related literatures were taken from the Medical and Surgical nursing book, Anatomy and
Physiology books, Nursing Care Plan book, Drug Handbook and internet sources.
II. ASSESSMENT
A. ASSESSMENT TOOL
3
I - GENERAL INFORMATION
Name: Patient X Age: 25 years old
Birthday: December 7, 1983 Civil Status: Married
Sex: Female Religion: Roman Catholic Occupation: Housewife
Informant: Patient X Relation: Patient
Admission Date: February 10, 2009 Time: 1:35 pm
Chief Complaint: None
Reason for admission: Scheduled Chemotherapy
Attending Physician: Dr. Gabatan
Diagnosis/Impression: Systemic Lupus Erythematosus
History of Present Illness:
(Refer to appendix A)
Past Medical/Surgical History:
History Date
Gave birth to a healthy full term baby boy through a November 9, 2002
normal spontaneous vaginal delivery (NSVD) at
Northern Mindanao Medical Center (NMMC)
Hospitalized and Diagnosed with GI Ulcer (admitted Late February 2008 (pt.
at Maria Reyna Hospital) can’t recall the exact
date)
Diagnosed with SLE by Dr. Fabia at Maria Reyna Around April 2008 (pt.
Hospital can’t recall the exact
date)
Hospitalized at German Doctors Hospital for January 10, 2008
Patient’s symptoms of SLE worsened
Scheduled first chemotherapy with Diagnosis of January 12, 2008
Lupus Nephritis by Doctor Saavedra
Vital Signs: HR = 80 bpm RR= 19 cpm BP = 100/60 mmHg

Temp = 37 °C
Vital Signs: Temperature Heart Rate Respiratory Blood Pressure

02/15/09 37⁰C 80bpm 19cpm 100/60mmHg
02/17/09 37.9⁰C 94bpm 25cpm 110/70mmHg
02/19/09 36.9⁰C 93bpm 20cpm 100/70mmHg
02/20/09 36.9⁰C 89bpm 21cpm 100/70mmHg
II - ACTIVITY/REST
Subjective
Usual activities/hobbies: Doing household chores, cooking and selling foods and
snacks, and hang-out with family
Leisure time activities: Watching TV, reading books
Limitations imposed by condition: Cannot perform usual activities due to stay in
4
hospital and difficulty walking due to her wound
at left lower leg
Sleep number of hours: 3-4 hours Naps: twice/day (9-10am and 3-4pm)
Aids: none
Difficulty in sleeping: none
Feeling on awakening: Patient doesn’t feel well rested even after sleeping
Others/Comments:
“Lisod kayo ko maglihok tungod sa hubag ug samad sa akong tiil, dapat
alalayan pajud ko aron dli kaau sakit, lisod na matumba palang ko” as
verbalized by the patient.
“Gakatulog ko’g 12 sa gabii dayon mata2x jud ko permi tungod sa saba ug sa

mga tao dani sa akong palibot ug tungod kay sakit akong tiil.” as verbalized
by the patient.
“Pangbawi sa akong tulog matulog ko ug ginagmay sa buntag ug hapon” as

“Dili ko galisod og tulog pero kajut rapud lagi akong tulog,” as verbalized by
the patient.
Objective
Observed response to activity:
Cardiovascular: Increased PR- 94bpm Respiratory: Increased RR-25cpm
Mental Status: Alert Posture: Slouched
LOM: Slow movement Tremors: None
Others/Comments: Patient is cautious with movements to prevent pain and injury
at left lower leg.
III – CIRCULATION
Subjective
History of hypertension: (+) Paternal Heart trouble: None
Ankle/leg edema: Present; Facial and bipedal Slow healing: Present
Claudication: (+) Left lower leg Cough/hemoptysis: None
Extremities: Numbness: (+) Left lower leg Tingling: (+) Left lower leg
Change in frequency/amount of urine: None
Others/Comments:
“High blood man ang akong papa,” as verbalized by the patient.
“Karon pajud ko nasamad nga ingon ani dayon pagmasamad ko dugay2x pud
siya maayo” as verbalized by the patient.
“Katong mang-gahi akong mga tudlo kada panglaba nako, ako ra man pud
silang ibalik… dili na kinahanglan iingon sa doctor.”, as verbalized by the
patient.
5
“Nanghupong man ko adtong pagka-admit nako. Dani sa akong nawong og
tiil. Naa pa gani sya hantud karun,” as verbalized by the patient.
“Init akong paminaw. Tan-awa daw kung gihilantan ba ko,” as verbalized by

the patient.
Objective
BP R: Lying: 100/70mmHg Sitting: 100/70mmHg
Standing: 100/70mmHg
L: Lying: 100/70mmHg Sitting: 110/70mmHg
Standing: 100/70mmHg
Pulse Pressure: 40mmHg PMI: Apex of the heart
Heart Sounds: Rate: 80bpm Rhythm: Normal sinus rhythm
Pulse: Carotid: Palpable Radial: Palpable
Popliteal: Palpable Temporal: Palpable
Femoral: Palpable Dorsalis Pedis: Palpable
Vascular Bruit: None Breath Sounds: Bronchovesicular
Jugular Vein Distention: None
Extremities: Temperature: warm to touch
Color: Normal skin color of patient: Dark
Capillary Refill: Immediate return of color(less than 2 secs.)
Homan’s sign: None
Varicosities: None
Color/Cyanosis: Nail beds: Pale Lips: Dry, pinkish
Mucous membranes: Moist, pinkish
Sclera: slightly yellowish sclera, capillaries sometimes evident
Others/Comments: Patient has normal sinus rhythm; noted facial and bipedal
edema is only mild which makes the pulses palpable.
IV - EGO INTEGRITY
Subjective
Report of Stress Factors: Physically and emotionally stressed due to condition
Ways of handling stress: Rest, patient also wants to be alone
Financial Concerns: Present, always a problem felt by the family
Relationship Status: Married; Husband is very supportive and caring to the
patient
Lifestyle: Patient does not smoke, does not practice alcohol and substance
abuse; however, she does not practice exercise and safety measures.
Recent changes: Patient is in bed and can’t perform usual activities
independently due to pain experienced at left lower leg
Feelings of: Helplessness: None Hopelessness: None
Powerlessness: None
Other/Comments:
6
“ Gaka-guol jud ko mapangit najud ko ug samot, Dili na gani ko ganahan mag
tan-aw sa samin kay mga rashes ra nako ako gakakit-an’” as verbalized by
the patient.
“Gusto ko ako ra isa dili ko ganahan makit-an sa uban na inani akong nawong
Sakit pud akong tiil maypag magpuyo, arang2x pa kung ako nalang isa.” as
“Dili man ko gakawad-an ug pag-asa kay o.k raman ko” as verbalized by the
patient.
“Akong bana ra gyud ang gabantay sa ako karon kay akong mga ginikanan
layo, naa sa Medina”, as verbalized by the patient.
Objective
Emotional status (Check those that apply)
(√) Calm ____Anxious ____ Angry
____ Withdrawn ____Fearful ____ Irritable
____ Euphoric
Observed physiologic response: Response and behavior are appropriate

Others/Comments: Patient is very cooperative.
V – ELIMINATION
Subjective
Usual Bowel Pattern: Every morning before breakfast
Character of Stool: Soft, formed, yellowish brown in color, aromatic and
moderate in amount
Last BM: 06:30 AM (Feb. 15, 2009) Laxative use: none
History of bleeding: None Hemorrhoids: None
Constipation: None Diarrhea: None
Usual voiding pattern: 8x a day; scanty in amount Incontinence: None
Urgency: None Retention: None Frequency: (+)
Pain/Burning/Difficulty in voiding: None
History of kidney/bladder disease: (+), diagnosed with Lupus Nephritis by Dr.
Saavedra Last January 12, 2009
Others/Comments:
“Ok man akong pagkalibang, kas-a ra jud ko sa isa ka adlaw malibang” as
“Dili man jud ko palainom of tubig pero sige lang gihapon ko og ihi-ihi2x. Sa
isa ka adlaw mga ka-siyam siguro ko gapangihi,” as verbalized by the patient.
Objective
Abdomen: Tender: None Soft/Firm: Soft
Palpable Mass: None Size/Girth:42 inches
Bowel Sounds: Present (15 bowel sounds per minute)
7
Bladder palpable: Not palpable Distended: No distention
Others/Comments: Urinary elimination is altered. Patient has urinary frequency
with scanty amount of urine.
VI - FOOD/FLUID
Subjective
Usual diet (type): DAT Number of meals daily: 3 meals a day
Last meal/intake: Lunch (12:00nn)(Feb. 15, 2009) Loss of appetite: (+)
sometimes
Nausea/Vomiting: None Dentures: 4 in lower front teeth
Allergy/Food intolerance: (+) Crabs and shrimp
Heartburn/Indigestion: (+)
Mastication/swallowing problems: None
Usual Weight: 65 Kg Changes in weight: Increased-70kg
Diuretic use: None
Others/Comments:
“Mahilig jud ko ug karne labin nag baboy. Usahay pag walay kwarta, isda
nalang. Dili kayo ko hingaon ug gulay, makabuot man pud ko kay ako man
ang galuto. Dili pud kaau ko makakaon ug prutas kay wala may kwarta”as
“Dili pud ko mahilig ug gatas, Kape nuon kaisa sa usa ka adlaw. Usahay pud
juice kung wala jud, tubig akong ga.imnon” as verbalized by the patient.
“Niniwang jud ko sauna kay dili naman kaayo ko gakaon. Sauna pud, katong
wala pa ko nagsugod ug tumar sa tambal, pait akong baba dli ko kasabot
murag taya, ambot basta murag ingana. Mawala raman pud pag tootbrushan
pero mubalik napud mao na di kaau ko ganahan magkaon kay pait jud akong
paminaw” as verbalized by the patient.
“Kabuhion jud ko usahay labon na kung mapasmo ko unya mokaon dayon

diretso” as verbalized by the patient.
“Nanghupong man ko adtong pagka-admit nako. Dani sa akong nawong og

tiil. Naa pa gani sya hantud karun,” as verbalized by the patient.
Objective
Current Weight:70 kg Height: 5’4”
Body Build: Round and plump
Skin Turgor: Good Mucous membranes: Moist, pinkish
Hernia/Mass: None
Edema: General: None Dependent: None
Periorbital: None Ascites: None
Thyroid enlarged: Not enlarged Halitosis: None
8
Condition of teeth/gums: With 28 adult teeth and four false teeth; smooth
yellowish tooth enamel; presence of plaque and cavities in the molars; gums are
pink and moist; no bleeding noted
Appearance of tongue: Pink and moist with thin whitish coating; slightly rough
with raised papillae
Others/Comments: Patient has Facial and Bipedal edema;
BMI= overweight- 26.7
VII – HYGIENE
Subjective
Activities of Daily Living (Dependent/Independent)
Pls. encircle
Mobility: D / I Feeding: D/I
Hygiene: D / I Dressing: D/I
Toileting: D/I
Others: None
Equipment/prosthetic devices required: None
Assistance provided by: Husband and son
Others/Comments:
“Galisod jud ko ug lakaw unya mahadlok pud ko musakit ug samot akong tiil
mao nang gapatabang ko sa akong bana sa pag.cr” as verbalized by the
patient.
Objective
General Appearance: Patient is dressed in clean pair of shorts and shirt, has
unkempt hair; skin on extremities look dry and clean with wound dressing at left
lower leg, face has butterfly rash that has darkened the skin on the bridge of the
nose and around patient’s cheeks.
Manner of dress: Appropriate for age Personal Habits: Takes a bath once a day
Body odor: None Condition of scalp: Dry, with flaking
Presence of vermin: (+)
Others/Comments: Patient appears neat except for her unkempt hair. Patient
also has pediculosis upon inspection.
VIII – NEUROSENSORY
Subjective
Fainting Spells/dizziness: None
Headache: Location: Temporal area
Onset: Occurs suddenly
Frequency: unpredictable
Seizures: None Aura: N/A How controlled: N/A
Eyes: Vision Loss: R: 120+ L: 120+
Last examination: around November of 2008
Glaucoma None Cataract: None
Ears: Hearing Loss R: None L: None Last examination: not examined
Sense of smell: No problem reported Epistaxis: None
9
Others/Comments:
“Ang sakit sa akong ulo kay kalit lang mutukar. Mawala ra siya pag akong
ipahulay. Dili pud ko gatumar ug tambal kung musakit akong ulo” as
Objective
Mental Status
Oriented / Disoriented Time: (√) Place: (√) Person: (√)
(√) Alert ____ Drowsy ____ Lethargic
____ Stuporous ____ Comatose (√) Cooperative
____ Combative
Affect: Appropriate Delusions: None Hallucinations: None
Memory: Recent: Good: Able to recall last meal intake
Remote: Good: Able to recall onset of signs and symptoms of existing disease
Speech pattern: Spontaneous Congruence: Congruent
Glasses: None Contacts: None Hearing Aids: None
Pupil size/reaction: R: PERRLA – 2mm L: PERRLA – 2mm
Facial droop: None Swallowing: Good: No problems with swallowing
Handgrip/release: R: Strong L: Strong
Posturing: Slouched DTR: normal - +2 Paralysis: None
Others/Comments: Patient is active, coherent and cooperative.
IX – PAIN
Subjective
Onset: Patient started to feel pain in early February of 2009. Since then pain
wasn’t relieved Duration: Pain is always present
Location: at the left lower leg Intensity: Pain score of 6 with 10 as the highest
Frequency: Pain is always present Quality: Bearable
Description of Pain (check all that apply)
____Shooting (√)__Stabbing ____Gnawing
(√)__ Sharp ____ Dull ____ Aching
____ Numb ____ Throbbing ____ Radiating
(√) Burning ____ Unbearable
Precipitating Factors: Lesions in lower left leg

Aggravating Factors: Exerting pressure on left lower leg such as upon movement
and contact with a surface.
How relieved: Slowed movement and placing of cold packs around the painful
area
Associated Symptoms: Headache
Others/Comments:
“Tulo mani ka burot, isa ka dako ug duha ka gagmay, sa pagka-admit nako
dani nibuto ni ang pinakadako. Sukad sa pagkasamad nako ani nga burot
sobra kasakit jud akong gibati unya dili gakawala ang sakit” as verbalized by
the patient.
10
“Dili ko ganahan mag-lihok2x kay musakit ug samot akong tiil. Pagmusakit
akong tiil musakit pud akong ulo”, as verbalized by the patient.
“Akong gabutangan ug botelya na naai bugnaw na tubig ang ibabaw sa

akong samad aron mahubsan ang ka-sakit,” as verbalized by client.
Objective
(Check all that apply)
____Grimacing ____ Being Irritable
____Moaning ____ Sitting Rigidly
(√) Sighing (√) Moving very slowly
(√) Limping ____ Clenching Teeth
(√) Avoiding Physical Activity ____ Narrowed focus
(√) Lying down during the day
(√) Requesting help with walking
(√) Walking with an abnormal gait
(√) Stopping frequently while walking
____ Frequently shifting posture or position
(√) Moving in a guarded or protective manner
____Holding or supporting the painful body area
____ Asking to be relieved from tasks or activities
____ Asking such questions as “Why did this happen to me?”
____ Using a cane, cervical collar, or other prosthetic
Others/Comments: Patient is able to tolerate pain.
X – RESPIRATION
Subjective
Dyspnea, related to: None
Cough/sputum: None
____ Bronchitis ____ Asthma ____ Tuberculosis
____ Emphysema ____ Recurrent Pneumonia
____ Exposure to noxious fumes
Smoker: No Pack/day: N/A Number of years: N/A
Use of respiratory aids: None Oxygen: None
Others/Comments:
“Dili ko gapanigarilyo. Wala jud koy problema sa akong pag-ginhawa, Pero sa
among balay gapanigarilyo akong magulang, dugay2x pud ko na-expose adto
kay sugod 14 hantod 19 years old man ko adto.” as verbalized by the patient.
Objective
Respiratory: Rate: 19 cpm Depth: Deep Symmetry: Symmetrical
Use of accessory muscle: None Nasal Flaring: None
Fremitus: Present Breath sounds: Bronchovesicular
Cyanosis: None Clubbing of fingers: None
11
Sputum characteristics: N/A
Mentation/restlessness: None
Others/Comments: Patients had no observable signs of respiratory problems.
Respiration rate and rhythm is within normal range.
XI – SAFETY
Subjective
Allergies/sensitivity: Crabs and shrimp
Reaction: Facial Redness and warmth
History of STD (date/type): None
Blood transfusion/number: None When: N/A
History of Accidental injuries: None
Fractures/dislocations: None
Arthritis/unstable joints: None
Back problems: None
Changes in moles: None Enlarged nodes: None
Prosthesis: None Ambulatory devices: None
Expression of ideation of violence (self/others): Patient is non violent to
Others/ comments:
“Allergic ko sa alimango ug uwang, kung makakaon ko mamula akong
nawong unya manginit” as verbalized by the patient.
Objective:
Temperature: 37°C Diaphoresis: None
Skin integrity: Dry but not intact at left lower leg; wound dressing present
Scars: Light scars present in both legs and arms
Rashes: Presence of butterfly rash in the face (across the bridge of the nose and
the cheeks)
Lacerations: None
Ulcerations: None Ecchymosis: None Blisters: None
Burns, degree/percent: None
Drainage (note location): None
General Strength: Patient is able to do daily activities but with some limitations in
movement due to pain felt at left lower leg; weakness is only noted when patient
experiences fever
Muscle tone: good
Gait: Abnormal-Limping Paresthesia/Paralysis: None
Others/Comments: Patient has an abnormal gait due to pain in the left lower leg.
XII – SEXUALITY
Sexually active: Not at the moment

Sexual concerns/difficulties: Unsatisfactory coitus due to pain felt in the lower
extremity
Recent change in frequency/interest: minimal sexual interaction
12
Subjective
Age of menarche: 14 y.o.
Length of cycle: irregular (ranging from 28 -60 days) Duration: 5 days
Last menstrual period: Jan. 15, 2009 Menopause: N/A
Vaginal discharge: Leukorrhea
Bleeding between periods: None
Deliveries/Pregnancies: G 1 P 1 T 1 P 0 A 0 L 1
Episiotomy: mediolateral (towards right side) Lochia: None
Complications of pregnancy: None Surgeries: None
Hormonal therapy/calcium use: Use of Calcium supplement for almost a month
(Jan 15- Feb 5 2009) as prescribed by Dr. Gabatan
Practices self-breast examination: No Discharges: None
Last Pap smear: Never Method of birth control: None
Others/Comments:
“Adtong mi-aging tuig ka lima ko wala nag mens. Tagsa ka bulan ang biya,
natingala jud ko.” as verbalized by the patient.
“Wala pa jud ko sukad naka pa pap smear”, as verbalized by the patient.
Objective
Examination:
Genitals: Not assessed due to patient’s refusal and lack of privacy. Patient
verbalized that her genitals are normal.
Breasts: Breasts are saggy, slightly unequal in size; skin smooth and intact; no
tenderness, masses or nodules
Vaginal warts/lesions: None
Others/Comments: No discharges from the breast were noted.
XIII - SOCIAL INTERACTIONS
Subjective
Marital status: Married Years in relationship: 6 years
Living with: Husband and son
Concerns/stresses: Financial concerns for needs and wants
Extended family: None
Other Support Persons: None
Role within family structure: Full time housewife and mother
Report of problems related to illness/condition: Painful left lower leg and
presence of butterfly rash on the face hinders social interaction thus, patient
wants to be alone.
Others/Comments:
“Dili nako ganahan na mag.gawas2x sa balay kai pangit na kaau ko ” as
“Gusto ko ako ra isa dili ko ganahan makit-an sa uban na inani akong nawong
Sakit pud akong tiil maypag magpuyo, arang2x pa kung ako nalang isa.” as
13
Objective
Speech: (√) Clear ____Slurred
____Unintelligible ____ Aphasic
Others/Comments: Patient is very accommodating and cooperative.
XIV - TEACHING/LEARNING
Subjective
Dominant Language (specify): Visayan Literate: (√)
rd
Educational Level: 3 year High School
Health beliefs/practices: Seeks herbal meds rather than medical advice; does not
report all felt signs and symptoms to the doctor; does not take the existing
condition seriously due to lack of knowledge regarding the disease.
Familial risk factors (check all that apply & indicate relationship):
(√) Diabetes Paternal
____Tuberculosis _______
____ Heart Disease _______
Stroke _______
(√) High BP Paternal
____ Epilepsy _______
____ Kidney Disease _______
Cancer _______
____ Mental Illness _______
Use of Alcohol (amount/frequency): No
Others/Comments:
“Mas ganahan jud ko ug herbal2x sa kaysa sa tambal jud” as verbalized by
the patient.
“Wala na sad ko nag ingon sa doctor atong nangalarot akong buhok kai ok ra
man pud to nako. Wala ra kayo ko nahadlok ato.”, as verbalized by the
patient
“Akong papa kay diabetic man to unya high blood pa jud” as verbalized by
the patient.
XV - Body Map: (Illustrate in the body map how your patient looks like, e.g. tubes
inserted, bruises, surgical incisions, physical abnormalities, affected areas. Mark with a
small “X” where it is located or draw it on the body map and then label it in the space
provided.)
Date: February 15,2009
xx General Appearance:
x Headache: Temporal area
Yellowish Sclera
Butterfly Rash
14
Vission loss: +120 OU
Dry lips
Pale nailbeds
X Use of Diaper
IVF#6- D5 0.3%NaCl @KVO rate
X X
Wound dressing
Skin is reddened,swollen &
X warm Pain score=6(10as
highest)
Cracked heels
X Moving slowly while
supporting
Painful area
Date: February 17, 2009

Yellowish Sclera
Butterfly Rash
Dry lips
Pale nailbeds
X X X Venipuncture with dry
cottonball
Use of diaper
Wound dressing
X Skin is reddened,swollen &
warm Pain score=6(10as
highest) X
15
Moving slowly while supporting
Painful area
Cracked heels

Yellowish Sclera
Butterfly Rash
Dry lips
Pale nailbeds
X X X Venipuncture with dry
cottonball
Use of Diaper
Wound dressing
X Skin with reduced redness &
X swelling
warm;Pain score=5(with10 as
highest)
Cracked heels
Moving slowly while
supporting
Painful area
Yellowish Sclera
Butterfly Rash
Dry lips
IVF#10- D5 0.3%NaCl KVO
Pale nailbeds
X X
16
Venipuncture with dry
cottonball
X Wound dressing
Skin with reduced redness &
swellingwarm;
Pain=4(with10as highest)
X Moving slowly while supporting
Painful area
Cracked heels
B. DIAGNOSTICS AND LAB RESULTS
I. LATEST LAB RESULTS
URINALYSIS (February 20, 2009)
Color Yellow Normal

Transparency Slightly Hazy Normal
Protein ++++ Proteinuria due to patient’s
lupus nephritis.
pH 6.0 Normal
Specific Gravity 1.030 Normal
Pus Cells >50/hpf May reveal some
destructive or healing
process in the urinary tract
17
anywhere from the kidney
to the bladder.
RBC 13-15/hpf Can be due to infection,
trauma or any kidney
disease that alters its
permeability.
Squamous Moderate Normal
Bacteria Few Normal
Mucus thread Few Normal
HEMATOLOGY (February 18, 2009)
Hematocrit 38.0 Normal

Hemoglobin 12.6 Normal
WBC Count 8,600 Normal
Differential Count:
Segmenters 65 Normal
Lymphocytes 32 Normal
Platelet Count 313 Normal
URINALYSIS (February 14, 2009)
Color Yellow Normal

Transparency Hazy Normal
Protein +++ Proteinuria due to patient’s
lupus nephritis.
pH 7.0 Normal
Pus Cells 0-2/hpf Normal
RBC 13-15/hpf Normal
Squamous Rare Normal
Bacteria Rare Normal
BLOOD CHEMISTRY (February 11, 2009)
FBS 98.0 Normal

Creatinine in Serum 0.6 Normal
Sodium 133.9 Hyponatremia which can be
manifested through nausea,
vomiting, headache and
malaise.
Potassium 3.7 Normal
Hematocrit 38.0% Normal

Hemaglobin 12.7% Normal
18
FBS 98.0 Normal
Sodium 133.9 Hyponatremia which can be
manifested through
nausea,vomiting, headache
and malaise.

Hemoglobin 12.7% Normal
WBC Count 17,000 Leukocytosis due to
inflammation, bacterial
infection, trauma and
stress.
Differential Count:
Segmenters 86% Normal
Lymphocytes 14% Normal
Platelet Count 350,000 Normal
ESR 110.0 mm/hr A very high ESR usually
has an obvious cause, such
as a marked increase in
globulins that can be due to
a severe infection. A rising
ESR can mean an increase
in the inflammation or a
poor response to a therapy.
ECG RESULT (February 10, 2009)
NAME: Patient X ID NUM.: 219406

AGE: 25 years old SPEED: 25mm/sec
SEX: Female DATE: Feb. 10, 2009
REQUESTING PHYSICIAN: Dr. Gabatan PERFORMED BY: Therese Beth Akut
(Refer to appendix D-Figure 1)
II. PREVIOUS LAB RESULTS:
URINALYSIS (January 26, 2009)
Color Dark Yellow Concentrated urine can be

due to dehydration.
Transparency Cloudy Indicative of infection and
stasis of urine.
19
Protein ++++ Proteinuria may be due to
patient’s lupus nephritis or
any other disease involving
the kidneys.
Sugar Negative Normal
pH 6.5 Normal
Pus Cells 50 > TNTC Infection present.
permeability.
Squamous Abundant Acute tubular necrosis may
be present with the
infection.
Bacteria Abundant Infection is present in the
urinary tract.
HEMATOLOGY (January 25, 2009)

Hemoglobin 14.2 gm/dL Normal
WBC Count 13,700 Leukocytosis due to
inflammation, bacterial
infection, trauma and
stress.
Differential Count:
Segmenters 90% Infection present
Lymphocytes 10% Indicative of immune
deficiency that decreases
T-lymphocytes.
a severe infection.
BLOOD CHEMISTRY (January 8, 2009)
FBS 88.0 mg/dL Normal

Creatinine in Serum 0.8 mg/dL Normal
Blood Uric Acid 5.4 mg/dL Normal
Albumin 4.3 mg/dL Normal
Alkaline Phosphatase 159.0 IU/L Normal
SGOT 41.0 IU/L Normal
Sodium 134.3 meq/L Normal
20
Potassium 3.1 meq/L Hypokalemia resulting from
diarrhea, increased diuresis
or vomiting.
HEMATOLOGY (January 8, 2009)
Hematocrit 44% Normal

Differential Count:
T-lymphocytes.
Eosinophils 2% Normal
Stabs 6% Normal
a severe infection.
URINALYSIS (January 5, 2009)
Color Amber Normal

Transparency Cloudy Indicative of infection and
stasis of urine.
the kidneys.
pH 6.0 Normal
Pus Cells 0-2/hpf Infection present.
RBC Abundant Can be due to infection,
permeability.
Squamous Few Normal
Bacteria Few Infection is present in the
urinary tract.
21
URINALYSIS (December 20, 2008)
Color Yellow Normal

Transparency Hazy Indicative of infection and
stasis of urine.
Protein +++ Proteinuria may be due to
the kidneys.
pH 6.0 Normal
Casts:
Coarsely Granular 0-1 Suggest renal disease is
present.
Finely Granular 0-1 A significant renal disease
is present.
permeability.
be present with the
infection.
Bacteria Abundant Infection in the urinary tract.
HEMATOLOGY (December 5, 2008)
ESR 89 mm/hr A very high ESR usually

a severe infection.
HEMATOLOGY (December 3, 2008)

WBC Count 14,300 Infection is present.
Differential Count:
Segmenters 89% Infection present.
T-lymphocytes.
22
URINALYSIS (December 3, 2008)
Color Amber Normal

Transparency Turbid Indicative of bacterial
infection.
the kidneys.
pH 6.0 Normal
RBC >50/hpf Can be due to infection,
permeability.
Squamous Few Normal
Amorphous Crystals Few Normal
URINALYSIS (November 19, 2008)
Color Yellow Normal

stasis.
the kidneys.
pH 6.5 Normal
permeability.
Bacteria Abundant Infection is present in the
urinary tract.
Mucus Thread Few Normal
23
HEMATOLOGY (October 25, 2008)

WBC Count 10,900 Infection is present.
Differential Count:
Lymphocytes 27% Normal
a severe infection.
URINALYSIS (November 19, 2008)
Color Yellow Normal

stasis.
Protein +++ Proteinuria may be due to
the kidneys.
pH 6.0 Normal
permeability.
be present with the
infection.
Bacteria Few Infection is present in the
urinary tract.
Mucus Thread Few Normal
CRP RESULT (September 25, 2008)

24
AGE: 24 years old DATE: Sept. 25, 2008
SEX: Female: RESULT: Negative
INTERPRETATION:
ECG RESULT (September 25, 2008)

AGE: 24 years old SPEED: 25mm/sec
SEX: Female DATE: Sept. 25, 2009
REQUESTING PHYSICIAN: Dr. Gabatan PERFORMED BY: Chona Giputa
(Refer to Appendix D- Figure 2)
URINALYSIS (September 25, 2008)
Color Yellow Normal

Transparency Turbid Bacterial infection present.
Protein ++++ Proteinuria due to patient’s
lupus nephritis.
pH 6.0 Normal
Pus Cells >50 TNTC May reveal some
destructive or healing
process in the urinary tract
anywhere from the kidney
to the bladder.
RBC 1-3/hpf Normal
Bacteria Few Infection is present.
BLOOD CHEMISTRY (September 25, 2008)
FBS 80.1 Normal

Blood Uric Acid 4.1 Normal
Albumin 2.2 Low albumin level can
suggest conditions in which
the body does not absorb
25
or digest protein or in which
large amount of proteins
are lost from the intestines.
Alkaline Phosphatase 144.7 Normal
SGOT 60.9 SGOT increase can be due
to liver damage due to
medications, trauma and
diseases.
Sodium 137.6 Normal
HEMATOLOGY (October 25, 2008)

Differential Count:
Segmenters 90% Infection present
T-lymphocytes.
a severe infection.
ANA DETERMINATION (April 21, 2008)
RESULT: Positive (++++) TITER: 1:80

PATTERN: Homogenous Pattern Predominating
INTERPRETATION: Result indicates that the person is positive with SLE (Systemic
Lupus Erythromatosus
26
). A titer of 1:80 is considered a low-positive and the homogenous pattern is most often
seen in patients with SLE.
ANATOMY AND PHYSIOLOGY
SKIN
The skin is the outer covering of the body, also known as the epidermis. It is the
largest organ of the integumentary system made up of multiple layers of epithelial
tissues, and guards the underlying muscles, bones, ligaments and organs. The
adjective cutaneous literally means "of the skin".
Because it interfaces with the environment, skin plays a very important role in
protecting (the body) against pathogens. Its other functions are insulation, temperature
regulation, sensation, synthesis of vitamin D, and the protection of vitamin B folates.
Severely damaged skin will try to heal by forming scar tissue. This is often discolored
and depigmented.
Skin has pigmentation, or melanin, provided by melanocytes, which absorb some

of the potentially dangerous ultraviolet radiation (UV) in sunlight. It also contains DNA-
repair enzymes that help reverse UV damage, and people who lack the genes for these
enzymes suffer high rates of skin cancer. One form predominantly produced by UV
light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can
often be deadly. Human skin pigmentation varies among populations in a striking
manner. This has led to the classification of people(s) on the basis of skin color.
27
The skin serves as a protection, an anatomical barrier from pathogens and
damage between the internal and external environment in bodily defense; sensation,
contains a variety of nerve endings that react to heat and cold, touch, pressure,
vibration, and tissue injury; heat regulation, the skin contains a blood supply far greater
than its requirements which allows precise control of energy loss by radiation,
convection and conduction. Dilated blood vessels increase perfusion and heat loss
while constricted vessels greatly reduce cutaneous blood flow and conserve heat;
control of evaporation, the skin provides a relatively dry and impermeable barrier to fluid
loss. Loss of this function contributes to the massive fluid loss in burns; aesthetics and
communication, others see our skin and can assess our mood, physical state and
attractiveness; storage and synthesis, acts as a storage center for lipids and water, as
well as a means of synthesis of vitamin D by action of UV on certain parts of the skin.;
excretion, sweat contains urea, however its concentration is 1/130th that of urine, hence
excretion by sweating is at most a secondary function to temperature regulation;
absorption, oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in small
amounts, some animals using their skin for their sole respiration organ. In addition,
medicine can be administered through the skin, by ointments or by means of adhesive
patch, such as the nicotine patch or iontophoresis. The skin is an important site of
transport in many other organisms; water resistance, the skin acts as a water resistant
barrier so essential nutrients aren't washed out of the body.
LYMPH NODE
A Lymph node is an organ consisting of many types of cells, and is a part of the
lymphatic system. Lymph nodes are found all through the body, and act as filters or
traps for foreign particles. They contain white blood cells. Thus they are important in the
proper functioning of the immune system.
Lymph nodes also have clinical significance. They become inflamed or enlarged
in various conditions, which may range from trivial, such as a throat infection, to life-
threatening such as cancers. In the latter, the condition of lymph nodes is so significant
28
that it is used for cancer staging, which decides the treatment modalities to be
employed, and for determining the prognosis.
Lymph nodes can also be diagnosed by biopsy whenever they are inflamed.
Certain diseases affect lymph nodes with characteristic consistency and location.
Pathogens can set up infections anywhere in the body. However, lymphocytes

will meet the antigens in the peripheral lymphoid organs, which include lymph nodes.
The antigens are displayed by specialized cells in the lymph nodes. Naive lymphocytes
(meaning the cells have not encountered an antigen yet) enter the node from the
bloodstream through specialized capillary venules. After the lymphocytes specialize
they will exit the lymph node through the efferent lymphatic vessel with the rest of the
lymph. The lymphocytes continuously recirculate the peripheral lymphoid organs and
the state of the lymph nodes depends on infection. During an infection, the lymph nodes
can expand due to intense B-cell proliferation in the germinal centers, a condition
commonly referred to as "swollen glands".
WHITE BLOOD CELL
White blood cells, or leukocytes, are cells of the immune system defending the
body against both infectious disease and foreign materials. Five different and diverse
types of leukocytes exist, but they are all produced and derived from a multipotent cell
in the bone marrow known as a hematopoietic stem cell. Leukocytes are found
throughout the body, including the blood and lymphatic system
29
.
The number of leukocytes in the blood is often an indicator of disease. There are
normally between 4×109 and 11×109 white blood cells in a litre of blood, making up
approximately 1% of blood in a healthy adult. In conditions such as leukemia, the
number of leukocytes is higher than normal, and in leukopenia, this number is much
lower. The physical properties of leukocytes, such as volume, conductivity, and
granularity, may change due to activation, the presence of immature cells, or the
presence of malignant leukocytes in leukemia.
KIDNEYS
The kidneys are organs that have numerous biological roles. Their primary role is
to maintain the homeostatic balance of bodily fluids by filtering and secreting
metabolites (such as urea) and minerals from the blood and excreting them, along with
water, as urine. Because the kidneys are poised to sense plasma concentrations of ions
such as sodium, potassium, hydrogen, oxygen, and compounds such as amino acids,
creatinine, bicarbonate, and glucose, they are important regulators of blood pressure,
glucose metabolism, and erythropoiesis (the process by which red blood cells
(erythrocytes) are produced). The medical field that studies the kidneys and diseases of
the kidney is called nephrology.
30
In humans, the kidneys are located in the posterior part of the abdominal cavity.
There are two, one on each side of the spine; the right kidney sits just below the
diaphragm and posterior to the liver, the left below the diaphragm and posterior to the
spleen. Above each kidney is an adrenal gland (also called the suprarenal gland). The
asymmetry within the abdominal cavity caused by the liver results in the right kidney
being slightly lower than the left one while the left kidney is located slightly more medial.
The bulk of water re-absorption in the vertebrate kidney takes place in the loop of
Henle.
The kidneys are retroperitoneal and range from 9 to 13 cm in diameter; the left
slightly larger than the right. They are approximately at the vertebral level T12 to L3.
The upper parts of the kidneys are partially protected by the eleventh and twelfth ribs,
and each whole kidney and adrenal gland are surrounded by two layers of fat (the
perirenal and pararenal fat) and the renal fascia which help to cushion it. Congenital
absence of one or both kidneys, known as unilateral (on one side) or bilateral (on both
the sides) renal agenesis, can occur. Renal agenesis is also the base for the renal anal
gland which helps the large intestine absorb water.
The kidneys receive unfiltered blood directly from the heart through the
abdominal aorta which then branches to the left and right renal arteries. Filtered blood
then returns by the left and right renal veins to the inferior vena cava and then the heart.
Renal blood flow accounts for 20-25% of the cardiac output.
Blood Filtering
The renal corpuscle is the site of the nephron, where blood is "filtered".
The blood enters the kidney through the renal artery in the renal sinus. It
branches into segmental arteries, which further divide into interlobar arteries penetrating
the renal capsule and extending through the renal columns between the renal pyramids.
The interlobar arteries then supply blood to the arcuate arteries that run through the
boundary of the cortex and the medulla. Each arcuate artery supplies a variety of
additional interlobar arteries that feed into the afferent arterioles to be filtered through
the nephrons. After filtration occurs the blood moves through a small network of venules
that converge into interlobar veins. As with the arteriole distribution the veins follow the
same pattern, the interlobar provide blood to the arcuate veins then back to the
interlobar veins which come to form the renal vein exiting the kidney for transfusion for
blood.
Blood filtering takes place in the (nephron), which is found in the kidney.
Excretion of waste products
The kidneys excrete a variety of waste products produced by metabolism,

including the nitrogenous wastes: urea (from protein catabolism) and uric acid (from
nucleic acid metabolism) and water.
Homeostasis
31
The kidney is one of the major organs involved in whole-body homeostasis.
Among its homeostatic functions are acid-base balance, regulation of electrolyte
concentrations, control of blood volume, and regulation of blood pressure. The kidneys
accomplish these homeostatic functions independently and through coordination with
other organs, particularly those of the endocrine system. The kidney communicates with
these organs through hormones secreted into the bloodstream.
Acid-base balance
The kidneys regulate the pH of blood by adjusting H+ ion levels, referred as

augmentation of mineral ion concentration, as well as water composition of the blood.
Blood pressure
Sodium ions are controlled in a homeostatic process involving aldosterone which

increases sodium ion reabsorption in the distal convoluted tubules.
Plasma volume
Any significant rise or drop in plasma osmolality is detected by the hypothalamus,

which communicates directly with the posterior pituitary gland. A rise in osmolality
causes the gland to secrete antidiuretic hormone, resulting in water reabsorption by the
kidney and an increase in urine concentration. The two factors work together to return
the plasma osmolality to its normal levels.
ADH binds to principal cells in the collecting duct that translocate aquaporins to
the membrane allowing water to leave the normally impermeable membrane and be
reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the
body.
There are two systems that create a hyperosmotic medulla and thus increase the
body plasma volume: Urea recycling and the 'single effect.'
Urea is usually excreted as a waste product from the kidneys. However, when
plasma blood volume is low and ADH is released the aquaporins that are opened are
also permeable to urea. This allows urea to leave the collecting duct into the medulla
creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the
nephron and be excreted or recycled again depending on whether ADH is still present
or not.
The 'Single effect' describes the fact that the ascending thick limb of the loop of
Henle is not permeable to water but is permeable to NaCl. This means that a
countercurrent system is created whereby the medulla becomes increasingly
concentrated setting up a osmotic gradient for water to follow should the aquaporins of
the collecting duct be opened by ADH.
32
Hormone secretion
The kidneys secrete a variety of hormones. Erythropoietin is released in
response to low levels of O2 in the renal circulation. It stimulates erythrocyte production
in red bone marrow. Renin is involved in the regulation of aldosterone secretion by the
renin-angiotensin-aldosterone system. Calcitriol, the activated form of vitamin D,
promotes the absorption of Ca2+ from the blood and the excretion of PO 32-. They both
help to increase Ca2+ levels.
NEPHRON
Nephron is the basic structural and functional unit of the kidney. Its chief function
is to regulate the concentration of water and soluble substances like sodium salts by
filtering the blood, reabsorbing what is needed and excreting the rest as urine. A
nephron eliminates wastes from the body, regulates blood volume and blood pressure,
controls levels of electrolytes and metabolites, and regulates blood pH. Its functions are
vital to life and are regulated by the endocrine system by hormones such as antidiuretic
hormone, aldosterone, and parathyroid hormone.In humans, a normal kidney contains
800,000 to one million nephrons.
Two general classes of nephrons are cortical nephrons and juxtamedullary

nephrons, both of which are classified according to the location of their associated renal
corpuscle. Cortical nephrons have their renal corpuscle in the superficial renal cortex,
while the renal corpuscles of juxtamedullary nephrons are located near the renal
medulla. The nomenclature for cortical nephrons varies, with some sources
distinguishing between superficial cortical nephrons and midcortical nephrons;
33
Each nephron is composed of an initial filtering component (the "renal
corpuscle") and a tubule specialized for reabsorption and secretion (the "renal tubule").
The renal corpuscle filters out large solutes from the blood, delivering water and small
solutes to the renal tubule for modification.
Renal corpuscle
Composed of a glomerulus and Bowman's capsule, the renal corpuscle (or

Malpighian corpuscle) is the beginning of the nephron. It is the nephron's initial filtering
component.
The glomerulus is a capillary tuft that receives its blood supply from an afferent
arteriole of the renal circulation. The glomerular blood pressure provides the driving
force for water and solutes to be filtered out of the blood and into the space made by
Bowman's capsule. The remainder of the blood (only approximately 1/5 of all plasma
passing through the kidney is filtered through the glomerular wall into Bowman's
capsule) passes into the narrower efferent arteriole. It then moves into the vasa recta,
which are collecting capillaries intertwined with the convoluted tubules through the
interstitial space, in which the reabsorbed substances will also enter. This then
combines with efferent venules from other nephrons into the renal vein, and rejoins the
main bloodstream.
The Bowman capsule, also called the glomerular capsule, surrounds the
glomerulus. It is composed of a visceral inner layer formed by specialized cells called
podocytes, and a parietal outer layer composed of a single layer of flat cells called
simple squamous epithelium. Fluids from blood in the glomerulus are filtered through
the visceral layer of podocytes, and the resulting glomerular filtrate is further processed
along the nephron to form urine.
Renal tubule
The renal tubule is the portion of the nephron containing the tubular fluid filtered
through the glomerulus. After passing through the renal tubule, the filtrate continues to
the collecting duct system, which is not part of the nephron.
The components of the renal tubule are: proximal tubule, loop of Henle
(descending limb of loop of Henle and ascending limb of loop of Henle), and distal
convoluted tubule.
The nephron carries out nearly all of the kidney's functions. Most of these
functions concern the reabsorption and secretion of various solutes such as ions (eg,
sodium), carbohydrates (eg, glucose), and amino acids (eg, glutamate). Properties of
the cells that line the nephron change dramatically along its length; consequently, each
segment of the nephron has highly specialized functions.
The proximal tubule as a part of the nephron can be divided into an initial
convoluted portion and a following straight (descending) portion. Fluid in the filtrate
entering the proximal convoluted tubule is reabsorbed into the peritubular capillaries,
34
including approximately two-thirds of the filtered salt and water and all filtered organic
solutes (primarily glucose and amino acids).
The loop of Henle, also called the nephron loop, is a U-shaped tube that extends
from the proximal tubule. It consists of a descending limb and ascending limb. It begins
in the cortex, receiving filtrate from the proximal straight tubule, extends into the medulla
as the descending limb, and then returns to the cortex as the ascending limb to empty
into the distal convoluted tubule. The primary role of the loop of Henle is to concentrate
the salt in the interstitium, the tissue surrounding the loop.
Considerable differences distinguish the descending and ascending limbs of the

loop of Henle. The descending limb is permeable to water but completely impermeable
to salt, and thus only indirectly contributes to the concentration of the interstitium. As the
filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows
freely out of the descending limb by osmosis until the tonicity of the filtrate and
interstitium equilibrate. Longer descending limbs allow more time for water to flow out of
the filtrate, so longer limbs make the filtrate more hypertonic than shorter limbs.
Unlike the descending limb, the ascending limb of Henle's loop is impermeable to
water, a critical feature of the countercurrent exchange mechanism employed by the
loop. The ascending limb actively pumps sodium out of the filtrate, generating the
hypertonic interstitium that drives countercurrent exchange. In passing through the
ascending limb, the filtrate grows hypotonic since it has lost much of its sodium content.
This hypotonic filtrate is passed to the distal convoluted tubule in the renal cortex.
The distal convoluted tubule has a different structure and function to that of the
proximal convoluted tubule. Cells lining the tubule have numerous mitochondria to
produce enough energy (ATP) for active transport to take place. Much of the ion
transport taking place in the distal convoluted tubule is regulated by the endocrine
system. In the presence of parathyroid hormone, the distal convoluted tubule reabsorbs
more calcium and excretes more phosphate. When aldosterone is present, more
sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes
the distal convoluted tubule to excrete more sodium. In addition, the tubule also
secernates hydrogen and ammonium to regulate the pH.
After traveling the length of the distal convoluted tubule, only about 1% of water
remains, and the remaining salt content is negligible.
Collecting duct system
Each distal convoluted tubule delivers its filtrate to a system of collecting

ducts, the first segment of which is the collecting tubule. The collecting duct
system begins in the renal cortex and extends deep into the medulla. As the
urine travels down the collecting duct system, it passes by the medullary
interstitium which has a high sodium concentration as a result of the loop of
Henle's countercurrent multiplier system.
35
Though the collecting duct is normally impermeable to water, it becomes
permeable in the presence of antidiuretic hormone (ADH). ADH affects the function of
aquaporins, resulting in the reabsorption of water molecules as it passes through the
collecting duct. Aquaporins are membrane proteins that selectively conduct water
molecules while preventing the passage of ions and other solutes. As much as three-
fourths of the water from urine can be reabsorbed as it leaves the collecting duct by
osmosis. Thus the levels of ADH determine whether urine will be concentrated or
diluted. An increase in ADH is an indication of dehydration, while water sufficiency
results in low ADH allowing for diluted urine.
Lower portions of the collecting duct are also permeable to urea, allowing some
of it to enter the medulla of the kidney, thus maintaining its high concentration (which is
very important for the nephron).
Urine leaves the medullary collecting ducts through the renal papillae, emptying
into the renal calyces, the renal pelvis, and finally into the urinary bladder via the ureter.
Because it has a different origin during the development of the urinary and
reproductive organs than the rest of the nephron, the collecting duct is sometimes not
considered a part of the nephron. Instead of originating from the metanephrogenic
blastema, the collecting duct originates from the ureteric bud.
Juxtaglomerular apparatus
The juxtaglomerular apparatus is a specialized region of the nephron responsible

for production and secretion of the hormone renin, involved in the renin-angiotensin
system. This apparatus occurs near the site of contact between the thick ascending limb
and the afferent arteriole. It contains three components: the macula densa,
juxtaglomerular cells, and extraglomerular mesangial cells.
Because of its importance in body fluid regulation, the nephron is a common

target of drugs that treat high blood pressure and edema. These drugs, called diuretics,
inhibit the ability of the nephron to retain water, thereby increasing the amount of urine
produced.
HEART
The heart is a muscular organ in all vertebrates responsible for pumping blood
through the blood vessels by repeated, rhythmic contractions, or a similar structure
annelids, mollusks, and arthropods.
The heart of a vertebrate is composed of cardiac muscle, an involuntary muscle

tissue which is found only within this organ. The average human heart, beating at 72
beats per minute, will beat approximately 2.5 billion times during a lifetime (about 66
years). It weighs on average 250 g to 300 g in females and 300 g to 350 g in males.
36
In animals, the function of the right side of the heart is to collect de-oxygenated
blood, in the right atrium, from the body (via superior and inferior vena cavae) and pump
it, via the right ventricle, into the lungs (pulmonary circulation) so that carbon dioxide
can be dropped off and oxygen picked up (gas exchange). This happens through the
passive process of diffusion. The left side collects oxygenated blood from the lungs into
the left atrium. From the left atrium the blood moves to the left ventricle which pumps it
out to the body (via the aorta). On both sides, the lower ventricles are thicker and
stronger than the upper atria. The muscle wall surrounding the left ventricle is thicker
than the wall surrounding the right ventricle due to the higher force needed to pump the
blood through the systemic circulation.
Starting in the right atrium, the blood flows through the tricuspid valve to the right
ventricle. Here it is pumped out the pulmonary semilunar valve and travels through the
pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein
to the left atrium. It then travels through the mitral valve to the left ventricle, from where
it is pumped through the aortic semilunar valve to the aorta. The aorta forks and the
blood are divided between major arteries which supply the upper and lower body. The
blood travels in the arteries to the smaller arterioles, then finally to the tiny capillaries
which feed each cell. The (relatively) deoxygenated blood then travels to the venules,
which coalesce into veins, then to the inferior and superior venae cavae and finally back
to the right atrium where the process began.
The heart is effectively a syncytium, a meshwork of cardiac muscle cells

interconnected by contiguous cytoplasmic bridges. This relates to electrical stimulation
of one cell spreading to neighboring cells.
MUCOUS MEMBRANE
The mucous membranes are linings of mostly endodermal origin, covered in

epithelium, which are involved in absorption and secretion. They line various body
cavities that are exposed to the external environment and internal organs. It is at
several places continuous with skin: at the nostrils, the lips, the ears, the genital area,
and the anus. The sticky, thick fluid secreted by the mucous membranes and gland is
37
termed mucus. The term mucous membrane refers to where they are found in the body
and not every mucous membrane secretes mucus.
The oral mucosa is the mucous membrane epithelium of the mouth. It can be
divided into three categories. Masticatory mucosa is a keratinized stratified squamous
epithelium, found on the dorsum of the tongue, hard palate and attached gingiva. Lining
mucosa is non-keratinized stratified squamous epithelium, found almost everywhere
else in the oral cavity. Specialized mucosa is found specifically the regions of the taste
buds on the dorsum of the tongue.
ESOPHAGUS
The esophagus or oesophagus, sometimes known as the gullet, is an organ in

vertebrates which consists of a muscular tube through which food passes from the
pharynx to the stomach. In humans the esophagus is continuous with the laryngeal part
of the pharynx at the level of the C6 vertebra. The esophagus passes through a hole in
the thoracic diaphragm called the esophageal hiatus. It is usually 25-30 cm long which
connects the mouth to the stomach. It is divided into cervical, thoracic, and abdominal
parts.
Food is passed through the esophagus by using the process of peristalsis.

Specifically, it connects the pharynx, which is the body cavity that is common to the
digestive factory and respiratory system with the stomach, where the second stage of
digestion is initiated.
The esophagus is deeply lined with muscle that acts with peristaltic action to
move swallowed food down to the stomach. Due to the fact that the esophagus lacks
the mucus lining like that of the stomach, it can get irritated by stomach acid that passes
the cardiac sphincter.
38
STOMACH
The stomach is a hollow muscular organ of the gastrointestinal tract involved in

the second phase of digestion, following mastication. The stomach lies between the
esophagus and the duodenum (the first part of the small intestine). It is on the left side
of the abdominal cavity. The top of the stomach lies against the diaphragm. Lying
beneath the stomach is the pancreas, and the greater omentum which hangs from the
greater curvature.
Two smooth muscle valves, or sphincters, keep the contents of the stomach
contained. They are the esophageal sphincter (found in the cardiac region) dividing the
tract above, and the Pyloric sphincter dividing the stomach from the small intestine.
The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic

(inhibitor) plexuses (anterior gastric, posterior, superior and inferior, celiac and
myenteric), which regulate both the secretory activity and the motor activity of the
muscles.
In humans, the stomach has a relaxed volume of about 45 ml; it generally

expands to hold about 1 litre of food, but can hold as much as 1.5 liters.
Sections
The stomach is divided into four sections, each of which has different cells and
functions. The sections are: Cardia, it is where the contents of the oesophagus empty
into the stomach. Fundus is formed by the upper curvature of the organ. Body or corpus
is the main, central region. Pylorus or antrum is the lower section of the organ that
facilitates emptying the contents into the small intestine.
Blood supply
The lesser curvature of the stomach is supplied by the right gastric artery
inferiorly, and the left gastric artery superiorly, which also supplies the cardiac region.
39
The greater curvature is supplied by the right gastroepiploic artery inferiorly and the left
gastroepiploic artery superiorly. The fundus of the stomach, and also the upper portion
of the greater curvature, is supplied by the short gastric artery.
Like the other parts of the gastrointestinal tract, the stomach walls are made of
the following layers, from inside to outside: mucosa is the first main layer. This consists
of an epithelium, the lamina propria composed of loose connective tissue and which has
gastric glands in it underneath, and a thin layer of smooth muscle called the muscularis
mucosae. submucosa is the layer that lies under the mucosa and consists of fibrous
connective tissue, separating the mucosa from the next layer. The Meissner's plexus is
in this layer. muscularis externa is found under the submucosa, the muscularis externa
in the stomach differs from that of other GI organs in that it has three layers of smooth
muscle instead of two. serosa is the layer under the muscularis externa, consisting of
layers of connective tissue continuous with the peritoneum.
Control of secretion and motility
The movement and the flow of chemicals into the stomach are controlled by both
the autonomic nervous system and by the various digestive system hormones: Gastrin
is a hormone which causes an increase in the secretion of HCl, pepsinogen and intrinsic
factor from parietal cells in the stomach. It also causes increased motility in the
stomach. Gastrin is released by G-cells in the stomach to distenstion of the antrum, and
digestive products. It is inhibited by a pH normally less than 4 (high acid), as well as the
hormone somatostatin. Cholecystokinin (CCK) has most effect on the gall bladder, but it
also decreases gastric emptying and increases release of pancreatic juice which is
alkaline and neutralizes the chyme. In a different and rare manner, secretin, produced in
the small intestine, has most effects on the pancreas, but will also diminish acid
secretion in the stomach. Gastric inhibitory peptide (GIP) decreases both gastric acid
and motility. Enteroglucagon decreases both gastric acid and motility. Glycogen,
produced in the brain and stomach, affects the liver and level of glucose in the stomach.
Other than gastrin, these hormones all act to turn off the stomach action. This is in
response to food products in the liver and gall bladder, which have not yet been
absorbed. The stomach needs only to push food into the small intestine when the
intestine is not busy. While the intestine is full and still digesting food, the stomach acts
as storage for food.
The three basic/main functions of the stomach are to kill any bacteria ingested,
break down the food into smaller pieces to create a larger surface area for easier
digestion, and to hold food and release it at a constant rate. The stomach is a highly
acidic environment due to hydrochloric acid production and secretion which produces a
luminal pH range usually between 1 and 2 depending on the species, food intake, time
of the day, drug use, and other factors. Combined with digestive enzymes, such an
environment is able to break down large molecules (such as from food) to smaller ones
so that they can eventually be absorbed from the small intestine. A zymogen called
pepsinogen is secreted by chief cells and turns into pepsin under low pH conditions and
is a necessity in protein digestion.
40
The human stomach can produce and secrete about 2.2 to 3 liters of gastric acid
per day with basal secretion levels being typically highest in the evening. The stomach
can expand to hold between 1-1.5 liters of food. It is a temporary food storage area, and
in the process of digestion, the food goes into the stomach first.
Absorption of vitamin B12 from the small intestine is dependent on conjugation to

a glycoprotein called intrinsic factor which is produced by parietal cells of the stomach.
Other functions include absorbing some ions, water, and some lipid soluble
compounds such as alcohol, aspirin, and caffeine.
Menstruation is the shedding of the uterine lining (endometrium). It occurs on a

regular basis in reproductive-age females of certain mammal species. Overt
menstruation (where there is bleeding from the vagina) is found primarily in humans and
chimpanzees. The females of other placental mammal species have estrous cycles, in
which the endometrium is reabsorbed by the animal (covert menstruation) at the end of
its reproductive cycle. Many zoologists regard this as different from a "true" menstrual
cycle.
Eumenorrhea denotes normal, regular menstruation that lasts for a few days
(usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal).The average
blood loss during menstruation is 35 millilitres with 10-80 mL considered normal; many
females also notice shedding of the endometrium lining that appears as tissue mixed
with the blood. (Sometimes this is erroneously thought to indicate an early-term
miscarriage of an embryo.) An enzyme called plasmin — contained in the endometrium
— tends to inhibit the blood from clotting. Because of this blood loss, premenopausal
women have higher dietary requirements for iron to prevent iron deficiency. Many
women experience uterine cramps, also referred to as dysmenorrhea, during this time,
caused largely by the contractions of the uterine muscle as it expels the endometrial
blood from the woman's body. A vast industry has grown to provide drugs to aid in these
cramps, as well as sanitary products to help manage menses.
Menstruation is the most visible phase of the menstrual cycle. Menstrual cycles
are counted from the first day of menstrual bleeding, because the onset of menstruation
corresponds closely with the hormonal cycle.
During pregnancy and for some time after childbirth, menstruation is normally
suspended; this state is known as amenorrhoea, i.e. absence of the menstrual cycle. If
menstruation has not resumed, fertility is low during lactation. The average length of
postpartum amenorrhoea is longer when certain breastfeeding practices are followed;
this may be done intentionally as birth control (lactational amenorrhea method).
Flow
The normal menstrual flow follows a "crescendo-decrescendo" pattern; that is, it
starts at a moderate level, increases somewhat, and then slowly tapers. Sudden heavy
flows or amounts in excess of 80 mL (hypermenorrhea or menorrhagia) may stem from
hormonal disturbance, uterine abnormalities, including uterine leiomyoma or cancer,
41
and other causes. Doctors call the opposite phenomenon, of bleeding very little,
hypomenorrhea.
Duration
The typical woman bleeds for two to seven days at the beginning of each
menstrual cycle. Prolonged bleeding (metrorrhagia, also meno-metrorrhagia) no longer
shows a clear interval pattern. Dysfunctional uterine bleeding is hormonally caused
bleeding abnormalities, typically anovulation. All these bleeding abnormalities need
medical attention; they may indicate hormone imbalances, uterine fibroids, or other
problems. As pregnant patients may bleed, a pregnancy test forms part of the
evaluation of abnormal bleeding.
RED BLOOD CELLS
Red blood cells are the most common type of blood cell and the vertebrate
body's principal means of delivering oxygen to the body tissues via the blood. The cells
are filled with hemoglobin, a biomolecule that can bind to oxygen. They take up oxygen
in the lungs or gills and release it while squeezing through the body's capillaries. The
blood's red color is due to the color of hemoglobin. In humans, red blood cells develop
in the bone marrow, take the form of flexible biconcave disks, lack a cell nucleus,
subcellular organelles and the ability to synthesize protein, and live for about 120 days.
Red blood cells are also known as RBCs, red blood corpuscles (an archaic term),
haematids or erythrocytes. The capitalized term Red Blood Cells is the proper name in
the US for erythrocytes in storage solution used in transfusion medicine.
When erythrocytes undergo shear stress in constricted vessels, they release

ATP which causes the vessel walls to relax and dilate.
When their hemoglobin molecules are deoxygenated, erythrocytes release S-

nitrosothiols which also acts to dilate vessels, thus directing more blood to areas of the
body depleted of oxygen.
Erythrocytes also play a part in the body's immune response: when lysed by
pathogens such as bacteria, their hemoglobin releases free radicals that break down
the pathogen's cell wall and membrane, killing it.
Human erythrocytes
A typical human erythrocyte disk has a diameter of 6–8 µm and a thickness of 2
µm, much smaller than most other human cells. A normal erythrocyte has a volume of
about 90 fL. About a third of that volume is hemoglobin, a total of 270 million
hemoglobin molecules, with each carrying four heme groups.
Adult humans have roughly 2–3 × 1013 red blood cells at any given time (women have
about 4 to 5 million erythrocytes per microliter (cubic millimeter) of blood and men about
5 to 6 million; people living at high altitudes with low oxygen tension will have more).
Red blood cells are thus much more common than the other blood particles: there are
about 4,000–11,000 white blood cells and about 150,000–400,000 platelets in each
microliter of human blood.
42
In humans, hemoglobin in the red blood cells is responsible for the transport of
more than 98% of the oxygen; the remaining oxygen is carried dissolved in the blood
plasma.
The red blood cells of an average adult human male store collectively about 2.5
grams of iron, representing about 65% of the total iron contained in the body.
Life cycle
The process by which red blood cells are produced is called erythropoiesis.
Erythrocytes are continuously produced in the red bone marrow of large bones, at a rate
of about 2 million per second. (In the embryo, the liver is the main site of red blood cell
production.) The production can be stimulated by the hormone erythropoietin (EPO),
synthesised by the kidney; this is used for doping in sports. Just before and after leaving
the bone marrow, the developing cells are known as reticulocytes; these comprise
about 1% of circulating red blood cells.
Erythrocytes develop from committed stem cells through reticulocytes to mature

erythrocytes in about 7 days and live a total of about 100-120 days.
The aging erythrocyte undergoes changes in its plasma membrane, making it

susceptible to recognition by phagocytes and subsequent phagocytosis in the spleen,
liver and bone marrow. Much of the important breakdown products are recirculated in
the body. The heme constituent of hemoglobin is broken down into Fe3+ and biliverdin.
The biliverdin is reduced to bilirubin, which is released into the plasma and recirculated
to the liver bound to albumin. The iron is released into the plasma to be recirculated by
a carrier protein called transferrin. Almost all erythrocytes are removed in this manner
from the circulation before they are old enough to hemolyze. Hemolyzed hemoglobin is
bound to a protein in plasma called haptoglobin which is not excreted by the kidney.
Membranes and surface proteins

The membranes of red blood cells play many roles that aid in regulating immune
recognition and deformability.There are two main types of proteins on the surface:Band
3, Glycophorins such as glycophorin C
The blood types of humans are due to variations in surface glycoproteins of

erythrocytes.
Disorders of the proteins in these membranes are associated with many

disorders, such as hereditary spherocytosis, hereditary elliptocytosis, hereditary
stomatocytosis, and paroxysmal nocturnal hemoglobinuria.
HAIR FOLLICLE
A hair follicle is part of the skin that grows hair by packing old cells together.
Attached to the follicle is a sebaceous gland, a tiny sebum-producing gland found
everywhere except on the palms, lips and soles of the feet. The thicker density of hair,
the more sebaceous glands are found.
43
Also attached to the follicle is a tiny bundle of muscle fiber called the arrector pili
that are responsible for causing the follicle lissis to become more perpendicular to the
surface of the skin, and causing the follicle to protrude slightly above the surrounding
skin (piloerection). This process results in goose bumps (or goose flesh). Stem cells are
located at the junction of the arrector and the follicle, and are principally responsible for
the ongoing hair production during a process known as the Anagen stage.
The average growth rate of healthy hair follicles on the scalp is 400 µm per day.
Certain species of Demodex mites live in the hair follicles of mammals (including
those of humans) where they feed on sebum.
Papilla
At the base of the follicle is a large structure that is called the papilla. The papilla
is made up mainly of connective tissue and a capillary loop. Cell division in the papilla is
either rare or non-existent.
Matrix
Around the papilla is the hair matrix, a collection of epithelial cells often
interspersed with the pigment producing cells, melanocytes. Cell division in the hair
matrix is responsible for the cells that will form the major structures of the hair fiber and
the inner root sheath. The hair matrix epithelium is one of the fastest growing cell
populations in the human body, which is why some forms of chemotherapy that kill
dividing cells or radiotherapy may lead to temporary hair loss. The papilla is usually
ovoid or pear shaped with the matrix wrapped completely around it except for a short
stalk-like connection to the surrounding connective tissue that provides access for the
capillary.
Root Sheath
The root sheath is composed of an external root sheath (Henle's layer), a middle
layer (Huxley's layer), and an internal cuticle that is continuous with the outermost layer
of the hair fiber.
44
Hair Fiber
The hair fiber is composed of a cuticle that is continuous with the root sheath, an
intermediate cortex, and an inner medulla.
Other Structures
Other structures associated with the hair follicle include arrector pili muscles,
sebaceous glands and apocrine sweat glands. Hair follicle receptors sense the position
of the hairs.
Morphogenesis
In utero, the epithelium and underlying mesenchyma interact to form hair follicles.
Hair-follicle cycling
Hair grows in cycles of various phases. anagen is the growth phase; catagen is
the involuting or regressing phase; and telogen, the resting or quiescent phase. Each
phase has several morphologically and histologically distinguishable sub-phases. Prior
to the start of cycling is a phase of follicular morphogenesis (formation of the follicle).
There is also a shedding phase, or exogen, that is independent of anagen and telogen
in which one of several hairs that might arise from a single follicle exits. Normally up to
90% of the hair follicles are in anagen phase while, 10–14% are in telogen and 1–2% in
catagen. The cycle's length varies on different parts of the body. For eyebrows, the
cycle is completed in around 4 months, while it takes the scalp 3–4 years to finish; this
is the reason eyebrow hairs have a much shorter length limit compared to hairs on the
head. Growth cycles are controlled by a chemical signal like epidermal growth factor.
Anagen Phase
Anagen is the active growth phase of hair follicles. The cells in the root of the hair
are dividing rapidly, adding to the hair shaft. During this phase the hair grows about 1
cm every 28 days. Scalp hair stays in this active phase of growth for 2-7 years. The
amount of time the hair follicle stays in the anagen phase is genetically determined. At
the end of the anagen phase an unknown signal causes the follicle to go into the
catagen phase.
Catagen Phase
The catagen phase is a short transition stage that occurs at the end of the
anagen phase. It signals the end of the active growth of a hair. This phase lasts for
about 2–3 weeks while a club hair is formed.
Telogen Phase
The telogen phase is the resting phase of the hair follicle. The club hair is the
final product of a hair follicle in the telogen stage, and is a dead, fully keratinized hair.
Fifty to one-hundred club hairs are shed daily from a normal scalp.
45
Hair growth cycle times
Scalp: The time these phases last vary from person to person. Different hair
colour and follicle shape affects the timings of these phases. Anagen phase, 2–3 years
(occasionally much longer). Catagen phase, 2–3 weeks. Telogen phase, around
3 months.
46

Systemic Lupous Erythematosus (SLE)

Uploaded by

Copyright:

Available Formats

Systemic Lupous Erythematosus (SLE)

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Systemic Lupous Erythematosus (SLE)

Uploaded by

Copyright:

Available Formats

I.

Lupus is an autoimmune disease characterized by acute and chronic

Systemic Lupus Erythematosus (SLE) is a form of an autoimmune disease that

At the end of 1 hour, we will be able to:

C. SCOPES AND LIMITATIONS

Past Medical/Surgical History:

Vital Signs: HR = 80 bpm RR= 19 cpm BP = 100/60 mmHg

Vital Signs: Temperature Heart Rate Respiratory Blood Pressure

“Gakatulog ko’g 12 sa gabii dayon mata2x jud ko permi tungod sa saba ug sa

“Pangbawi sa akong tulog matulog ko ug ginagmay sa buntag ug hapon” as

“Init akong paminaw. Tan-awa daw kung gihilantan ba ko,” as verbalized by

Observed physiologic response: Response and behavior are appropriate

“Kabuhion jud ko usahay labon na kung mapasmo ko unya mokaon dayon

“Nanghupong man ko adtong pagka-admit nako. Dani sa akong nawong og

Precipitating Factors: Lesions in lower left leg

“Akong gabutangan ug botelya na naai bugnaw na tubig ang ibabaw sa

Others/Comments: Patient is able to tolerate pain.

Sexually active: Not at the moment

XIII - SOCIAL INTERACTIONS

Date: February 15,2009

Date: February 17, 2009

Date: February 19, 2009

Date: February 20, 2009

B. DIAGNOSTICS AND LAB RESULTS

I. LATEST LAB RESULTS

URINALYSIS (February 20, 2009)

Color Yellow Normal

HEMATOLOGY (February 18, 2009)

Hematocrit 38.0 Normal

URINALYSIS (February 14, 2009)

Color Yellow Normal

BLOOD CHEMISTRY (February 11, 2009)

FBS 98.0 Normal

HEMATOLOGY (February 11, 2009)

Hematocrit 38.0% Normal

HEMATOLOGY (February 10, 2009)

Hematocrit 38.0% Normal

ECG RESULT (February 10, 2009)

NAME: Patient X ID NUM.: 219406

(Refer to appendix D-Figure 1)

II. PREVIOUS LAB RESULTS:

URINALYSIS (January 26, 2009)

Color Dark Yellow Concentrated urine can be

HEMATOLOGY (January 25, 2009)

Hematocrit 42.5% Normal

BLOOD CHEMISTRY (January 8, 2009)

FBS 88.0 mg/dL Normal

HEMATOLOGY (January 8, 2009)

Hematocrit 44% Normal

URINALYSIS (January 5, 2009)

Color Amber Normal

Color Yellow Normal

ESR 89 mm/hr A very high ESR usually

HEMATOLOGY (December 3, 2008)

Hematocrit 41% Normal

Color Amber Normal

URINALYSIS (November 19, 2008)

Color Yellow Normal

Hematocrit 39% Normal