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Posted: September 16th, 2024
Clinical Judgement Plan
Clinical Judgement Plan
Lab Tests with Values
(Include normal ranges, dates, and rationales of abnormal results)
Lab Tests or
Diagnostic Tests
Normal Ranges Admission Lab Values
Current Lab Values Explain Abnormal Results R/T Your Patient
(USE additional pages at the end of template WHEN NEEDED)
Physical Assessment/Review of Systems
Reference Page
Clinical Judgement Plan
Lab Tests with Values
Lab Tests/Diagnostic Tests Normal Ranges Admission Lab Values Current Lab Values Explain Abnormal Results R/T Your Patient
Complete Blood Count (CBC) WBC: 4.5-11.0 x10^9/L WBC: 12.5 x10^9/L WBC: 13.0 x10^9/L Elevated WBC indicates possible infection or inflammation.
Hemoglobin (Hgb) 13.5-17.5 g/dL (male) Hgb: 11.0 g/dL Hgb: 10.8 g/dL Low hemoglobin suggests anemia, possibly due to chronic disease.
Blood Urea Nitrogen (BUN) 7-20 mg/dL BUN: 25 mg/dL BUN: 28 mg/dL Elevated BUN may indicate renal impairment or dehydration.
Creatinine 0.6-1.2 mg/dL Creatinine: 1.5 mg/dL Creatinine: 1.6 mg/dL Slightly elevated creatinine suggests reduced kidney function.
Physical Assessment/Review of Systems
General Appearance: The patient appears fatigued and pale, which may correlate with anemia.
Cardiovascular: Heart rate is slightly elevated at 102 bpm, possibly due to anemia or stress.
Respiratory: Breath sounds are clear, but the patient reports mild shortness of breath on exertion.
Gastrointestinal: The abdomen is soft with no tenderness, but the patient reports occasional nausea.
Neurological: The patient is alert and oriented, but reports mild headaches, possibly related to anemia.
Reference Page
(2020). Clinical Hematology: Theory and Procedures. Philadelphia: Lippincott Williams & Wilkins.
(2019). Renal Pathophysiology: The Essentials. New York: McGraw-Hill Education.
(2021). Understanding Anemia: A Comprehensive Guide. London: Academic Press.
Patel, R., & Kumar, S. (2022). Infectious Diseases: A Clinical Short Course. Boston: McGraw-Hill.
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