👤 Patient
| Field | Value |
|---|---|
| Name | Yasmin Binti Abdul Wahab |
| Age / Sex / DOB | 45 Y / F / 22-Feb-1981 |
| IC | 810222-02-5452 |
| Hospital MRN | KD200039 |
| Lab | PATHLAB (Pathology & Clinical Laboratory, Petaling Jaya) |
| Lab No. | 37308063 (pre-op) / 37310975 (post-op) |
| Hospital | Global Doctors Hospital, Mont Kiara KL |
Blood Type (verified pre-op)
O RH(D) (DU) NEGATIVE
O Negative, Du negative — note: Du is a weak D variant, clinically O neg
🔴 Critical Pre-Op Findings
1. ANEMIA (mild, hypochromic microcytic): MCV 78 fL (low), MCH 26 pg (low). Pattern consistent with iron deficiency or chronic disease. Likely related to her heavy menstrual bleeding from fibroids.
2. GLYCOSURIA (2+ glucose in urine): But BLOOD GLUCOSE was normal (4.7 mmol/L). Renal threshold issue or pre-diabetes — worth monitoring.
3. ELEVATED CHOLESTEROL & TRIGLYCERIDES: Total 5.7, LDL 2.7, TG 3.4 (all borderline high). Common in hypothyroid/metabolic syndrome.
4. LOW ALKALINE PHOSPHATASE (45 U/L, ref 46-116): Marginal. Could be low B6/B12/zinc or hypothyroidism.
5. HEPATITIS B S ANTIBODY: NONREACTIVE — Lab recommends Hepatitis B vaccination (immunisation to be considered).
6. THYROID FUNCTION: NORMAL (TSH 1.93, FT4 14.7, FT3 5.0) — not hypothyroid despite symptoms
7. TUMOR MARKERS: ALL NORMAL (AFP, CA125, CA15.3, CA19.9, CEA, Beta HCG) — cancer markers negative
8. HIV/SYPHILIS/RHEUMATOID: ALL NONREACTIVE — infection screen negative
📊 Side-by-Side Comparison
Same lab, same patient, 4 days apart. ▼ = value dropped, ▲ = value rose, = = same.
🩸 Complete Blood Count (CBC)
| Test | Pre-Op (23-Jun) | Post-Op (27-Jun) | Delta | Status |
|---|---|---|---|---|
| Haemoglobin | 12.3 g/dL ✅ (11.5-15.0) | 11.5 g/dL ⚠️ low (11.5-15.0) | ▼ 0.8 | Borderline anemia post-surgery (expected blood loss) |
| PCV / HCT | 37% (35-45) | 34% (35-45) | ▼ 3 | Low (below range) |
| RBC | 4.8 (3.9-5.2) | 4.4 (3.9-5.2) | ▼ 0.4 | Borderline low |
| MCV | 78 fL L (80-96) | 78 fL L (80-96) | = same | Microcytic (chronic iron deficiency) |
| MCH | 26 pg L (27-32) | 26 pg L (27-32) | = same | Low (chronic) |
| MCHC | 33 (32-36) | 34 (32-36) | ▲ 1 | Stable |
| RDW | 14.2 (12-14.8) | 14.3 (12-14.8) | = same | Borderline high (variation in RBC size) |
| WBC | 6.5 (4.0-11.2) | 8.7 (4.0-11.2) | ▲ 2.2 | Slight rise (surgery stress response, normal) |
| Platelets | 259 (150-400) | 213 (150-400) | ▼ 46 | Still normal range (slight drop, expected) |
| ESR | 3 mm/hr (0-12) | — | — | Not re-tested post-op |
🧪 Kidney Function
| Test | Pre-Op | Post-Op | Delta | Status |
|---|---|---|---|---|
| Urea | 3.5 mmol/L (3.2-8.2) | 2.7 mmol/L L (3.2-8.2) | ▼ 0.8 | Low (low protein intake, common post-op) |
| Creatinine | 70 (49-90) | 53 (49-90) | ▼ 17 | Better (low = good kidney function) |
| eGFR | 94 (≥90 normal) | 113 ▲ 19 | Improved | Kidney function is excellent |
⚡ Electrolytes
| Test | Pre-Op | Post-Op | Delta | Status |
|---|---|---|---|---|
| Sodium | 142 (136-145) | 141 (136-145) | = same | Normal |
| Potassium | 3.8 (3.5-5.1) | 3.8 (3.5-5.1) | = same | Normal |
| Chloride | 106 (98-107) | 107 (98-107) | ▲ 1 | Borderline high (slight dehydration possible) |
| Calcium | 2.39 (2.08-2.65) | 2.08 (2.08-2.65) | ▼ 0.31 | Lower (close to threshold) |
| Corrected Calcium | 2.31 (2.08-2.65) | 2.10 (2.08-2.65) | ▼ 0.21 | Lower but still normal |
| Phosphate | 1.11 (0.78-1.65) | 0.85 (0.78-1.65) | ▼ 0.26 | Lower (within range) |
| Uric Acid | 0.26 (0.18-0.46) | 0.18 (0.18-0.46) | ▼ 0.08 | At low threshold |
🔬 Glucose & Proteins
| Test | Pre-Op | Post-Op | Delta | Status |
|---|---|---|---|---|
| Glucose (blood) | 4.7 mmol/L ✅ | — | — | Not re-tested (normal pre-op) |
| Total Protein | 70 g/L (57-82) | — | — | Not re-tested |
| Albumin | 44 g/L (32-48) | 39 g/L (32-48) | ▼ 5 | Lower but still normal range |
🧬 Lipid Profile (PRE-OP ONLY — not re-tested)
| Test | Result | Reference | Status |
|---|---|---|---|
| Total Cholesterol | 5.7 H mmol/L | <5.2 | Borderline high |
| HDL | 1.47 mmol/L | >1.04 | Good |
| Non-HDL | 4.2 H | <3.4 | High |
| LDL | 2.7 H | <2.6 | Borderline high |
| Triglycerides | 3.4 H | <1.7 | High (2x normal) |
| Total/HDL Ratio | 3.9 | <5.0 | OK |
| Homocysteine | 8.4 µmol/L | 5.0-15.0 | Normal |
🧪 Liver Function (PRE-OP ONLY — not re-tested)
| Test | Result | Reference | Status |
|---|---|---|---|
| Total Bilirubin | 8 µmol/L | 5-21 | Normal |
| Alk Phos | 45 L U/L | 46-116 | Low (marginal) |
| SGOT (AST) | 18 U/L | <34 | Normal |
| SGPT (ALT) | 17 U/L | 10-49 | Normal |
| GGT | 24 IU/L | <38 | Normal |
🦠 Hepatitis Screen (PRE-OP ONLY)
| Test | Result | Action |
|---|---|---|
| Hepatitis B S Antigen (HBsAg) | NONREACTIVE | — |
| Hepatitis B S Antibody (HBsAb) | NONREACTIVE | Needs vaccination ⚠️ |
| Hepatitis C Antibody | NONREACTIVE | — |
🦠 Urinalysis (PRE-OP)
| Test | Result | Status |
|---|---|---|
| Glucose | 2+ | Abnormal (renal threshold / pre-diabetes flag) |
| Protein | Negative | OK |
| Blood / WBC / RBC | Nil | OK |
| pH | 6.0 (4.8-8.4) | OK |
📈 Key Trends (Pre → Post)
✅ IMPROVED Post-Op
- eGFR 94 → 113 mL/min (kidney function excellent)
- Creatinine 70 → 53 µmol/L (lower = better filtration)
⚠️ DROPPED Post-Op (expected from surgery)
- Haemoglobin 12.3 → 11.5 g/dL (at low threshold — surgery blood loss)
- PCV/HCT 37% → 34% (below 35% threshold)
- RBC 4.8 → 4.4 (borderline low)
- Platelets 259 → 213 (still normal)
- Calcium 2.39 → 2.08 (at low threshold — could need calcium supp)
- Albumin 44 → 39 g/L (lowered)
- Urea 3.5 → 2.7 (below 3.2 — low protein intake post-op)
🩺 WBC Rose (expected inflammation response)
- WBC 6.5 → 8.7 (normal surgical stress response, still within range)
🏥 Doctor's Action Items (Follow-up 30-Jun 14:30)
Things to ASK doctor:
- Haemoglobin dropped to 11.5 — should I take iron supplements? Pre-op MCV/MCH were low (chronic iron deficiency from fibroids bleeding)
- Calcium at 2.08 (low threshold) — should I take calcium + vitamin D?
- Urea 2.7 (below range) — is this low protein intake? Should I eat more eggs/meat?
- Urine glucose 2+ but blood glucose normal — is this a renal threshold issue? Should I recheck HbA1c?
- Cholesterol/LDL/Triglycerides high — diet plan needed?
- Hepatitis B vaccine — should I start the series now?
Things to REPORT to doctor:
- Bowel adhesions were found + lysed (Dr. A-Tarmizi) — chronic history now documented
- 5 fibroids removed, left ovarian cyst removed, endometriosis excised
- Heavy bleeding post-op (control with Tranexamic Acid)
- Currently on: Xylid + Metrogyl + Arcoxia + Paracetamol + Ganaton + Loratidine
📅 Reference Dates
| Date | Event |
|---|---|
| 23-Jun-2026 12:00 | Pre-op blood drawn (Day of admission 11:30) |
| 23-Jun-2026 11:30 | Admitted to Global Doctors Hospital |
| 23-Jun-2026 (PM) | 5 laparoscopic procedures performed by Dr. A-Tarmizi |
| 27-Jun-2026 08:00 | Post-op blood drawn (Day of discharge) |
| 27-Jun-2026 14:00 | Discharged |
| 30-Jun-2026 14:30 | Follow-up appointment |
📂 Source Documents
- 📄 Pre-op CBC:
Yasmin_after_laproscopy/blood_reports/20260627_153442.jpg(Pathlab 37308063) - 📄 Pre-op Glucose/Kidney:
20260627_153450.jpg - 📄 Pre-op Lipid/Liver/Hep B/Calcium/Electrolytes:
20260627_153455.jpg - 📄 Pre-op Tumor Markers/Thyroid/Serology/UA:
20260627_153501.jpg - 📄 Pre-op Urinalysis:
20260627_153508.jpg - 📄 Post-op CBC:
20260627_153732.jpg(Pathlab 37310975) - 📄 Post-op Renal Profile/Electrolytes:
20260627_153742.jpg
All saved locally at /home/ubuntu/PERMANENT/Family/medical/Yasmin_after_laproscopy/blood_reports/ + Drive-synced.