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Laboratory Report

Patient
Name: Ferreira, Vicente
DOB: 26-DEC-1941 (Age: 83)
Gender: male
Address:
R São Domingos 111
2645-065 Alcabideche (Portugal)
ID: 7321-512116-8
Report
Date: 22-JUL-2025
Laboratory
dr Ample, Ex
Boulevard du Jardin Botanique 32
1000 Brussels
Requested by
CASP -Centro de Apoio Social do Pisão
2710-631 Sintra (Portugal)
Specimen
Collected: 21-JUL-2025

This seems not to be an HL7 Europe Laboratory Report (type coding LOINC 11502-2)

Chemistry

Test 21 Jul 2025 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 64.7 L 70 - 99 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 16.8 7 - 50 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 1.9 H 0.9 - 1.3 mg/dL
Calcium [Mass/volume] in Serum or Plasma 9.7 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Serum or Plasma 137.4 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 4.5 3.5 - 5.3 mmol/L
Chloride [Moles/volume] in Serum or Plasma 109.4 H 96 - 108 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 27.4 22 - 32 mmol/L
Ketones [Presence] in Urine by Test strip Urine ketone test = ++
Hemoglobin A1c/Hemoglobin.total in Blood 3.6 L 4 - 6 %
Glucose [Mass/volume] in Blood 64.7 L 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 16.8 7 - 50 mg/dL
Creatinine [Mass/volume] in Blood 3.5 H 0.9 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.7 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 137.4 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.5 3.5 - 5.3 mmol/L
Chloride [Moles/volume] in Blood 109.4 H 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 27.4 22 - 32 mmol/L

Urinalysis

Test 21 Jul 2025 Reference Range Unit
Glucose [Mass/volume] in Urine by Test strip 0.9 0 - 1 mg/dL
Glucose [Presence] in Urine by Test strip ++
Bilirubin.total [Mass/volume] in Urine by Test strip 0.7 0 - 1.2 mg/dL
Bilirubin.total [Presence] in Urine by Test strip Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip 1.5 0 - 4 mg/dL
Specific gravity of Urine by Test strip 1.0 L 1.01 - 1.03 {nominal}
pH of Urine by Test strip 5.4 4.6 - 7 pH
Protein [Mass/volume] in Urine by Test strip 266.1 H 0 - 14 mg/dL
Protein [Presence] in Urine by Test strip Urine protein test = ++
Nitrite [Presence] in Urine by Test strip Urine nitrite negative
Hemoglobin [Presence] in Urine by Test strip Urine blood test = negative
Leukocyte esterase [Presence] in Urine by Test strip Urine leukocyte test negative

Annotation

Conclusion and Recommendations based on this report and previous findings known to us
The patient shows persistent renal dysfunction (elevated creatinine), significant proteinuria, and abnormal urine findings (cloudy, brown, low specific gravity, protein, glucose, ketones, bilirubin). There is also recurrent hypoglycemia (low glucose, low HbA1c). No evidence of urinary tract infection. Findings suggest chronic kidney disease with nephrotic-range proteinuria and possible glycemic dysregulation. Recommend clinical correlation for underlying etiology, medication review, and further nephrology and endocrinology evaluation.