LABORATORY DATA: White count 9.6, hemoglobin 12.8, hematocrit 38.4 with platelets of 332,000. Sodium 141, potassium 4.1, chloride 104, bicarb 28, BUN 19, creatinine 0.9 with a glucose of 112. Troponin less than 0.05 x5, MB normal with a CPK of 36 and 35. D-dimer 640. CT angiogram showed no evidence of pulmonary embolism or aortic dissection, severe emphysematous changes, a 1.8 x 2.4 spiculated right upper lobe superior segment lesion and a noncalcified nodule in the posterior segment of the left upper lobe with some parenchymal scarring in the left upper lobe and in the apices. Chest x-ray showed no acute pulmonary pathology. EKG showed a normal sinus rhythm.
LABORATORY DATA: Electrolytes are normal. BUN and creatinine 18 and 2.2. Blood sugar 154. White count 7.6, hemoglobin 11.4 with hematocrit 34.4, platelets 182,000. LFTs were normal. Hemoglobin A1c 7.4. TSH 1.80. Troponin I was normal on 3 occasions.
Chest x-ray showed an enlarged heart with postoperative changes but no evidence of acute pathology. EKG shows probable left atrial enlargement, low voltage QRS, probable inferior wall myocardial infarction and anterior wall infarction, age undetermined.
DIAGNOSTIC DATA: ECG: Sinus rhythm, rate 92. No acute infarction evident. Shallow T-wave inversions are present in V1 through 4. T-inversions are also present in III and aVF. Chest x-ray showed mild diffuse interstitial changes with mild cardiomegaly.
LABORATORY AND DIAGNOSTIC DATA: Electrolytes unremarkable. Echocardiogram was done yesterday and showed severe left ventricular dysfunction, 20% to 25% with diastolic dysfunction, mild aortic insufficiency, mild to moderate mitral regurgitation and mild tricuspid insufficiency.
LABORATORY AND DIAGNOSTIC DATA: Laboratory data is pertinent for a normal BMP, except for glucose of 142. Troponin I is 0.03. Hemoglobin is 13.6, WBC count 12.2. Normal coagulation studies with an INR of 1.2. PO2 is 106 with pH of 7.36 and a CO2 of 42 on 100% non-rebreather mask. A 12-lead EKG reveals sinus rhythm at 96 beats per minute with new inferior wall mild ST-T depressions and T-wave inversions. Chest x-ray shows no acute cardiopulmonary disease.
LABORATORY AND DIAGNOSTIC DATA: White count 2.8, H and H 9.6 and 27.4, platelets 146. Sodium 138, potassium 3.7, chloride 108, CO2 of 26, BUN 30, creatinine 0.7, glucose 100, calcium 8, phosphate 3.6, magnesium 3.2. TSH 3. Recent chest x-ray is stable, bilateral pleural effusions. Abdominal CT showed no obvious cause of abdominal pain. Splenic and liver lesions stable. Diverticulosis. Coronary atherosclerosis. Chest CT showed no PE, bilateral lower lung field infiltrates, bilateral pleural effusions, interstitial infiltrates, nonspecific mass in posterior segment of right hepatic lobe.
Lab Data Transcription Examples #1 Lab Data Transcription Examples #2
LABORATORY DATA: CBC: WBC is elevated at 13.6, hemoglobin is low at 8, hematocrit 23 with low MCV of 70. Platelet count is 404, which is elevated. There is a left shift. Chemistry: Sodium 138, potassium is low at 2.8, chloride 106, CO2 of 26, BUN 18, creatinine 0.7, glucose is elevated at 104. AST is mildly elevated at 44, ALT 30, alkaline phosphatase 85, total bilirubin 0.7. Calcium is low at 8.2. Albumin also low at 1.8. Total protein 5.8. N-peptide is elevated at 3850; this was 55.2 previously. Cardiac enzymes showed an elevated CK of 404 and CK-MB of 8.2 Troponin is within normal limits at 0.22. Urinalysis shows cloudy appearance, 30 protein and moderate blood, otherwise negative for urinary tract infection. ABG is significant for an elevated PH of 7.52, PCO2 of 30 and PO2 of 52 as well as oxygen saturation of 90% on room air. Bicarbonate is within normal limits at 26.
DIAGNOSTIC DATA: Initial EKG showed SVT with 160 beats per minute. Repeat EKG showed sinus rhythm with 66 beats per minute with left ventricular hypertrophy, no evidence of ischemia. Telemetry showed normal sinus rhythm; however, he had a wide-complex tachycardia versus atrial fibrillation. Chest x-ray, no acute process, just only significant for mild cardiomegaly.
LABORATORY DATA: INR is 0.90. WBC 7.6, hemoglobin 15.8, hematocrit 46, platelets 229,000. LFTs completely normal. Sodium is 141, potassium 3.7, chloride 106, CO2 of 26, BUN 11, creatinine 1.1, glucose 104. Lipids; cholesterol 172, HDL 26, LDL 72, triglycerides 388. CPK is 370. Troponins are negative x3. TSH completely normal. Magnesium was 1.8, which has been repleted.
LABORATORY DATA: WBC count 12.2, hemoglobin 11.8, hematocrit 36.6, platelet count 224,000. Sodium 142, potassium 4.1, chloride 104, bicarbonate 30, glucose 150, BUN 26. LFTs are within normal limits. BNP upon admission was 262. Urinalysis revealed cloudy urine, nitrite negative, leukocyte esterase 3+, wbc’s more than 50, bacteria 3+. Urine culture obtained on admission revealed more than 100,000 colonies of Proteus mirabilis and Morganella morganii. Susceptibility reports reviewed. Morganella is resistant to all the antibiotic classes, except carbapenems and tobramycin. Proteus is pretty much susceptible to all third-generation cephalosporin and carbapenems, resistant to quinolones.
Normal Lab Values Common Lab / Diagnostic Words and Phrases
RADIOLOGIC DATA: CT scans reviewed reveals a solitary functioning left kidney, which appears to function and drain appropriately with no abnormalities. There is an atrophic right kidney. There is a normal-appearing bladder and enlarged prostate. There is a 2.6 cm mass involving the aortic bifurcation. MRI is reviewed and is consistent with the above findings. There is no urologic abnormality noted. Flexible cystoscopy performed today at the bedside reveals a normal urethra, evidence of benign prostatic hypertrophy with high tight bladder neck with blood in the prostatic fossa. Once this was washed free, there was no mucosal abnormality noted. The bladder was unremarkable with no trabeculation, no mass, erythema or other lesions noted. There was clear urine effluxing from the left ureteral orifice. There was a large intravesical component of the prostate.
LABORATORY DATA: WBC 7.2, hemoglobin 9.6, hematocrit 29.6 and platelets of 284,000. Basic metabolic profile significant for potassium of 2.7, BUN of 8 and creatinine of 0.7. LFTs are normal. Amylase and lipase are normal. Serum iron of 22, ferritin of 79, TIBC of 232 with percent saturation of 10. Stool for fecal leukocytes positive. Ova and parasite, CDT screen and cultures in progress. CT scan of the abdomen and pelvis with contrast showed cyst in the liver and a 2.8 cm focal area of questionable mural thickening involving sigmoid colon.
LABORATORY DATA: WBC 7.4, hemoglobin 10.9 with hematocrit of 33 and platelet count of 384,000. Chemistry showed sodium 132, potassium 4.0, BUN and creatinine of 27 and 2.1 respectively. Calcium is 7.7, albumin less than 1, total protein is 6.8, slightly elevated LDH. BNP was 2144. The patient’s 24-urine test showed creatinine clearance of 34 mL/minute, protein of more than 5 g. HIV antibody was positive. Western blot is pending. The patient’s absolute CD4 count is 76.
LABORATORY DATA: CBC: White blood cell count 10.2, hemoglobin 8.2 down from over 10 and platelets 229,000. BMP: Creatinine 0.7, BUN 8. Glucose 176, possible gestational diabetes. Potassium 3.2, sodium 134, chloride 106 and CO2 of 22. Urinalysis; pH 6.0, albumin 1+, ketone 3+, bilirubin negative, occult blood trace, nitrites negative and urobilinogen normal. Leukocyte esterase 2+, yellow and hazy. Urine microscopy, 20 to 50 white blood cells, 0 to 4 red blood cells, squamous cell 5 to 10 and bacteria 2+.
LABORATORY DATA: White cell count is 6.2, hemoglobin 13.8 and platelet count 186,000. Sodium 136, potassium 4.1 and glucose 98. Liver functions; slightly high AST at 60 and ALT at 102. CSF was examined. Tube #1, no nucleated cells and 2 red cells, clarity was clear, colorless. Tube #4 was also clear, colorless with 3 nucleated cells and 1 red cell. Xanthochromia negative in both tubes. CSF glucose 60 and CSF protein 38.
LABORATORY AND DIAGNOSTIC DATA: A 12-lead EKG is not available at this time. We will order a 12-lead EKG now. WBC 39 with 34% bandemia, H&H 10.2 and 32 and platelet count 712,000. INR is 1.3. Chloride is 112, BUN and creatinine 27 and 0.8 and glucose is 56. Cardiac enzymes x 1 negative. UA showed 3+ blood, nitrite positive, 3+ leukocyte esterase, 10-20 wbc’s, more than 50 rbc’s and 2+ bacteria. ABG showed pH 7.3, pCO2 of 34, pO2 of 216 and saturation 100%. Chest x-ray was negative. Recent 2D echocardiogram showed normal left ventricular size and systolic function. No significant valvular pathology seen.
