Lab Data Medical Transcription Format and Words

Examples of Lab Section Format / Template / Words in Medical Transcription

LABORATORY AND DIAGNOSTIC DATA:  INR 2.14, white count 9400, hemoglobin 11.4, hematocrit 34.2, and platelets 288,000. Sodium 136, potassium 5.2, chloride 96, CO2 of 26, glucose 94, BUN 84, creatinine 8.6, and calcium 9.8. Echocardiogram revealed mildly diminished left ventricular systolic function with hypertensive cardiovascular disease. The porcine prosthesis appeared to be functioning normally. MRI of the brain revealed bilobed versus adjacent pituitary lesions. These could represent pituitary adenomas; although, choristomas could not be excluded given the posterior location. Rathke’s cleft cyst also cannot be excluded. There is no impingement on the optic chiasm. The remainder of the brain demonstrated moderate degree of a small vessel ischemia. Chest x-ray revealed COPD, cardiomegaly, and no significant change from the prior exam. Blood cultures x2 were negative.

LABORATORY DATA:  CBC showed WBC 7.6, hemoglobin 14.2, hematocrit 42.6, platelets 164. PT 9, PTT 26, INR 0.96. Sodium 134, potassium 3.8, chloride 102, bicarb 26, and glucose 116. BUN 22, creatinine 1.4, and calcium 9.8. Liver function test was within normal limits. ALT 23, AST 19, within normal limits. HDL 74, LDL 92, triglycerides 192, cholesterol 154, VLDL 38. Cardiac enzymes were within normal limits. Urine creatinine random 242, urine sodium random 44, and urine protein random 19. Urinalysis is within normal limits.

LABORATORY DATA:  White count 5800, hemoglobin 15.2, platelet count 254,000 with 77 neutrophils, 4 bands, 5 lymphs, and 12 monos. Sodium 131, potassium 3.8, chloride 94, CO2 of 24, glucose 156, BUN 46, and creatinine 4.4. Alk phos 82, ALT 16, AST 18, amylase 19, CK 46, lipase 18, and troponin 0.3. Urinalysis; dark yellow, hazy, 2+ albumin, trace ketones, 2+ occult blood, positive nitrites, 1+ leukocyte esterase, 5 to 10 rbc’s, 10 to 20 wbc’s, 2+ bacteria, and 2+ yeast. Blood cultures x2 are pending and the urine culture is pending. Chest x-ray shows stable interval chest exam without any focal new infiltrates. There is evidence of COPD. Renal ultrasound done shows slight increase in the echotexture of the kidneys, which is nonspecific. There are two systemic kidneys bilaterally with Bosniak category I and II cysts in the kidneys bilaterally. Bosniak category cyst in the left kidney should be reassessed with a followup ultrasound in 3 to 6 months to document stability. CT of the pelvis showed severe circumferential wall thickening of the colon compatible with pseudomembranous colitis. Findings have markedly progressed. CT of the abdomen again showed marked circumferential wall thickening of the entire colon. The pattern was compatible with pseudomembranous colitis.

LABORATORY DATA: Serum chemistries within normal range with a creatinine of 1.2 and glucose of 106. CBC showed a white count of 9.4 with normal differential and hemoglobin of 12.4 and was otherwise unremarkable. Cardiac markers, CK-MB, and troponin I were negative. BNP was negative at 6.8. D-dimer was positive at 964. Urinalysis showed moderate leukocyte esterase, 16 white cells, and 2 red blood cells.

DIAGNOSTIC DATA:  Chest x-ray shows no acute cardiopulmonary pathology. CTPA shows no evidence of cardiopulmonary pathology and no evidence of pneumonia. EKG performed for indication dyspnea shows sinus tachycardia at a rate of 106 beats per minute. She had normal axis with normal intervals. Her QTc was 432 milliseconds. There were no ST changes or T-wave inversions.

Lab Data Samples #1

LABORATORY DATA:  The patient has a white count of 8.9, hemoglobin 10.6, hematocrit 32.6, and platelets 146,000. PT is 17.4. INR is 1.4. Glucose 216, creatinine 1.6. Total bilirubin 1.7. Other parameters are within normal limits. CK-MB was high at 40.2. Troponin level was high at 13.72. B-type natriuretic peptide is 514. Urine Legionella is negative. Urinalysis shows a white count of greater than 50, bacteria 2+, budding yeast 2+, and blood 3+.

DIAGNOSTIC AND LAB STUDIES:  A chest x-ray obtained and read showed no obvious infiltrate or pneumothorax. She had an initial EKG read as sinus tachycardia with a rate of 106. She had inverted T-waves in leads III and aVF as well as V1 through V6. We repeated this EKG and read it again probably an hour later. This showed a sinus rhythm with the T-wave inversions that we saw earlier all completely resolved. She had a rate of 90 on this EKG. She had laboratory studies, including a normal troponin, a normal D-dimer. White count 7.2, hemoglobin 13.4, hematocrit 39.8. She had a glucose of 92, BUN 14, creatinine 0.8, sodium 136, potassium 3.6, chloride 106, CO2 of 26.

LABORATORY AND DIAGNOSTIC DATA:  WBC 12,200, hemoglobin 14, hematocrit 42, normal platelet count. INR was 1.2 upon admission. Chemistry showed sodium 138, potassium 3.9, bicarb 32, BUN/creatinine 32 and 1.4 respectively. Albumin 2.8. BNP was more than 4000. Urinalysis upon admission shows cloudy urine, specific gravity of more than 1.030, 1+ albumin, 2+ bilirubin, 2+ urobilinogen, 2+ bacteria. Chest x-ray showed cardiomegaly with bilateral interstitial infiltrates consistent with CHF. The patient also has bilateral small pleural effusions.

LABORATORY DATA:  Laboratory studies included a CBC with a white blood cell count of 8.4, hemoglobin 13.8, hematocrit 40.2, and platelets 374. Renal panel shows sodium of 138, potassium 3.2, chloride 106, bicarbonate 26, BUN 11, creatinine 0.6, and glucose 160. Cardiac enzymes are normal with a CK-MB of less than 1.0. Troponin was less than 0.05. BNP was 10.8. D-dimer is less than 100.

EKG shows a normal sinus rhythm at a rate of 60 with T-wave inversions in the inferior leads. This is unchanged with comparison to her most recent EKG. She does have flattening of the T-waves in the lateral leads, which appears new. PR intervals are 164. QRS 94. QT 408. QTc 408. She has a normal axis, no acute ischemic changes and no ST elevation.

LABORATORY DATA:  Laboratory investigations revealed a normal CBC, except hemoglobin of 9.6 g with normocytic normochromic indices and normal platelet count, neutrophils 99%. CMP revealed elevated blood glucose of 172, normal creatinine, and BUN 46 mg/dL. The patient has hypoproteinemia with total protein of 4.6 g/dL, albumin 1.8 g/dL, globulin 2.7 g/dL, and magnesium 2.0 mg/dL. Antinuclear antibody positive 1:1280, mixed pattern of homogeneous and mitotic spindle and antinuclear antibody index 5.04. Urinalysis is unremarkable. Stool for guaiac is negative.

Lab Data Samples #2

LABORATORY DATA:  Hemoglobin 5.8, hematocrit 18.6, and platelets 562,000 on admission. Followup hemoglobin was 8 with hematocrit of 24.4. PT 15.2 with PTT of 26.4. D-dimmer 3.24. Comprehensive metabolic profile was significant for BUN of 42 and creatinine of 2.1. LFTs normal. CPK with troponin negative. Serum iron 10, ferritin 5 and TIBC 406. UA shows 10 to 20 wbc’s per high power field with 4+ bacteria. A V/Q scan showed definite perfusion defect involving the superior segment of the right lower lobe, probably pulmonary emboli.

LABORATORY DATA:  Serum chemistries show potassium of 4.8 with a BUN and creatinine of 34 and 5.2 respectively. Her glucose was normal at 120. CBC shows a white count of 16.6 with a 5% bandemia. Hemoglobin 12.4. Platelet count was critically low at 33. LFTs, lipase, and ammonia are pending at this time as is the lactate. PT and PTT were 39.8 and 84.0 respectively with an INR of 4.4 off of a peripheral line. CK-MB and troponin I were markedly elevated at 14.2 and 6.02.

EKG was performed for indication of mental status changes and tachycardia and showed atrial fibrillation with a rapid ventricular response of 140 beats per minute. She had a narrow QRS 86 milliseconds with a QTc of 450 milliseconds. She had T-wave inversions in lead I and aVL as well as V4 through V6 with no acute ST elevations. Chest x-ray shows a right tunneled IJ in place with no acute cardiopulmonary pathology.

LABORATORY DATA:  Sodium 134, potassium 4.0, chloride 114, CO2 of 16, BUN 30, creatinine 1.9, and glucose 94. WBC 1.9, hemoglobin 10.8, hematocrit 33.4, and platelet count 242,000. B-type natriuretic peptide 2890. Ammonia level 256. Cardiac enzymes are negative x1. EKG shows sinus rhythm with ST depression in lead V5 with a Q wave in lead aVL and left ventricular hypertrophy. Chest x-ray shows right upper lobe infiltrate.

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