Lab Data and Diagnostic Medical Transcription Terms

NOTE:  Always refer to your normal lab value sheet for normal ranges. The values indicated in this webpage are unique to each patient's specific disease/condition!! 

LABORATORY DATA:  White count on admission 9700, hemoglobin 14.4, hematocrit 44.6, and platelets 225,000.  Sodium 140, potassium 4.2, chloride 101, CO2 30, BUN 14, creatinine 1.2, glucose 103, calcium 9.2, total bilirubin 0.7, and total protein 8.1.  AST 195, ALT 116, alkaline phosphatase 120, albumin 4.1, lipase 241, and troponin I is less than 0.1.  Urinalysis shows trace protein, 1+ occult blood, negative nitrites, negative leukocyte esterase, 5-10 red blood cells and less than 2 wbc's, trace bacteria, trace mucus, and rare epithelial cells.  Valproic acid level is 61.6.

EKG showed no ST changes.  Abdominal x-ray showed a possible bezoar and distended loop of bowel.  Chest x-ray showed no acute pulmonary process with a positive gastric air bubble.

LABORATORY DATA:  On admission labs, white blood cell count 6.5, H&H 13.5 and 39.1, platelets 251,000, sodium is 134, potassium 4.1, chloride 102, bicarbonate 25, BUN and creatinine 13 and 1.2, and platelet 364,000.  PT 12.2, INR 0.8, PTT 29, D-dimer is 0.43.  Alkaline phosphatase 103, AST was 35, ALT 497.  cardiac enzymes x3 were negative.

LABORATORY DATA:  White blood count 5500, hemoglobin 14.4, hematocrit 40.6, and platelets 234,000.  Sodium 135, potassium 3.7, chloride 103, bicarbonate 25, BUN 5, creatinine 1.2, glucose 107, calcium 8.8, and albumin 4.3.  Alkaline phosphatase 83, AST 65, ALT 68, total bilirubin 0.6.  UA revealed trace blood.  Chest x-ray was normal.

LABORATORY DATA:  Laboratories on admission; blood gases show pH 7.39; pCO2 40.5, normal; pO2 60.2, decreased.  O2 saturation 90.8.  Urine drug screening came back positive for benzodiazepines and cannabinoids.  CK, myoglobin elevated.  Troponin was normal.  CBC shows WBC 6800, H&H 12.3 and 39.  Platelets normal at 262,000.  Chemistry profile on admission showed sodium 146.  Rest of the electrolytes are normal.  BUN, creatinine, and blood sugar were normal.  Liver profile was unremarkable.  Dilantin level on admission was 4.3.

LABORATORY DATA:  Laboratory workup showed hemoglobin of 10.5, hematocrit 31.8, WBC count of 7900, and platelet count of 92,000, bands 16 and polys 73.  Chemistry showed BUN of 13.9, creatinine of 2.8, glucose 148, calcium 9.5, albumin of 3.3, SGOT 46, SGPT 56, alkaline phosphatase 202, and anion gap of 10.

X-ray of the chest showed evidence of congestive heart failure.  EKG showed sinus rhythm and left ventricular hypertrophy with ischemia.

LABORATORY DATA:  Chest x-ray done in the ER showed a right lower lobe infiltrate, questionable infiltrate in left lower lobe.  CMP showed sodium 139, potassium 3.6, chloride 102, bicarbonate 22, BUN 11, creatinine 0.8, and blood glucose of 243.  Her CBC showed white blood cell count of 13,900, hemoglobin 13.2, hematocrit of 39.7, and platelets of 234,000.  The poly count was 90.5% and the lymphocytes were 6.4.  Also, the patient's amylase was 74 and lipase 29.  Albumin 4.3.  Calcium 9.3.  AST, ALT, and alkaline phosphatase were within normal limits.

LABORATORY STUDIES:  Initial white count of 6600 with hemoglobin of 13.8 gm%, segs of 78%.  Another white count was 7130 and 7370 and hemoglobin ranging from 13 to 14.7, segs remained increased at 85% and 78%.  Urinalysis showed presence of sugar and a small amount of blood, protein.  No leukocyte esterase, wbc's negative, and bacteria trace.  Subsequent urine was negative.  Admission electrolytes showed sodium 142, chloride 99, blood sugar 156, creatinine 1.4, BUN 14, subsequent BUN was 11 and creatinine of 1.3.  LFTs showed normal studies and the magnesium initially was only 1.21, improving to 1.9 and 2.2.  TSH was 1.33, troponin I was 0.  Urine culture was negative.

A 12-lead EKG showed functioning pacemaker.  CAT scan of the pelvis without contrast was unremarkable.  CAT scan of the abdomen was also unremarkable except for punctate granuloma at the base of the lung.  No ascites.  Abdominal ultrasound showed a tiny 3 mm left renal calculus, which was nonobstructing.  HIDA scan was negative.  Chest x-ray showed low lung volume without any acute disease.

PERTINENT LABORATORY DATA:  On admission, CBC was 13.1.  Hemoglobin and WBC were fine.  Then, followup of the hemoglobin was down to 11.2.  Urinalysis was unremarkable.  BMP and electrolytes were normal.  BUN was a little bit high at 20.  Creatinine was a little bit high at 1.4.  Blood sugar was 172.  I did not do the followup.  The kidney function was done, back to normal.  Blood sugar was down to 72.  Electrolytes were unremarkable.  Magnesium level is low at 1.8.  The blood gases on admission; the pO2 was 76 with normal pH and pCO2.

We did a KUB on admission.  No change in position of the right ureteral stone at the level of the sacroiliac joint.  Chest x-ray:  The heart is normal, no active infiltrate.  EKG showed regular sinus rhythm.  No fascicular block or evidence of any acute changes.  Cardiac enzymes were unremarkable.

TEST RESULTS:

1.  Chest x-ray:  Cardiomegaly, otherwise unremarkable.
2.  CT of the abdomen and pelvis revealed circumferential diffuse wall thickening of the colon, most likely Clostridium difficile colitis and prominent cardiomegaly, otherwise unremarkable.
3.  CT, pelvis part; diverticulosis of sigmoid, thickening of the entire colon and rectosigmoid, Clostridium difficile colitis.
4.  White blood cells on hospital discharge down to 7400, hemoglobin 12.1, and platelets 275,000.  Sodium 135, potassium 4, creatinine 0.5.  Digoxin level is 0.9.  ALT is 31-39, normal.

LABORATORY AND X-RAY DATA:  At the time of admission, the patient had leukocytosis.  At discharge, her white blood count was normal.  Her hemoglobin had gone from 10.1 on admission to 9.5 at discharge.  Diagnosis of probable iron-deficiency anemia had been made.  The patient was found to have elevated fasting glucoses.  Her electrolytes were normal.  Admission urinalysis showed a trace of glucose, large ketones, and trace leukocyte esterase.

Chest x-ray showed some right minor fissure thickening with no acute cardiopulmonary disease.  Final pathology showed a portion of the cecum and appendix with gangrenous appendicitis, perforation, formation of periappendiceal abscess, and a portion of the large bowel with submucosal edema, mural and subserosal, acute inflammation without any evidence of malignancy.

LABORATORY STUDIES:  Electrolytes were normal.  BUN 17, creatinine 1.2, and blood sugar 99 mg%.  Magnesium 1.8, troponin 0, digoxin level was 0.69, subsequent troponin level remained 0.  PT was 12.6 with INR of 1.1.  White count was 9880 with 76% segs.  Urinalysis was unremarkable.

A 12-lead EKG showed functioning pacemaker.

LABORATORY STUDIES:  Sodium 133, potassium 4.2, and BUN 24.  Random blood sugar was 147 mg%.  Troponin I was 0.  Blood sugar 144.  T4 was 6.4.  TSH was 1.57, which is normal.  Initial white count was 20,000 with hemoglobin 17.9 mg%, hematocrit 53 mg%, 85 segs.  Repeat white count 2 days later was 11,400 and later this came down to 8400.  Urinalysis was negative.  Subsequent BUN went up to 36 mg% with creatinine of 1.3.  His PSA level was 3.2.  A repeat ABG showed pH of 7.37, pCO2 of 44, and pO2 of 114 on 36% of oxygen.  The urine culture did not grow any organism.

A 12-lead EKG on admission showed supraventricular tachycardia.  Followup EKG showed sinus rhythm with heart rate down to 83 per minute without any acute changes.  Chest x-ray showed chronic obstructive pulmonary disease with granulomatous lung disease and a tiny, small pleural effusion.  No definite pneumonia.  Renal ultrasound showed no evidence of hydronephrosis.  There was a 5.7 simple cyst in the right kidney.  Bladder ultrasound showed postvoid of 340 mL, which is very significant.

LABORATORY EXAMINATION:  Hemoglobin 12.3, hematocrit 35.5, white blood cell count 4070, and platelet count of 164,000.  Sedimentation rate of 5.  UA shows no blood, no protein, no nitrites.  Sodium 142, potassium 4.5, chloride 102, CO2 31.5, BUN 17, creatinine 1.1, glucose 88, protein 6.7, albumin 3.8, calcium 9.3.  Bilirubin 0.51, AST 14, ALT 31, alkaline phosphatase 85.  Amylase 48 and lipase 180.  Triglyceride 88, cholesterol 164, HDL 53, LDL 93.  PSA 1.78.  Iron 125, TIBC 344.  B12 of 247, folic acid of 14.  Herpes zoster IgG was 81, herpes zoster IgM was 15.  Serum protein electrophoresis was normal.  Urine culture was negative.

LABORATORY EXAMINATION:  Hemoglobin 10.3, hematocrit 32, white blood cell count 10,800, and platelet count 384,000.  UA showed no protein, no blood, and no glucose.  Sodium 142, potassium 3.2, chloride 103, CO2 of 25, BUN 9, creatinine 1.2, glucose 107, protein 6.1, albumin 2.9, calcium 8.2.  Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87.  Amylase 96, lipase 547, repeat lipase 494.  Magnesium 1.4.  Iron 24, TIBC 282.  C-reactive protein 16.  CEA 2.2.  RPR negative, rheumatoid factor negative, ANA negative, pH 7.35, pCO2 34, pO2 80, and bicarbonate of 19.  Urine negative.

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