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Laboratory and Diagnostic Data Medical Transcription Examples

LABORATORY DATA: Showed amylase and lipase normal at 42 and 43 respectively. UA showed small blood, 3-5 red cells, 5-10 white blood cells, 3-5 hyaline casts, 0-3 granular casts, and occasional WBC clumps. Glucose 97, BUN 11, creatinine 0.7, sodium 137, potassium 3.9, chloride 102, CO2 of 26. White count 13.3, hemoglobin 12.5, hematocrit 37.1, 84% neutrophils, 9% lymphocytes. Liver functions were normal.


LABORATORY DATA: Laboratory data reviewed today included CBC showing a hemoglobin of 12.7, hematocrit of 32, white blood cell count of 10, platelet count of 395. Renal panel was fairly uneventful with a sodium of 138, potassium 4.4, chloride of 103, CO2 of 26, BUN of 13, and creatinine of 1.3 with a glucose random of 154 which is elevated slightly. His fingerstick glucoses have ranged from 170-255 in the past 24 hours.


LABORATORY DATA:  BMP:  Sodium 138, potassium 6.4, chloride 108, bicarbonate 18, BUN 86, creatinine 6.4, glucose 138, phosphorus 6.9, magnesium 2.6. Liver Function Tests:  AST 26, ALT 20, alkaline phosphatase 229, total bilirubin 0.7, albumin 3, total protein 6.9. Troponin I 0.03. i-STAT lactate 2.1. CBC:  White blood cell count 8.2, hemoglobin 10.4, hematocrit 31, platelets 277. Coagulation Studies:  PT greater than 110, INR greater than 14, PTT 146.7. ABG:  pH 7.26, pCO2 37, pO2 163, oxygen saturation 99% on 3 liters nasal cannula. Urinalysis:  Trace protein, trace glucose, large blood, moderate epithelial cells, 4 to 10 hyaline casts, 20 to 50 red blood cells, few bacteria, 2 to 5 white blood cells.

Head CT without contrast, per radiology reading, shows extensive atrophy and chronic white matter ischemic changes. No acute infarct. No hemorrhage or mass. Old right cerebellar hemispheric infarct. Portable chest x-ray, per radiology reading, showed cardiomegaly without superimposed failure. The retrocardiac infiltrate previously seen has almost completely resolved. EKG shows atrial fibrillation at a rate of 84, normal axis. No ischemic ST or T wave changes. There is some nonspecific T wave flattenings in leads III and aVF, which are unchanged compared with prior EKG. QTc is prolonged at 495 milliseconds.


LABORATORY DATA: Include CBC with a white blood cell count 11.2, hemoglobin 13.6, hematocrit 40.1, platelets 236. Renal panel shows sodium 138, potassium 3.6, chloride 108, bicarbonate 23, BUN 12, creatinine 1, glucose 87. INR is 4.1. Urinalysis shows trace ketones, moderate blood, 100 protein, 10-20 red blood cells, too numerous to count white blood cells, moderate bacteria. This was sent for culture. Urine pregnancy test is negative. Wet prep is negative for trichomonas, negative for yeast.


LABORATORY DATA: Laboratory studies include a CBC with a white blood cell count of 8.7, hemoglobin 14.6, hematocrit 42.9, platelets 408. Renal panel shows sodium 138, potassium 3.9, chloride 108, bicarbonate 24, BUN 12, creatinine 0.9, glucose 88. Cardiac enzymes are normal with a CK-MB of less than 1, troponin less 0.05. Second set was also normal at less than 1 and less than 0.05 respectively. She had a urinalysis showing 30 protein, trace ketones, many bacteria, trace leukocyte esterase, 3-5 white blood cells, moderate blood, 3-5 red blood cells, 4.0 urobilinogen. Urine pregnancy test is negative. Urine tox screen is positive for cocaine.


LABORATORY DATA: Her CBC shows a white count of 14.2. Hemoglobin is 13.5. Platelets are 239. Neutrophils are 90%. Lymphocytes are 5%. Her renal shows a sodium of 144, potassium 3.2, chloride 103, bicarbonate 24. BUN 17 and creatinine 0.9. Glucose is 143. AST 21, ALT 17, bilirubin 3.6 total, bilirubin direct 0.5. Protein is 8. Albumin is 5. Calcium is 10. Lipase is 21. Alkaline phosphatase is 49. Her urinalysis was orange and hazy. Specific gravity was 1.032. She had 100 protein and 80 ketones. Glucose was negative. There were many bacteria. Negative for leukocyte esterase. Negative nitrites. She had 3 white blood cells, was negative for blood, 5 red blood cells. Moderate bilirubin in urine. She had 2 urobilinogen. Her beta hCG was negative.


LABORATORY DATA:  CBC showed WBC of 11,600, neutrophils 31% and lymphocytes 44%, and hemoglobin 14.6.  On MM/DD/YYYY, his WBC was 16,400, hemoglobin 13.8, and neutrophils 40%, and lymphocytes 48%.  Serum chemistry revealed normal serum electrolytes, revealed a low calcium of 8.2, total protein 4.3, and albumin 1.3.  Urinalysis; 3+ protein.  On MM/DD/YYYY, urinalysis showed 3+ protein and WBC 14,700, hemoglobin 13.4, neutrophils 38%, lymphocytes 53%, and platelets 576,000.  Serum chemistry still showed a low albumin of 1.7, total protein of 5.4, potassium of 5.8, CO2 of 18, and glucose 120.  A 24-hour urine revealed a total protein of 1100.  Serum chemistry revealed significant improvement with normal electrolytes, creatinine of 0.3, BUN 19, total protein 6, albumin 2.8, and calcium 9.3.  His cold agglutinin also was reported positive at 1:512.  His RSV was negative.


LABORATORY/DIAGNOSTIC DATA: Serum chemistries were within normal limits, except for markedly elevated glucose of 425 with no anion gap. CBC was within normal limits with a white count of 5.7. Serum ketones were negative. LFTs showed mild elevation of his AST at 97, but otherwise unremarkable. Lipase was normal at 32. Calcium, magnesium and phosphorous were within normal limits. Cardiac markers, CK-MB and troponin I were negative on the first two sets with a BNP of less than 5. Chest x-ray shows no acute cardiopulmonary pathology. EKG: Shows normal sinus rhythm at 84 beats per minute. He had sinus rhythm with a first-degree AV block and PR interval of 212 milliseconds. He had left axis deviation with a left anterior fascicular block and a QRS of 90 milliseconds and QTc was 422 milliseconds. He had mild T-wave flattening in V3 with poor R-wave progression in the precordial leads in comparison to a prior EKG. There was no significant change.


LABORATORY AND DIAGNOSTIC DATA:  Hemoglobin 10.4, hematocrit 30.6, white blood cell count 7400, and platelet count 286,000.  Stool for occult blood negative.  Sodium 142, potassium 3.6, chloride 102, CO2 of 30, BUN 16, creatinine 1.8, glucose 86, phosphorus 3.4, calcium 8.6, and magnesium 1.6.  Triglycerides 124, cholesterol 104, HDL 25, and LDL 154.  Urine culture showed pseudomonas and Staphylococcus aureus.

CT of the abdomen showed small pleural effusions, cholecystectomy, and no CA.  CT of the pelvis showed sigmoid diverticulitis.  CT of the chest showed left subclavian axillary vein thrombosis with atelectasis.  V/Q scan showed no evidence of pulmonary embolus.   Chest x-ray showed no infiltrate.  Venous Doppler study showed thrombi in the axillary, basal, and cephalic veins of the left upper extremity.  EKG showed right bundle branch block.


LABORATORY AND DIAGNOSTIC DATA:  Hemoglobin 10.6, hematocrit 31.2, white blood cell count 10,600, and platelet count 384,000.  UA showed no protein, no blood, and no glucose.  Sodium 143, potassium 3.3, chloride 104, CO2 of 26, BUN 9, creatinine 1.2, glucose 106, protein 6.1, albumin 2.8, calcium 8.3.  Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87.  Amylase 97, lipase 546, repeat lipase 493.  Magnesium 1.4, iron 24, TIBC 282.  C-reactive protein 16.  CEA 2.2.  RPR negative.  Rheumatoid factor negative.  ANA negative.  A pH of 7.35, pCO2 34, pO2 80, and bicarbonate of 19.  Urine negative.

CT of the brain showed old bilateral infarcts.  MRI of the brain, old bilateral infarcts were seen.  HIDA scan, gallbladder not visualized consistent with cystic duct obstruction.  Chest x-ray showed no infiltrate.  Abdominal ultrasound showed a single gallstone, mild right hydronephrosis.  Renal ultrasound showed mild prominence of the right extrarenal pelvis.  EEG showed slowing secondary to diffuse cortical dysfunction.  EKG showed normal sinus rhythm with nonspecific ST changes.


LABORATORY AND DIAGNOSTIC DATA:  CBC showed white count of 6300, hemoglobin 11.1.  On MM/DD/YYYY, white count was around 3200 and hemoglobin was around 9.1.  On MM/DD/YYYY, white count was 4200, hemoglobin 9.2, platelets 256,000, 64 segs, 23 lymphos, and 8 monos.  Urinalysis showed trace amount of blood.  Sodium was 142 on admission, potassium 3.8, chloride 104, CO2 of 18, glucose 140, BUN 26 and creatinine 1.3.  LFT was normal.  Electrolytes on MM/DD/YYYY was essentially unremarkable.  On MM/DD/YYYY, sodium 138, potassium 4.6, chloride 105, CO2 of 24, glucose 125, BUN 12, creatinine 1.1, and magnesium 1.5.  Magnesium was 1.4 on MM/DD/YYYY.  Free T4 was 0.8.  TSH was 1.2, which was normal.  Amylase and lipase was 72 and 199 on MM/DD/YYYY, which were in the normal range.  Urine culture and sensitivity showed no growth.

Chest x-ray showed no active infiltrate.  EKG, nonspecific ST-T changes.  No ischemic changes were noted.  Normal sinus rhythm.  Flat and upright abdomen showed some findings consistent with possible ileus with some bowel distention.  CT of the abdomen on MM/DD/YYYY was unremarkable.  Flat and upright abdomen on MM/DD/YYYY again showed some bowel distention.  No evidence of free air was noted.


ADMITTING LABORATORY DATA:  Hematology showed a white blood cell count of 9.7, hemoglobin 16.4, hematocrit 49.8, platelet count 137, slightly elevated RDW at 29.5, neutrophil number was 7.3.  Coagulation studies:  PT is elevated at 18.3, INR is 1.5, PTT 29.2.  Chemistry, sodium 143, potassium 3.7, chloride 100, CO2 of 33, anion gap 10, BUN 14, creatinine 1, estimated GFR of 76.8, glucose 107, calcium 10.1, total bilirubin 1.2, direct bilirubin 0.5, AST 50, ALT 35.  CK was 233.  Troponin done at 1840 was 0.03.  Repeat troponin at 2230 was 0.01.  Total protein 7.2, albumin 4, alkaline phosphatase 86, amylase 94 and lipase 69.  Urine was dark yellow, clear, with 2+ protein, negative for glucose, trace ketones, negative for blood and nitrites.  Urine bilirubin 1+, urobilinogen 2, leukocyte esterase is negative, bacteria were few, hyaline casts 2 to 5.  Urine C and S is pending.


LABORATORY DATA:  Initial laboratory studies; white blood cell count is 13.4 with 49% neutrophils and 40% lymphocytes.  Hemoglobin is 14.2.  Platelets are 408.  Sodium is 136, potassium is 4.2, chloride is 103, bicarbonate is 24, BUN is 14, creatinine 0.8, glucose is 220, magnesium is 1.74.  Coagulation studies were within normal limits.  Troponins were cycled on two occasions and were all less than 0.01.  Bedside glucoses were monitored and ranged between 120 and 310, with most readings in the high 100-200 range.  Lipid panel revealed triglycerides 129, cholesterol 176, HDL 36, LDL 116.  Lipid profile was within normal limits with the exception of an alkaline phosphatase of 119, which is slightly elevated.  Amylase was 34 and lipase was 12.  Initial imaging studies; chest x-ray revealed normal chest for age group.  An EKG revealed sinus rhythm, rate 88, with no significant ST-T wave changes.  Other imaging studies; the patient had a myocardial stress test, which revealed normal myocardial scan and left ventricular ejection fraction 70%.  He had a barium swallow, which revealed no evidence of esophageal stricture and mild esophageal dysmotility.  She had a 2-D echocardiogram, which revealed overall preserved LV and RV functions with mild pulmonary hypertension with an RV systolic pressure of around 30-35 mmHg.  Left ventricular ejection fraction was noted to be in excess of 60%.


LABORATORY DATA:  CBC; RBC was 5.54, hemoglobin 11.6, hematocrit 35.2, platelets 142.  BMP was within normal limits except her glucose, which was 178.  Bedside glucoses varied from 175 to low 300s. LFTs were elevated with an AST of 124, ALT of 118.  Urine toxicology; one was positive for methadone, cocaine and cannabis and then three random urine toxicologies gathered thereafter were negative.  Hepatitis C was reactive.  Iron was 86.  TIBC was 444 and iron binding was 360.


LABORATORY DATA:  At the time of admission, the patient's sodium 134, potassium 4.3, chloride 102, CO2 of 26, BUN 14, creatinine 1.2, glucose 96, calcium 9.2, phosphorus 3.6, magnesium 1.86, bilirubin 2.8, AST/ALT were 23 and 16, troponin was 0.01, BNP was 3769, triglycerides 58, cholesterol 128, LDL 92, HDL 24, alkaline phosphatase is 169.  Chest x-ray was performed at the time of admission, which showed a left cardiac pacemaker in place, cardiomegaly, and pulmonary vascular markings are within normal limits.  No evidence of effusion or pneumothorax.  An EKG was performed at the time of admission, which showed normal sinus rhythm at a rate of 88 with right axis deviation and no ST changes.  The patient's PT and INR were 16 and 1.2.  PTT was 30.2.


LABORATORY DATA/DIAGNOSTIC DATA: Serum chemistries were within normal limits with a creatinine of 1.3 and a mildly elevated glucose of 245. CBC was within normal limits with a mild left shift and his white count was 7.8. His CK-MB and troponin I were negative on the first set. BNP was normal at 62. Coagulation studies were within normal limits. Chest x-ray shows no acute cardiopulmonary pathology and EKG performed for indication of chest pain showed normal sinus rhythm at a rate of 72 beats per minute. He had Q waves in lead III. He had no acute ST elevations or T-wave inversions. He had normal intervals with QTc of 405 milliseconds in comparison to prior EKG. There was no significant change.


LABORATORY DATA: WBC 19.2, hemoglobin 17.8, hematocrit 54.2, platelets 212,000. MCV was 91. The differential was 1 band, 21 neutrophils, 74 lymphocytes, no eosinophils. His sodium was 136, potassium was 3.5, chloride was 106, BUN was 25 and creatinine was 1.1, glucose was 119. AST was 20, ALT was 22. Bilirubin total was 0.7, bilirubin direct was 0.1. Total protein was 8.6, his albumin was 4.8, lipase was 24. PT of 13 and an INR of 1. UA was negative for bacteria, negative for leukocyte esterase and negative for nitrites.


LABORATORY DATA/DIAGNOSTIC DATA: Her initial white count was 17,800, hemoglobin 12.4. Electrolytes were normal. Blood sugar was 115, creatinine 0.7, BUN 7. Her calcium was 9.2. She had moderate bacteria, but negative nitrites, leukocyte esterase and bilirubin. Pregnancy test was negative. Her initial chest x-ray showed clear lungs. The area of right lower lobe opacity was not clearly seen on that chest x-ray. CT angiography was a poor study because of her fat distribution. Pulmonary artery branches were suspicious for diagnostic pulmonary emboli. There is a wedge-shaped area of air space disease in the peripheral aspect of the right lower lobe suspicious for pulmonary infarct. There are bilateral pulmonary nodules, ill-defined in nature, but possibly malignant or septic, as there is a large left axillary lymph node and right hilar lymph node. Mildly dilated pulmonary arteries and a trace of right pleural effusion. CT scan of the abdomen showed a 2.5 cm hypodense lesion in the mid pole of the left kidney considered to be a cyst. There was a left retroaortic renal vein. CT scan of the pelvis showed a mildly enlarged uterus suggesting uterine fibroid and no evidence of a calculus or other disease to cause discomfort.


LABORATORY DATA: The patient's renal panel was obtained which was normal except for blood sugar of 242. CBC is within normal limits. UA hCG is pending. CK-MB and troponin was less than 1 and less than 0.05. BNP was 640. An ABG was obtained after the patient was intubated which was 7.25, CO2 of 56, O2 of 56 and bicarbonate of 26, base excess of 1.4. INR of 1.3. The patient did have an EKG obtained. The EKG showed a sinus rhythm with an abnormal P-wave morphology, with a rate of 90 beats per minute, with a left deviated axis of approximately negative 30 degrees, with normal PR, QRS and QT intervals. The patient had signs of right ventricular hypertrophy with inverted T-waves in leads I, aVL, V1, 2, 3, 4, 5 and 6.


LABORATORY/DIAGNOSTIC DATA: WBC is 4600, hemoglobin 10.4, hematocrit 33.6, and platelets 144,000. INR 1.42. LFTs within normal limits. Cardiac enzymes negative x2. Sodium 141, potassium 4.1, chloride 105, CO2 of 27, BUN 24, creatinine 1.3, and glucose 164. BNP 1637. Triglycerides 61, total cholesterol 134, HDL 31, and LDL 92. Blood culture, no growth to date. Chest x-ray: Increased perihilar markings suggestive of some possible pulmonary edema. A 2-D echocardiogram has been ordered. EKG from yesterday revealed atrial fibrillation, 82 beats per minute, and right bundle branch block.


LABORATORY/DIAGNOSTIC DATA: INR is 0.91. WBC 7.5, hemoglobin 15.8, hematocrit 45, platelet 226,000. LFTs completely normal. Sodium is 141, potassium 3.5, chloride 104, CO2 of 26, BUN 12, creatinine 1.1, glucose 104. Lipids: Cholesterol 174, HDL 26, LDL 72, triglycerides 385. CPK is 371, troponins are negative x3. TSH completely normal. Magnesium was 1.7, which has been repleted. Initial EKG showed SVT with 162 beats per minute. Repeat EKG showed sinus rhythm with 67 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.

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