Examples of Lab Section Format / Words in Medical Transcription
LABORATORY DATA: A CT of the brain without contrast, upon presentation, demonstrated atrophy and ischemic white matter change. Lab screening includes an arterial blood gas with a pO2 of 114, pCO2 of 36, pH 7.46. CMP revealed albumin of 2.8 and total bilirubin 1.2. CPK on presentation 1300, several days later 920. Troponins borderline. Myoglobin elevated. PT/PTT normal. Hemoglobin 12.9. WBC count 10,000, platelet count 192,000. Sedimentation rate 14. West Nile serology is pending.
LABORATORY DATA: Urinalysis showed 40 ketones, positive nitrites, urobilinogen 2.0, wbc’s 27, rbc’s 5, and many bacteria. CT of the brain showed no acute abnormality. C-spine showed straightening of the cervical lordosis and diskogenic degenerative changes in the lower lumbar spine. No evidence of fracture or subluxation. Chest x-ray showed moderately severe cardiomegaly that was stable. No acute findings. CMP within normal limits, except for GFR of 69, albumin 2.7, calcium 8.4, alkaline phosphatase 104, AST 62, total bilirubin 2.4, and potassium 3.4. CPK 150, lipase 22, PTT 28.2, PT 12.0, and INR 1.2. White count 4.8, hemoglobin 12.6, hematocrit 37.6, and platelets 104,000.
LABORATORY DATA: White count was 8.4, hemoglobin 8.8, and platelet count of 182,000. Sodium 136, potassium 2.6, chloride 102, CO2 of 32, glucose 122, BUN 7 creatinine 0.7. Urinalysis: Dark yellow, 1+ albumin, 3+ nitrites, greater than 50 rbc’s, 2-4 wbc’s, multiple squamous cells, and 2+ bacteria. Urine culture, no growth.
LABORATORY DATA: Hematocrit 39%, white cell count 11,400, and platelet count is 296,000. Electrolytes: 136, 4.2, 106, 22 with a random glucose of 168, BUN 28 and creatinine of 1. Cardiac enzymes and biomarkers are negative x2. Total cholesterol 104, triglycerides 66, HDL 42, and LDL 60.
LABORATORY DATA: White count 15.4, hematocrit 35.2, and platelet count 302,000. Sodium 138, potassium 4.2, chloride 102, CO2 of 30, BUN 34, creatinine 1.8; on admission, creatinine was normal. TSH 2.8. Lipase 24. Urinalysis done yesterday was 1+ albumin, negative for glucose, ketones, bilirubin, occult blood, and nitrites, and urobilinogen. The patient has trace leukocyte esterase, wbc’s 5-10, and bacteria 2+. Has a Foley specimen. Urine culture shows no growth.
LABORATORY DATA: Rapid strep test was done and was negative. Throat culture was sent. A CBC was obtained and values were white blood cell count of 2.6, hemoglobin 13.6, hematocrit 39.8, platelets 214,000. CMP was obtained. Glucose 92, BUN 7, creatinine 0.7, sodium 136, potassium 3.4, chloride 98, CO2 of 30, calcium 9.2, albumin 4.6, AST 18, ALT 8, and alkaline phosphatase 146. Total bilirubin was 0.4.
LABORATORY DATA: Laboratory performed today reveals white count of 14.8, hemoglobin 12.4, hematocrit 38.2, and platelets 252,000. Creatinine 1.4. CDT assay negative x1. Nares culture negative. Blood culture negative, 1 out of 1 bottle. Repeat blood cultures negative, 2 out of 2 bottles. Urinalysis revealed 3+ leukocyte esterase, 68 wbc’s, 3+ wbc clumps, and 2+ yeast. Urine culture showed MRSA.
LABORATORY DATA: BUN and creatinine 110 and 3.4, sodium 136, potassium 5.2, chloride 104, bicarbonate 15, anion gap 16, and glucose 118. CBC from yesterday; white count was 17,800 with 27% eosinophils noted on smear. H&H 14.2 and 42.4. Platelets were 334,000. The patient’s urinalysis showed negative protein, negative glucose, too numerous to count wbc’s, 3-5 rbc’s. Culture grew E. coli, which was sensitive to all antibiotics tested.
LABORATORY DATA: Serum chemistries within normal limits with mildly elevated creatinine of 1.2. No baseline creatinine was available. Sugar was normal at 92. CBC showed a normal white count at 10.2. X-ray shows no acute cardiopulmonary pathology. LFTs were within normal range. Initial cardiac markers, CK-MB and troponin I were negative. EKG was performed for indication of chest pain, which showed normal sinus rhythm at a rate of 74 beats per minute. She had a left axis deviation with a left anterior fascicular block pattern. She had ST depressions of less than 1 mm in leads II, III and aVF concerning for ischemia with no acute ST elevations. No reciprocal changes. She had poor R-wave progression in the precordial leads.
LABORATORY DATA: Initial urinalysis was unremarkable. WBC count was 8600, hemoglobin 13.2, and platelet count 228,000, 45% polys, 30 lymphs, 18 monocytes. Albumin 2.8, bilirubin 0.5, direct bilirubin 0.1, SGOT 118, and SGPT 156. Followup liver function showed progressive elevation of liver enzymes to 143, now it is 279, and SGPT of 307. The last liver functions obtained yesterday showed bilirubin elevated to 2.2, direct bilirubin 1.4, SGOT 492, SGPT 554, and alkaline phosphatase 176. Hepatitis profile drawn showed hepatitis surface antigen positive, hepatitis B core antibody IgM negative, hepatitis A IgM negative, and hepatitis C antibody negative.
LABORATORIES: EKG showed normal sinus rhythm. EKG performed for indication of TIA. It shows normal sinus rhythm at a rate of 86 beats per minute. She had a left axis deviation with a slightly prolonged QTc of 460 milliseconds. She had Q waves in lead III as well as poor R-wave progression with T-wave inversion in leads I and aVL. In comparison to prior EKG, there is no significant change.
Serum chemistries were within normal limits, except for a mildly elevated glucose of 170. Her CBC showed a white count of 11.4 and was otherwise unremarkable with a normal differential.
LABORATORY DATA: Blood gases done on room air showed a pH of 7.56, pCO2 of 32.4, pO2 of 52, bicarb 28.4, saturation of 91, FiO2 at 21%. PT was 23.8, INR 2.2, PTT 40.8. Glucose 134, BUN 14, creatinine 0.6, sodium 130, potassium 2.4, chloride 88, CO2 26, anion gap 14. CK 164, MB 2.4, calcium 9.2, digoxin 0.68. Troponin 0.08. White count 21,400, hemoglobin 13.2, hematocrit 39, MCV 60.8, platelets 390,000, bands 27%. Urinalysis showed +2 protein, trace glucose, trace occult blood.
Electrocardiogram showed atrial fibrillation at 144 beats per minute with somewhat of a depressed ST segment laterally. The electrocardiogram is being repeated.
LABORATORY DATA: Chest x-ray showed a left lower lobe infiltrate. Sodium 136, chloride 86, ALT 22, albumin 2.6, amylase 13, lipase 117, TSH 2.24. Troponin less than 0.04 and digoxin 1.1. White count 10,200, hemoglobin 10 and platelet count 356,000. Followup hemoglobin the next day was 8.2. Urinalysis showed 1+ ketones, 5-7 white cells.
DIAGNOSTIC STUDIES: Her ECG in the office today showed sinus rhythm with some nonspecific ST changes in the inferior and lateral leads. She had an echocardiogram. This was reported as showing normal LV function and size. She had aortic sclerosis with moderate AI. She underwent exercise stress testing. The test was nondiagnostic because of ST depression. She exercised for 4.6 METS. There was a 1.5 mm ST depression in the inferolateral leads.
LABORATORY DATA: CBC shows a white count of 2.8 and H and H 13.4 and 39.2, and platelet count 326,000. Coags show PT of 19.6 and INR 1.8 and PTT is 30.9. Renal panel shows a sodium of 140, potassium 3.8, chloride 112, CO2 of 22, BUN 19, creatinine 1.9, and glucose 98. Doppler studies of lower extremities negative bilaterally for deep venous thrombosis. CTPA for cardiopulmonary embolism negative. Urinalysis negative. Urine beta hCG negative. CK-MB is 1.5 and a troponin I of less than 0.05. Sestamibi scan negative. EKG for identification of chest pain shows sinus rhythm at rate 62 with QRS of 88 msec. QTc 424 msec. No acute ST-T wave abnormalities. Overall, this is interpreted as a normal sinus EKG. The patient also had a chest x-ray, which shows no acute cardiopulmonary disease.
LABORATORY DATA: White count normal at 6.2, hemoglobin 11.4, platelets 514,000 with a normal differential. Metabolic panel revealed a blood sugar of 154, BUN 18, creatinine 0.9. Electrolytes all within normal limits. Urinalysis revealed a slightly cloudy urine, specific gravity 1.030, protein 100, large blood with positive nitrites, negative leukocyte esterase, and 20-50 wbc’s with 50-100 rbc’s, bacteria rare.
X-rays, flat and upright, of the abdomen, two views, were reviewed and revealed a normal gas pattern, no air fluid levels and no presence of an ileus.
DIAGNOSTIC STUDIES: Electrocardiogram in the office revealed T-wave inversions in leads I, II, III, aVR, aVF, and V4 through V6.
LABORATORY DATA: Serum chemistries were within normal limits with creatinine 0.9 and glucose 134. CBC was entirely within normal limits with a normal differential. Cardiac markers, CK-MB, and troponin I were negative. EKG was performed for indication of chest pain and shows normal sinus rhythm, rate of 72 beats per minute with PVCs occurring in a trigeminal pattern. He had mild left axis deviation with normal intervals. QTc was 438 milliseconds. There were no acute ST elevations or T-wave inversions. Chest x-ray shows no acute cardiopulmonary pathology.
DIAGNOSTIC STUDIES: ECG showed sinus rhythm with first-degree block. There was an ST elevation in V2 and V3. There were no definite Q waves in the inferior leads.
LABORATORY STUDIES: CBC: WBC 8.6, hemoglobin 10.2, hematocrit 30.6, and platelet count 202,000. Metabolic panel: Potassium 4.2, BUN 26, and creatinine 0.8. Cardiac enzymes are negative. BNP was elevated at 460.
EKG shows normal sinus rhythm. There is some baseline artifact, and she has nonspecific T-wave abnormalities in leads II and III, but no acute ST segment changes.
LABORATORY DATA: D-dimer 0.34. Fasting lipid profile pending. Cardiac enzymes negative x1 with two pending. White blood count 8.2, hemoglobin 14.2, hematocrit 42.8, and platelets 244,000. Sodium 140, potassium 3.8, BUN 12, creatinine 0.9, glucose 108, ALT 18, and AST 26.
DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm at a rate of 86 with poor R wave progression in leads V1 through V3 and nonspecific ST-T wave changes. Chest x-rays shows no acute cardiopulmonary process.