MEDICAL TRANSCRIPTION COMMON LAB & DIAGNOSTIC TERMS:
LABORATORY/DIAGNOSTIC 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 3.8, chloride 102, bicarbonate 22, BUN 11, creatinine 0.7, and blood glucose of 245. Her CBC showed white blood cell count of 13,800, hemoglobin 13.2, hematocrit of 39.6, and platelets of 236,000. The poly count was 90.5% and the lymphocytes were 6.4. Also, the patient's amylase was 76 and lipase 28. Albumin 4.4. Calcium 9.4. AST, ALT, and alkaline phosphatase were within normal limits.
LABORATORY/DIAGNOSTIC DATA: Laboratory tests during this hospitalization showed the patient to have low sodium with sodium of 125. This low sodium was noted to resolve and the number did improve throughout the hospitalization. The patient had normal BUN with creatinine between 1.1 and 1.2. The patient had total cholesterol of 241. Cardiac enzymes were negative for myocardial infarction. B-type natriuretic peptide was slightly elevated at 120 with normal being between 0 and 100. CK-MB fractions were negative. Amylase as well as lipase were both within normal limits. Iron was 60. Urine sodium was low at 22. CA-125 was normal at 21.2. Alpha-fetoprotein was normal at 7.5. TSH was normal at 3.7. CEA was normal at 0.6. Folic acid was normal at 7.4. Vitamin B12 level was normal at 528. Hepatitis viral profile was negative for hepatitis B, hepatitis A, and hepatitis C. Urine osmolality was low at 148 with blood osmolality normal at 263. Urinalysis was negative for finding of urinary tract infection. Hemoglobin was ranging between 9.7 and 8.7, with the lowest being 8.7. This number did improve throughout the hospitalization. Hemoglobin electrophoresis was normal with no hemoglobin variation. The patient had an MRI of the brain performed, which showed no acute ischemia identified. There is mild age-related chronic small vessel ischemic disease. Noncontrast CAT scan of the head showed no evidence of acute infarct. There was no mass effect or midline shift. Chest x-ray showed eventration of the right hemidiaphragm, otherwise unremarkable. Abdominal ultrasound showed fatty liver changes and normal gallbladder. CAT scan of the abdomen performed showed liver, gallbladder, biliary tree, and pancreas unremarkable. The spleen was normal in size. There were no adrenal lesions. The kidneys were normal in size. There was no renal calcification seen. There was no hydronephrosis. There was no evidence of any retroperitoneal bleeding. The CAT scan of the pelvis performed showed what appeared to be routine IUD in place. There was right colonic diverticuli. Echocardiogram performed showed preserved left ventricular systolic function with evidence of possible diastolic compliance changes. There was trivial valvular flow abnormality. There was no gross mural thrombi or vegetations.
LABORATORY DATA: Initial laboratory results revealed CBC of 4300 with differential, polys 75,lymphs 19, monos 7. The remainder of the differential is not available. Hemoglobin 11.7 and platelets 186,000. SMA-7 was as follows; sodium 134, potassium 4.5, chloride 98, bicarbonate was low at 15. BUN was high at 21 with creatinine of 0.4. Initial glucose was 73. Urinalysis revealed large ketones and a concentrated urine culture was sent, and blood culture was sent, results are currently found to be negative.
LABORATORY/DIAGNOSTIC DATA: Lab profile; EKG as per chart, acute supraventricular tachycardia to ventricular tachycardia to sinus rhythm just before the discharge. There was a significant ST depression in the lateral chest lead, which became isoelectric. Chest x-ray was unremarkable except borderline heart. The LFTs were slightly elevated, came close to normal, and the cardiac enzymes, CPK, and troponin levels were also high. Coronary angiogram as per chart, which is consistent with complete block of the left circumflex and more than 50% block of rest of the arteries.
LABORATORY/DIAGNOSTIC DATA: At the time of admission, her labs showed WBC count of 12,800. Sodium 133, potassium 2.9, chloride 98, bicarbonate 18, creatinine 4, and blood glucose of 168. UA was done, which was negative. Negative for urine nitrites and leukocyte esterase negative. During her stay in the hospital, she had a chest x-ray that showed no infiltrate, no cardiomegaly, and x-ray of her abdomen, which showed no air fluid levels, no free air in the abdomen, which indicates no obstruction. She had a stool examination, which was positive for C. difficile toxin A and B. She also had a renal ultrasound because of the complaint of flank pain, which was consistent with medical renal disease. The biopsy, which was done, was consistent with medical interstitial nephritis with nephrosclerosis. It was not HIV nephropathy. She also had a renal nuclear scan, which was consistent with medical renal disease, no hydronephrosis, no obstruction, no extravasation in the surrounding tissue. Later on, two days before the discharge, she complained of pain in her abdomen. She had an ultrasound of her abdomen done, which showed gallstones with no signs and symptoms of cholecystitis, which was not changed from the previous ultrasound, which was done four months back.
DIAGNOSTIC/LABORATORY DATA: On study, no apparent thrombus or other source for emboli. Study technically difficult. Contrast injection performed. Mild concentric left ventricular hypertrophy. Ejection fraction 60%. Transmitral spectral Doppler flow pattern suggestive of impaired LV relaxation. No regional wall motion abnormality noted. Left atrium borderline dilated. Normal mitral valve. No regurgitation. Normal aortic valve. No regurgitation. Normal tricuspid valve. No regurgitation. No pericardial effusion. Ova and parasites not detected. White cells not detected. ANA antibody less than 7.5, homocysteine Ultra Quantitative 9.6 and within normal range. White cells none seen. CRP 1.5. Difficile toxin assay negative.
LABORATORY/DIAGNOSTIC DATA: CT showed small right lacunar infarct in basal ganglia. WBC 5800, hemoglobin 11.4, and platelet 154,000. Sodium 147, potassium 3.7, BUN 16, creatinine 1.1, chloride 106, bicarbonate 24, and glucose 160. PT 13.2, INR 1, and PTT 30. Calcium 9.4, CPK 229, and troponin less than 0.1. Chest x-ray showed no evidence of gross infiltrates. Final report of CT showed no abnormal area of attenuation appreciated. Normal noncontrast head CT. The patient underwent carotid Doppler study, which showed minimal ICA stenosis bilaterally and patent vertebrals bilateral. Stress thallium was done, which showed normal study with left ventricular ejection fraction to be 70%. EKG showed sinus bradycardia at the rate of 58 with first-degree AV block and right bundle-branch block. Three sets of cardiac enzymes came out to be negative.
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