Diagnostics – Mel LaFleur – Simulated Client Records

ABG

Legend: H= Critical High Value L=Critical Low Value
	Test	Reference Values (Adult)	Date/Time: _{day of admission} ₁₄₀₀	Date/Time: _{Admit +1} ₀₇₀₀	Date/Time:	Date/Time:	Date/Time:	Date/Time:
ABG	pH	7.35 – 7.45	7.30 L	7.35
	pCO₂ (mEq/L)	35 – 45	50 H	45
	pO₂ (mm Hg)	75 – 100	67 L	75
	HCO₃ (mEq/L)	22 – 26	30 H	26
	O₂ Sat. (%)	≥95	88 L	93 L

Legend: H= Critical High Value L=Critical Low Value
	Test	Reference Values (Adult)	Date/Time: _{Day of admission 1400}	Date/Time: _{Admit +}1 ₀₇₀₀	Date/Time:	Date/Time:	Date/Time:	Date/Time:
HEMATOLOGY	HgbA1C (%)	4.0-6.9	8.0 H
	RBC (X 106 cells/mm3)	4.0 – 6.2	5.0	5.0
	Hgb (g/dL)	Male: 135-175	98 L	82 L
	Hgb (g/dL)	Female: 120-160	98 L	82 L
	Hct (%)	Male: 43-49	44	36
	Hct (%)	Female: 38-44	44	36
	Platelets (X 109/L)	150 – 400	150	149
	WBC (X 103 cells/mm3)	4.5 – 11	13.8 H	15.0 H

Legend: H= Critical High Value L=Critical Low Value
	Test	Reference Values (Adult)	Date/Time: ^{Day of admission} ₁₄₀₀	Date/Time: _{Admit +1 0700}	Date/Time:	Date/Time:	Date/Time:	Date/Time:
CHEMISTRY	Na (mEq/L)	135 – 145	133 L	130 L
	K (mEq/L)	3.5 – 5.0	4	3.9
	Cl (mEq/L)	97 – 107	106	105
	Mg (mg/dL)	1.6 – 2.6	1.8
	Phosphorus. (mg/dL)	2.3 – 3.7	2.5
	Ca (mg/dL)	8.5 – 10.5	8.5	8.5

	CO2 (Total) (mEq/L)	23-29	33 H	27
	BUN (mg/dL)	8 – 20	22 H	15
	Cr (mg/dL)	_{Male: 70-120 umol/l Female: 50-90 umol/L}	92 H	88
	BUN/Creatinine Ratio	10:1 to 20:1
	Protein (Total) (g/dL)	6.0 – 8.0	7.0	8.0
	Albumin (g/dL)	3.4 – 4.8	3.8	3.8
	Iron (mcg/dL)	Male: 65-175	160
	Iron (mcg/dL)	Female: 50-170	160
	Bilirubin (Total) (mg/dL)	<1.5	1.0
	AST (Units/L)	8 – 20	9
	ALT (Units/L)	7 – 30	20
	Uric Acid (mg/dL)	Male: 4.4-7.6	2.5
	Uric Acid (mg/dL)	Female: 1.3-6.6	2.5
	Troponin I (ng/L)	<0.35	0.28
	Troponin T (ng/L)	< 0.2
	LDH (Units/L)	55 – 102
	Cholosterol, Total (mg/dL)	< 200
	HDL (mg/dL)	>60
	LDL (mg/dL)	<100
	Triglycerides (mg/dL)	<150

Legend: H= Critical High Value L=Critical Low Value
	Test	Reference Values (Adult)	Date/Time: _{Day of admsision 1500}	Date/Time:	Date/Time:	Date/Time:	Date/Time:	Date/Time:
COAGULATION	D-Dimer (ng/ml)	<1000
	PTT (seconds)	25 – 35
	INR	0.8-1.2	1.8 H

Legend: H= Critical High Value L=Critical Low Value
	Test	Reference Values (Adult)	Date/Time: _{Day of admission} ₁₈₀₀	Date/Time:	Date/Time:	Date/Time:	Date/Time:	Date/Time:
URINE	Color	Amber Yellow	Amber
	Appearance	Clear	Sediment
	Odor		No
	Specific Gravity	1.005-1.030	1.035 H
	pH	4.6-8.0	5
	Leukocyte Esterase	Negative	Negative
	Bilirubin
	Blood
	Epithelial
	Glucose	Negative	Negative
	Protein	None or up to 8 mg/dL	8.2 H
	Nitrite	Negative	Negative
	Ketones	Negative	Trace
	WBCs	0-4	2
	Micro: Bacteria
	Micro: RBC (casts)	None	None
	Micro: WBC (casts)	Negative	Negative

Legend: H= Critical High Value L=Critical Low Value
	Test	Reference Values (Adult)	Date/Time:	Date/Time:	Date/Time:	Date/Time:	Date/Time:	Date/Time:
MISCELLANEOUS	ANA	Negative
	CRP (mg/L)	0-4.9
	Rheumatoid factor (IU/mL)	0-20
	Digoxin (ng/mL)	0.8-2 Toxic level > 2.4