STUDENT:____________________ DATE:___________ UNIT:_________ Pt.

Age/Sex________________
Primary Diagnosis:_____________________________________________________________________
CODE STATUS:_______________ DIET:___________________ HX:______________________________
____________________________________________________________________________________
VITAL SIGNS: B/P:_____/_____ HR:_______ RESP:________ TEMP:_________ POX:_______ O2:_____

Lab Tests

CBC
Normal PRIOR PRIOR PREP CLINIC CORRELATION TO CURRENT
M HEALTH STATUS
F
RBCs 4.7-6.1
4.2-5.4
Hgb 14-18
12-16
Hct 42-52
37-47
MCV
80-95
MCH
27-31
MCHC
32-36
ESR <15
<20
WBC
5k-10k
Neutro B
55-70
S
Lymph
20-40%
Monos
2-8%
Eosino
1-4%
Basos
0.5-1.0%
Platelets
150-400
MPV
7.4-10.4
RDW 11.5-
14.5%
EGFR
<60
Morph

CoAg Normal PRIOR PRIOR PREP CLINIC CORRELATION TO CURRENT

AntiCoag HEALTH STATUS
Bld Time
1-9 min
PT 9.9-13
11-12.5
INR 0.9-1.2
1.5-3.5
aPTT 30-40
PTT 60-70
D-Dimer
< 250

CMP
Normal PRIOR PRIOR PREP CLINIC CORRELATION TO HEALTH STATUS
M
 F

Glucose
< 110
HgbA1c
5.6-7.5%
Sodium
136-145
Chloride
98-106
Potassium
3.5-5.0
Calcium
9.0-10.5
Magnesium
1.6-2.7
Phosphorus
3.0-4.5
Albumin
3.5-5
Bilirubin
0.1-1.9
Globulin
2.0-3.5
Protein
6.4-8.3
LDH
88-230
Iron
50-175
TIBC
250-460
Triglycer. 40-160
35-135
BUN
10-20
Creatinine 0.6-1.2
0.5-1.1
Uric Acid 4.0-8.5
2.7-7.3

DIAGNOSITC Hx CORRELATION TO HEALTH STATUS

EKG

MRI

CT Scan

EGD

Colonoscopy

Ultrasound

X-Ray

Liver Normal PRIO PRIOR PREP CLINIC CORRELATION TO HEALTH STATUS

Kidney M R
Pancrease F
 S. Albumin 3.5-6

Bilirubin
0.1-1.9
T. Protein
6-8.2

BUN
5-20

BUN/Creat
10:1-20:1
Ratio
Phosphorus
3.0-4.5

KIDNEY
Protein
0-8
Creatinine 97-137
clearance 88-128
S. Creatinine 0.7-1.3
0.6-1.1
Anion gap
12 (+/-4)

eGFR AA >60
N.AA >60
pH
4.6-8.0

U. Albumin
<30

U. Creatinine 14-26/kg
11-20/kg

LIVER
A.
40-130
Phosphatase
Bilirubin T- 0.1-1.2
D- <0.2
SGOT/AST
7-40

SGPT/ALT
5-50

PANCREASE
Amylase
23-85

Lipase
<95

Specific Normal PRIOR PRIOR PREP CLINIC CORRELATION TO HEALTH STATUS

M
Labs F
CARDIAC
CK/CPK
30-220
 BNP
<100

ANP
20-77

Troponin T <0.2
I <0.03
Myoglobulin
30-90

CRP
<3.0

LH
1.24-7.8

LDH
100-220

HBDH
<182

LDL/PLAC
<200

Alb/Creat Ratio
<30

LIPID
Cholesterol
<200
LDL
<130
HDL
>40
Triglyceride
<150

HORMONE
TSH
0.4-5.5
Free T3
230-619
Total T3
80-180
Free T4
0.7-1.9
Calcitonin <13.8
<6.4
Thyroglobulin
<60

UA
Normal PRIOR PRIOR PREP CLINIC CORRELATION TO HEALTH STATUS
M
F
UA clear,
amber
yellow,
aromatic
 Sp. Gravity 1.005-
1.030
pH
4.6-8.0

Protein
0-8

Creatinine 107-139
clearance 87-107
Leukocytes
negative

Blood
negative

RBC
0-3

WBC
0-3

Epithelial
some

Bacteria
0-1+

Further impressions or comments: