In this course project assignment, you are presented with laboratory and diagnostic test results for two different patients. Laboratory tests include results from blood and urine tests, along with testing of other body fluids such as feces, secretions, throat swabs, etc. Diagnostic testing includes procedures such as x-ray, MRI, CT scans, ultrasounds, echocardiograms, electrocardiograms, etc. These types of diagnostic procedures often require interpretation by a physician. In this case, you may find a separate document with the physician’s conclusions from the test results.
You will be exploring the medical terminology used in these test results and will be asked to interpret the meanings of various words and abbreviations.
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To complete this assignment, do the following:
- Download the test results for the two patients:
Brenda Jastik Test Results
Steve Nguyen Test Results
- Download, complete, and submit the document below. This document contains questions you will answer regarding the test results for each patient.
Module 04 Course Project Assignment Template
please write answers on separate Microsoft Word Document
Chief complaint
SOB, malaise, chest px
Vendor Order 1704PEQQ added on 04/06/17
Other
Imaging Order 1704PELA added on 04/06/17
Other
PATIENT
Brenda Jastik
DOB 07/15/1951
AGE
65 yrs
SEX Female
PRN BO958186
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 02/05/2017
AGE AT
DOS
65 yrs
Not signed
Orders
LAB ORDERS
3638 – CBC W Auto Differential panel – Blood
759 – Streptococcus pneumoniae Ag
IMAGING ORDERS
1769 – Chest X-ray 2 views
Free cloud based EHR
Encounter – Office Visit Date of service: 02/05/17 Patient: Bren… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/6/17, 4:21 PM
Northstar Laboratory
3456 Sunshine Way #300
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Brenda Jastik
DOB: 07/15/1951
Lab Results
Component Your Value Standard Range Units
WBC Count 18.0 4.5-11.0 K/UL
RBC Count 5.0 3.5-5.5 MIL/UL
Hgb 12.3 12.0-15.0 G/DL
Hematocrit 38.3 36.0-48.0 %
MCV 93.4 79.0-101.0 FL
MCH 29.6 25.0-35.0 PG
MCHC 33.4 31.0-37.0 %
RDW-CV 14.1 11.0-16.0 FL
Platelet Count 356 150-420 K/UL
Component Your Value Standard Range
Strep. Pneumon. Ag Positive NEG
Comments
CBC shows elevated WBC count, indicating infection. RBC and remaining components are WNL.
Strep. Pneumon. Ag test is positive, indicating a diagnosis of bacterial infection. Follow-up and
treatment is necessary.
Interpretation by: Pamela Yost, MD
Northstar Imaging Center
2345 Sunshine Way #200
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Brenda Jastik
DOB: 07/15/1951
Indication
SOB, Chest pain, Malaise, Fever
Clinical History
Symptoms have persisted and progressed for 2 weeks. Unresponsive to prior antibiotic tx.
Procedure
1. PA chest radiograph
2. Lateral chest radiograph
Findings
Comparison Exam is dated 11/01/06.
Cardiomediastinal silhouette is normal. There is a right lower lobe opacity with an air bronchogram; the
remaining lung fields are clear. There are no effusions. The bony thorax appears normal. The right lower
lobe opacity is new since the comparison exam.
Impression
1. Probable right lower lobe pneumonia.
2. Follow-up treatment is necessary.
Chief complaint
Hard to breathe
Vendor Order 1704PC04 added on 04/06/17
Other
Imaging Order 1704PBWM added on 04/06/17
Other
PATIENT
Steve Nguyen
DOB 03/15/1943
AGE
74 yrs
SEX Male
PRN SS892268
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 04/03/2017
AGE AT
DOS
74 yrs
Not signed
Orders
LAB ORDERS
407 – Cholesterol (Total)
2089-1 – Cholesterol in LDL
445 – HDL Cholesterol in Serum or Plasma
134 – Triglycerides
249 – Glucose (Fasting)
48 – HbA1c blood
IMAGING ORDERS
1276 – Aorta CT angiogram W contrast IV
5091 – Echocardiogram with doppler color flow
4724 – Coronary arteries CT angiogram and 3D reconstruction W contrast IV
Free cloud based EHR
Encounter – Office Visit Date of service: 04/03/17 Patient: Stev… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 1 4/6/17, 4:23 PM
Northstar Laboratory
3456 Sunshine Way #300
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Steve Nguyen
DOB: 03/15/1943
Lab Results
Component Your Value Standard Range Units
Total Cholesterol 268 0-200 mg/dL
HDL 36 30-75 mg/dL
LDL 162 0-100 mg/dL
Triglyceride 172 0-150 mg/dL
Component Your Value Standard Range Units
Blood Glucose (fasting) 221 80-100 mg/dL
Hemoglobin A1c 7.5 4.0-5.9 %
Comments
Cholesterol panel shows increased values for total cholesterol, LDL, and triglyceride tests. Continue
current medication and refer to nutritional counseling received from dietician on your last office visit.
Re-evaluation of these cholesterol levels is recommended in 3 weeks.
Blood glucose and A1c levels remain at diabetic levels. Consult with physician regarding your current
diabetes care plan. Medication alterations may be necessary.
Interpretation by: Pamela Yost, MD
Northstar Imaging Center
2345 Sunshine Way #200
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Steve Nguyen
DOB: 03/15/1943
Indication
Coronary CTA to evaluate the cause of chest pain or dyspnea. Evaluate need for bypass surgery or
intracoronary artery stent placement.
Clinical History
Chronic HTN with acute angina. Personal and family history of CHD.
Procedure
1. Selective coronary angiography with contrast was performed using CT scanner. Axial images
were obtained from the level of the subclavian artery/aortic arch/ascending aorta through to
the diaphragm at 0.6 collimation mm section thickness.
2. 65 ml of intravenous contrast was injected via a right/left antecubital intravenous catheter at 4
ml/sec with 50 ml of saline infused immediately afterward.
3. One dose of 0.4 mg sublingual/sublingual nitroglycerin was given approximately 5 min prior to
the CTA. The heart rhythm was regular without frequent atrial or ventricular premature beats.
Findings
HEMODYNAMICS: The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular
pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback
across the aortic valve reveals zero gradient.
ANATOMY: The left coronary artery main showed minimal calcification as well as the proximal LAD. No
stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.
The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis.
Atheromatous plaques present. The LAD gave off two early diagonal branches. The second was the
largest of the two and showed moderate lumen irregularities, and moderate 30 to 40% narrowing.
The RCA was a small non-dominant system with no focal stenosis and supplying the RV marginal. No
mitral regurgitation identified.
Impression
1. Moderate stenosis of coronary arteries including left anterior descending coronary artery.
2. Right coronary artery is free of atheromatous plaque.
3. Moderate Disease (30 – 40% occlusion of left coronary artery)
4. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications
and statin therapy.
Module 04 Course Project: Laboratory and Diagnostic Test Results
Each question is associated with the test results provided. Refer to these when answering each question. Please type your answer in the “Click here to enter text” space.
Patient A – Steve Nguyen
In the Imaging Orders section of this chart, an echocardiogram was ordered. What are the three word parts (and their meanings) that make up this term?
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The abbreviation “IV” appears twice in the Imaging Orders section of this chart. What does IV stand for in this context?
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In Steve’s lab results, both HDL and LDL were tested. What do these abbreviations stand for?
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Steve’s lab results show that his blood lipid levels are high. What is the medical term for this condition?
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Compare Steve’s blood glucose levels to the standard range. Does he have hyperglycemia or hypoglycemia? Define both terms.
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Steve’s angiography results use two abbreviations in the Clinical History section. List and define these two terms. (Use the most common abbreviation for both)
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In the procedure section of the angiography results, contrast was delivered to the patient intravenously. Define “intravenous” and identify which part of the body was punctured.
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The impression section of the imaging report identifies stenosis in which vessel?
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The impression section of the imaging report notes that the right coronary artery is free of _______ plaques. (Identify and define this term.)
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Patient B – Brenda Jastik
The first symptom listed under Brenda’s chief complaint is a 3-letter abbreviation. Identify this abbreviation and its meaning.
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Two lab tests are ordered on this office visit. The first test listed contains a 3-letter abbreviation. What does this stand for?
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The abbreviation “px” is used in Brenda’s chief complaint. What does this mean and what is another medical term that means “chest px” associated with a heart condition?
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Brenda’s lab results include many abbreviations. Which of these abbreviations could also be referred to as “leukocyte”?
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In what section of the imaging report is the word “malaise” found and what is its definition?
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The imaging report notes that Brenda’s symptoms were unresponsive to “antibiotic tx.” What 3 word parts are found in the term “antibiotic” and what does each mean?
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The imaging report notes that Brenda’s symptoms were unresponsive to “antibiotic tx.” What does “tx” mean in this context?
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An opacity with an air bronchogram is found in Brenda’s right lung. Define bronchogram.
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The Findings section of the imaging report shows that there are no abnormalities in the “bony thorax.” In your own words, define the term “thorax.”
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What is the likely diagnosis given in the Impression section of Brenda’s imaging report? Briefly describe this diagnosis.
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When referring to a radiograph (X-rays), what does the word “opacity” mean and what does it refer to with a radiograph (X-ray)?
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References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
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You will also likely need to use other course materials or resources to answer all of this assignment’s questions. If you used other references, cite them here:
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*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa
Select “References” on the left-hand panel and choose the type of reference you used.
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