Taibah University

College of Medical Rehabilitation Sciences

Respiratory Therapy Department
Patient Assessment Course (RT 244)

Laboratory investigations &

medical Record

Dr. Naseer Ahmad

Taibah University
 Investigations

• Laboratory investigations:
• Imaging: CXR, CT, Ultrasonography, MRI, PET-CT, V/Q
• PFT
• Bronchoscopy
• Thoracoscopy
• mediastinoscopy
 Laboratory medicine
Laboratory medicine involves the study of patient tissue and fluid
specimens and consists of five disciplines.

• Clinical biochemistry: involves the analysis of blood, urine, and other

bodily fluids for electrolytes and proteins
• Hematology: analyzes the cellular components of blood.
• Clinical microbiology tests blood and other bodily fluids for infectious
agents and includes the subspecialties that identify bacteria (bacteriology),
viruses (virology), fungi (mycology), and parasites (parasitology).
• Immunology: focusing on autoimmune and immunodeficiency diseases.
• Anatomic pathology: diagnosing diseases by analyzing tissue samples.
 Laboratory Investigations
• Blood: CBC, chemistry, enzymes, ABG, electrolytes, Coagulation
profile
• Urine: urine analysis, pneumococcal urinary antigen, legionella
urinary antigen
• Stool: stool analysis, microbes
• Sweat: sweat chloride test
• Sputum: Gram Stain, sputum culture & sensitivity, Acid fast bacilli
• Saliva
• Throat swab
• endotracheal aspiration
• Pleural effusion: pH, chemical, cytology, cytopathology
• Histopathology of biopsy from thoracic organs
 Electrolyte Tests
• Basic Chemistry Panel: The basic chemistry panel (BCP)
or basic metabolic panel includes the predominant electrolytes
sodium (Na+), potassium (K+), chloride (Cl−), total
carbon dioxide/bicarbonate (CO2), and glucose.
• A comprehensive metabolic panel includes electrolytes,
such as magnesium (Mg++), phosphorus (PO4−), and
calcium (Ca++).
 Coagulation Studies

• Platelets
• Prothrombin
time
• prothrombin
concentration
• INR
• D. Dimer
 Infection Monitoring
• Procalcitonin (PCT): In healthy individuals PCT levels are
less than 0.1 ng/ml. A diagnosis of sepsis is confirmed
when PCT levels are greater than 0.5 ng/ml and excluded
when PCT levels are 0.2 ng/ml or less.8
• Microbiology tests
• Sputum Gram Stain
• Sputum Culture
• Acid-Fast Testing
• Gram stain and culture from any specimens
If the Gram stain shows few (<25 per low-power
field) or no pus cells and numerous epithelial cells,
and the sample must be discarded = SALIVA.
A sample with numerous pus cells and few epithelial
cells is most likely a true lung sample and likely
reflects the infection source.
 Sweat chloride test
• Patients with cystic fibrosis have increased levels of Cl− in their sweat
because of an inability to reabsorb it.
• These patients typically have sweat Cl− levels greater than 60 mmol/L,
whereas values of 40 to 60 mmol/L are considered borderline for cystic
fibrosis.
• Sweat Cl− levels less than 40 mmol/L are considered unlikely to confirm
the diagnosis.

• Although the sweat electrolyte test is an important tool for diagnosing

cystic fibrosis, it must be combined with other tests.
 Medical record
• The medical record serves as the official document
regarding the patient’s medical history, illness, treatment,
and response.
• It is a legal document and is the source document in any
litigation. Therefore, it is extremely important that the
information accurately reflects the care rendered.
• Even in this day of computerized records, the old wise
saying “If you didn’t chart it, you didn’t do it” still rings
true.
 Medical record
• Several formats can be used to document respiratory
care services.
• They are the narrative note, the SOAP method,
checklist charting, and charting by exception (CBE).
• Charting by exception assumes that the response to an
intervention was normal. Therefore, only abnormal
findings are charted.
 Medical record
• One of the most important sources for the information contained in the
medical record is the patient (history taking).
• The medical record is that it contains sensitive and personal patient
information that is protected by law. The Health Insurance Portability
and Accountability Act (HIPAA) of 1996 protects the confidential
nature of that information.
• Violation of this act and the subsequent regulation known as the
“Privacy Rule” issued by the Department of Health and Human Services
may result in civil or criminal penalties.
• Because the RCP has access to this confidential information, the RCP
must never discuss this information outside of the scope of patient care.
 Review of the Medical record
1. Patient demographics (age, height, gender, race, religion, insurance
information)
2. Chief complaint/diagnosis
3. History of present illness, including:
a. Smoking history (pack/years)
b. Allergies
c. Current medications
4. Past medical history—major surgeries, hypertension, tuberculosis,
diabetes, cardiac or pulmonary disease, and any other major illness
5. Social history—marital and family status, living arrangements, alcohol
use, and sexual activity
6. Occupational history
7. Family history
8. Results of recent diagnostic procedures (x-ray, laboratory, pulmonary
function tests, electrocardiogram, etc.)
9. Recent progress notes
10. Physician orders
 Medical record documentation
(Charting)
• S = Subjective findings: usually in the words of the patient, such
as “I’m still coughing”

• O = Objective findings: patient assessment and other data

• A = Assessment: problem list (may include differential diagnosis)
• P = Plan: are any modifications to the care plan necessary?
• If a SOAP methodology is not used, the documentation may consist of
a narrative note, a simple checklist, or charting by exception. You should
be familiar with the forms and types of charting required by the clinical
agencies because it is the responsibility of the RCP to document
according to facility policy.