Sarcoidosis

This page is for those with a medical interest in my sarcoidosis.

Dr's Notes, Lab notes, and all clinical findings related to my sarcoidosis	Organ
This is how it all went down. It started with an appointment for a physical exam... I had requested a physical exam from my primary care. The process also involved a pap and some lab work. In addition, I requested an x-ray because of my history of smoking and not knowing if I had caused any damage. Mostly curiosity. Labs: 6/8/2001 Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE CHEM: SODIUM 137 133-145 meq/L POTASSIUM 4.4 3.5-5.5 meq/L CHLORIDE 105 97-108 meq/L C02 27 21-33 meq/L ANION GAP 5 5-17 meq/L TOTAL PROTEIN 6.6 6.0-8.2 gm/dL ALBUMIN 4.0 3.4-4.8 gm/dL GLOBULIN 2.6 1.9-3.8 gm/dL     SGOT (AST) 21 5-45 U/L SGPT (ALT) 18 5-55 U/L     ALK PHOS 84 25-123 U/L       BILIRUBIN, TOTAL 0.8 0.0-1.2 mg/dL CALCIUM 9.3 8.5-10.5 mg/dL     BUN 11 5-23 mg/dL CREATININE 1.0 0.6-1.5 mg/dL GLUCOSE 91 70-110 mg/dL TRIGLYCERIDES 135 25-220 mg/dL CHOLESTEROL 227 H 140-202 mg/dL HDL CHOLESTEROL 39 35-90 mg/dL CHOLEST INDEX 5.8 H 0.0-4.4 LDL CHOLESTEROL 161 H 30-143 mg/dL     T-3 UPTAKE 26.8 25.0-35.0 % T4 9.3 4.2-11.7 ug/dL T4 ADJUSTED 8.3 4.2-11.7     TSH (HIGH SENS) 6.09 0.30-6.50 uIU/ml CBC: WBC 5.5 4.5-10.8 x10^3/uL RBC 4.86 4.20-5.40 x10^6/uL HGB 15.0 12.0-16.0 g/dL HCT 43.9 36.0-47.0 % MCV 90.3 80.0-99.9 fL MCH 30.8 27.0-31.0 pg MCHC 34.1 33.0-37.0 g/dL RDW 13.0 11.5-14.5 % PLT 212. 150.-450. x10^3/uL MPV 9.0 7.4-10.4 fL LY% 15.8 L 20.5-51.1 % MO% 5.9 1.7-9.3 % GR% 78.3 H 42.2-75.2 LY# 0.9 0.7-4.9 x10^3/uL MO# 0.3 0.1-0.9 x10^3/uL GR# 4.3 1.5-7.2 x10^3/uL URINALYSIS:  COLOR YELL APPEARANCE SLT. HAZY SPECIFIC GRAVITY 1.5 PH 6 GLUCOSE NEG BILIRUBIN NEG KEYTONE NEG OCCULT BLOOD NEG PROTEING NEG UROBILINOGEN NORM NITRITE NEG LEUKOCYTES NEG     MICROSCOPIC/HPF  RBC RARE PUS 1-4 BACT. OCC. EPITH CELLS   OCC.  MUCOUS THREADS SM.	BLOOD
6/15/01 Primary care office note: "xx" comes in today to review results of her recents labs. She continues to smoke and is having some dyspnea on exertion. The eczema on her posterior neck has cleared. Physical examination: Lungs: Clear without wheezing. Skin: She has some facial redness/rash consistent with acne rosacea. Area of eczema on neck appears to be healing. Impression: 1. Smoker 2. Reactive airways Plan: The patient was given three samples of Zyban and the toll free numer for further information on the patch. I will see her back for follow-up in three weeks. She will finish her antibiotic in the meantime. A chest x-ray was obtained today which was normal. This was reviewed with the patient and she was reassured. xx, MD	CHEST
6/18/01 Phone message to Dr. [in my chart] For: Dr. xx Dr. xx [radiologist] Re:; patient xx. ABNORMAL CXR! MEDIASTINUM LOOKS ABNORMAL MAY BE MEDIASTINAL LYMPHADENOPATHY. RECOMMENDS CT-SCAN.	LYMPH NODES
6/15/01 Radiology notes on X-RAY: CLINICAL INFORMATION: Dyspnea, smoker. FINDINGS: The pulmonary interstitium is prominent. The lung volumes are large. These findings likely reflect smoking. Heart size is normal. Fullness of left aortopulmonary window is present, raising question of lymphadenopathy. In addition, the right paratrecheal stripe is thickened above the level of the azygous vein. IMPRESSION: Possible mediastinal lymphadenopathy. This could be furhter evaluated with CT scan of the chest with intravenous contrast. xx, MD	LYMPH NODES
6/22/01 Radiology notes on NEW x-Rays taken for CT scan comparison Examination: Chest (2 views) Clinical Information: An outside chest radiograph is reportedly abnormal Findings: Two views of the chest were performed as per my instructions for planning the scheduled chest CT and for correlation with that study. The cardiac volume is normal. The mediastinum and hila are abnormal with mediastinal and hilar lymphadenopathy present. The lungs appear clear. Impression: Mediastinal and bilateral hilar lymphadenopathy. xxMD [hello! huge red flag screaming sarcoidosis, so why didn't they tell me at that point. I was scared to death of cancer].	LYMPH NODES
6/22/01 CT scan: Clinical information: Abnormal chest radiograph with mediastinal and hilar lymphadenopathy Findings: The examination is performed with intravenous contrast and comparison is made with the concurrent chest radiograph. There are numerous enlarged mediastinal lymph nodes. Image # 16 shows a 2.8 cm x 2.0 cm pretracheal lymph node. Image #19 shows a 7.0 cm x 2.0 cm confluent left para-aortic lymph node. There is subcarinal lymphadenopathy. Bilateral hilar lymphadenopathy is present larger on the right. Image #23 shows a 3.0 cm x 2.2 cm right hilar lymph node. The lung parencyma appears normal. There is no pulmonary nodule. There is no pleural effusion. The study includes images of the upper abdomen. The liver is normal. The bile ducts and pancreas appear normal. There are several mildly enlarged retroperitoneal lymph nodes. There are enlarged lymph nodes in the hilum of the spleen. The spleen is normal in size but has numerous small low-attenuation regions best seen on the narrow windows. See spleen. Impression: Mediastinal and bilateral hilar lymphadenopathy consistent with either lymphoma or sarcoidosis. The presence of retroperitoneal lymphadenopathy and abnormal spleen suggest that lymphoma is more likely. xx,MD	LYMPH NODES SPLEEN
6/26/01 Oncologist visit [Notes edited for length, redundancy and privacy]. ...The patient is scheduled to leave tonight on an airplane which takes her on a vacation. She will not be back for about 10 days. We have offered her a tissue biopsy but she would like to wait. She already has an appointment with Dr. xx for surgical consideration....... Examination: ...I performed a lymph node palpation of her neck, supraclavicular, inguinal and exillary areas and found absolutely no evidence of palpable lymphadenopathy.....everything else he lists is just normal. Assessment and plan: 1. Diffuse adenopathy in the chest. I did show her the scans and she noted the lymphadenopathy as I did. I think we can do nothing until tissue is obtained. Unfortunately, I was unable to find any peripheral adenopathy that could be biopsied more easily than a mediastinosocopy. Since she is seeing Dr. xx soon, I believe that he will suggest a mediastinoscopy, which I would agree with. Obviously if this is lymphoma, she will need a full workup including CT scan of the chest, abdomen and neck, plus a bone marrow aspirate and biopsy bilaterally. If this is sarcoidosis then she will be treated with other drugs, probably Prednisone. 1. Allergies to Penicillin and Keflex 3. Skin infections. It is remotely possible that this is all secondary to infection, however tissue diagnosis is still required. She might merit an infectious disease consult with xx as to why she keeps getting these infections. xx, MD	LYMPH NODES
7/19/01 Mediastinoscopy notes from Surgeon: ANESTHESIA: General ANESTHESIOLOGIST: xx, MD PREOPERATIVE DIAGNOSIS: Mediastinal Adenopathy POSTOPERATIVE DIAGNOSIS: Mediastinal Adenopathy PROCEDURE: Cervical Mediastinoscopy FINDINGS: Enlarged lymph nodes in the pretracheal and the right paratracheal region consistent with probably lymphoma INDICATIONS: The patient is a 37-year-old female who underwent a routine physical examination. During the examination, she had a chest x-ray performed and was found to have probably mediastinal adenopathy. A CT scan was obtained which confirmed the presence of mediastinal adenopathy. Concerns were for lymphoma and , therefore, plans were made for mediastinoscopy for tissue diagnosis. She did not have any other enlarged lymph node stations that were more easily accessible. DETAILS OF PROCEDURE: The patient received Levaquin as she is allergic to Keflex. She is brought to the operating room and placed in supine position. Appropriate monitoring lines and pneumatic compression devices were placed. She underwent a general anesthetic. She was placed with her neck hyperextended. Her neck was prepped and draped in sterile fashion. A transverse incision was made just abo e the sternal notch. The incision was carried through to the platysma and between the strap muscles, onto the trachea. A plane was established in the pretracheal space down into the mediastinum. A mediastinoscope was inserted and dissection with the mediastinoscope revealed enlarged petracheal and right paratracheal lymph nodes consistent with what was seen on the CT scan. These lymph nodes were dissected and samples were taken for both pathology as well as for cultures. Hemostasis was achieved. The incision was then closed using 3-0 Vicryl to reapproximate the strap muscles and the platysma in separate layers. Then, skin was closed with 4-0 Vicryl subcuticular stitches. Dressing were applied. There were no apparent complications. xx, MD	LYMPH NODES
7/20/01 Pathology report: Tissue Source: Right lower paratracheal lymph nodes FINAL DIAGNOSIS: Right lower paratracheal lymph nodes: Lymph node parenchyma identified which shows extensive non-caseating granulomatosis with calcification. Consistent with sarcoidosis.	LYMPH NODES
7/25/01 Follow-up surgery visit at primary care. He does a big sweep of "negative" under the Reivew of Symptoms table, including skin, where the choices are rash lump itchy and dry. At this visit I told him I was concerned about a firm lump underneath my skin on my arm. He said "oh its just fat". He didn't note it. All he noted was my chronic skin lesion issue: "Pt is in today for followup of mediastinoscopy which showed a sarcoid. This may explain the skin lesions she has been suffering with. She has been using Triacinolone cream which seems to be helpful. She is still smoking but has cut down. Review of systems: Negative for ENT, cardiopulmonary. She has no pruritic chest pain, no other problems." [what?!]	SKIN
10/11/01 Pulmonologist [Notes edited for length, redundancy and privacy]. CHEST X-RAY demonstrates marked right peri-tracheal and peri-hilar fullness, consistent with hilar adenopathy. IMPRESSION: Stage 1 pulmonary sarcoidosis. The only question I have with respect to specific organ system involvement relates to the patient's skin. I have asked that she be evaluated by a dermatologist in this regard. The is no current indication for corticosteroids treatment..... Dr. Note to my primary care: Dear Dr. xx Thank you very much for sending Ms. xx to my clinic for evaluation of pulmonary sarcoidosis. Given the current clinical manifestations, she would be defined as having Stage 1 disease, which confers on her an 80% chance of spontaneous remission. I performed office spirometry and ECG today, which failed to demonstrate any significant abnormality. She will need an eye evaluation and her CBC, serum calcium, and liver function tests should be obtained at a baseline. <snip>	LYMPH NODES LUNGS
5/6/02 [10 months after my 1st complaint...] Bumps in right arm - x 1 year. "xx" was seen today for evaluation of a bump on her right arm. She has a history of sarcoidosis. This raises the question of whether the bumps are related to her sarcoidosis. She requested a biopsy today. PROCEDURE: After informed consent was obtained, the skin was anesthetized with 1% Xylocaine. A 5 mm punch biopsy was obtained and the specimen sent to pathology. The wound was closed with twho interrupted 5.0 nolon sutures. PLAN: Return in ten days for suture removal xx, MD	SKIN
5/7/02 Pathology report: SPECIMEN: Right arm biopsy CLINICAL DIAGNOSIS/DATA/HISTORY: Possible sarcoid DIAGNOSIS: Skin identified, consistent with arm region, which shows numerous non-caseating granulomas in dermis. Consistent with sarcoidosis. No cellular atypia. xx, MD	SKIN
5/16/02 Primary care note: 38 year old female presents with a rash on the right arm that was biopsied and turned out to be a sarcoid. She only has cutaneous and pulmonary but no ocular. She has been followed by a pulmonologist and opthalmologist but nothing is active so no specific treatment is required. She will educate herself about sarcoid and will get back to me if she has any active symptoms. xx, MD [Again, what? Nothing is active? and what rash??? I had a hard nodule underneath my skin, not a rash! My nodules were actively multiplying and getting bigger and darker and harder. I have not seen this Dr. since this visit]. * Note I quit smoking 3 days after this exam. Have not smoked since.	SKIN
8/28/2002 Follow-up Chest X-Ray. Findings: The adenopathy has incrased in size mildly to moderately since March. The lungs appear normal with no significant interstitial nodular disease identified. No pleural effusion. View x-ray Right before this x-ray I was laid off, and ran out of insurance shortly after. No more sarc checks for a while.	LYMPH NODES LUNGS
No sarcoid checks for 3 1/2 years Sept 2002 - Sept 2004: No insurance Sept 2004 -  May 2005: Blue Cross, but no sarc checks June 2005 - June 2006: United Healthcare Although insured through temp agency, it was not comprehensive, so sarc checks postponed 'til conversion to fulltime employment. But fate got in the way....
3/20/2006 Eyes! Bood-shot eyes, extreme light sensitivity, blurry vision and pain. Lasted only a couple of days. Ophthalmologist notes: Pt states very painful light sensitive os, started last night. Some tearing os. Diagnosis: Iridocyclitis - primary Assessment: Iritis os -- pt has sarcoid Plans: Use meds rx'd, rto 2-3 days....sooner if worsens [meds were optical steroid drops (predforte) for the inflamation, and dilation drops (cyclopentolate) to relax the iris and to halt dilation. Reason: the iris inflamation made the dilation changes horrendous] [These labs are a little hard to extract but I'll do my best here:] Anterior Segment Exam / OS Conjunctiva > Bulbar > 3+ redness 360 degrees Epithelium > wnl, small round opacity Depth/Cells/Flare > /trace /trace Optic Disc > size/ ratio > 0.2 / 0.2 Retina > vitreous > clear Exam method > 20 diopter, drops > MYD 1% * Note I asked the Dr. directly if my iritis was due to sarcoidosis and she said yes. ----- from uveitis.org ---- "Iridocyclitis is a term used to denote inflammation in two parts ofthe uveal tract of the eye; the iris and the ciliary body. It derives its name from combining iritis (inflammation of the iris) and cyclitis (inflammation of the ciliary body)."	EYES
January 2007: With stronger insurance that came with permanent employment, got on with an internal medicine Dr. who took over management of my sarc., so time for f/u chest x-ray Radiology notes: Findings: 2 views of the chest again demonstrate enlargement of the mediastinum consistent with lymphadenopathy. This involves the AP window and the right paratracheal region prominently. There is that slightly plump appearance of the hila is less prominent than before but similar. There is no infiltrate nor parenchymal lung abnormality identified. No pleural effusion. Bony thorax is unremarkable. Heart size is normal. Impression: Mediastinal adenopathy and probably hilar adenopathy, typical findings of sarcoidosis, and without definite change compared to previous exam [5 years ago]. No new abnormality. Or as the Pulmonologist simplly put it: Lymphadenopathy still present. No decrease or increase.	LYMPH NODES LUNGS HEART
2007 Note from myself: Issues with inflamation still continue. I suspect sarcoid playing a part in the unrelenting inflamation of my nasal membranes and turbinates. On a scale from 1-10 the effectiveness of Flonase is about 5. A (rare for me) cold virus got out of hand with pulmonary inflamation, producing short-term athsma and bronchitis. Sarc may have contributed to the inflammation. Remember, people don't usually die from sarcoidosis -- it however can make existing conditions (such as pneumonia) worse. I have just a small concern regarding lungs. A little more wheezy than used to be and shortness of breath occurs sooner. Sometimes I get really weird dry coughing attacks that make me gasp. Honestly, I assume its because I'm nasally congested 24/7/365. This stuff here is not a problem, just something I've noticed.	SINUSES LUNGS
2008 This was during a time of unemployment and no insurance. Working on curbing stress, and being positive. A Learning Experience: I had an idea to make the most out of a situation that I hate and have no control over. I got the notion in my head that the dermatology students at the nearby teaching university might enjoy seeing some cutaneous sarcoids so I contacted the school. Turns out they were just getting ready to have an annual event where about 100 students come in and look at some selected cases of unusual diseases and they invited me to be one of the cases. I went in and had my own room (very nice room with a view of the ship canal and I-5 bridge). I didn't do the gown since they would be able to see my arms from my tank top I wore. Groups of about 8 students plus an attending or resident came in for about 10 minute sessions, separated by the ringing of a bell. This went on for 4 hours. They did feed us and give us gas money. The students came in and I invited them to touch my arms and really get a feel for the depth and shape of my nodules. One student in each group would get to do a differential diagnosis. Most were very good. I didn't like the students who just stayed in the corner and stared, and the ones didn't touch or touched so light it was like a feather. I told them it wouldn't hurt me, but some were too wimpy. The ones that got in there and felt the depth got a nice surprise and they smiled with fascination and thanked me. Last but not least I also had the opportunity, when I remembered, to give the quick 411 on sarc and to suggest to the students that if they find sarc in a patient who doesn't have a previous diagnosis, to recommend they get a chest x-ray and evaluation from their doctor because they might have things going on that they didn't know about, and that sarc might explain lots of stuff going on that has been a mystery until the biopsy confirmed sarc. These are the terms used to describe my cutaneous sarcoidosis during examinations: Plaques (or plaque-like lesions) Violacious Non-scaly Indurated Some were annular, with central clearing (soft in clear area) Almost no blanching Apple jelly (yea, I thought that was weird too) Infiltrated in the dermis The plaque on my nose is called lupus pernio, just because its on my face My lip has a sarcoid lesion        See my skin Other things I didn't know. Diascopy, using a thin glass slide pressed down on a lesion, reveals currant, or apple jelly appearance Sarcoidosis plaques can be mistaken for tuberculosis plaques. Erethematous means red, and violacious means purple. The brownish red and purplish color is indicative of sarcoidosis. All but one of the Drs. called my sarcoids plaques, but also called them nodules. One Dr. said that they were nodules not plaques because of their depth. Picky picky. Erethema nodosum, a sarcoidosis related condition, is inflammation of the fatty tissue and usually happens on the legs. I don't have it but was told that if I get it to have it looked at right away. The dermis is thick, and if you have sub-cutaneous it is in the fatty layer underneath the dermis. That's why its uncommon. Mine appears to be mostly infiltrated into the dermis. Injected (not topical) corticosteroids may reduce or eliminate lesions. One attending said that some gulf war veterans seem to be getting sarcoidosis. So there you have it. My skin sarcs. I helped science and turned something that is negative into something positive. I also learned quite a bit about cutaneous sarcoidosis and my particular involvement. A very educational day. Incidentally, one of the administrative assistants who was there helping with the event told me that she happens to have pulmonary sarcoidosis that is in remission. It was so cool to finally meet another sarkie in person!	SKIN
11/20/08 Uninsured. Went to a free clinic for a check up. Asked about getting blood work to check my thyroid and cholesterol, since they've both been slightly out of range for several years. My last 2 physical exams (both different doctors), didn't include CBC. But this P.A. had put it in the lab orders. And I'm glad he did, because it had some interesting findings! Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE CBC: WBC 1.6 4.3-11.0 10e9/L RBCx10e12 5.16 3.79-5.25 /L HEMOGLOBIN 14.5 11.5-16.0 GM/DL HEMATOCRIT 43.8 34.5-47.0 VOL% MCV 84.9 80.0-100.6 FL MCH 28.1 25.0-33.4 PG MCHC 33.1 25.0-33.4 PG RDW-CV 14.4 32.3-36.5 GM/DL PLATELET COUNT 146 150-480 10e9/L MEAN PLT VOLUME 10.6 9.3-12.9 FL NEUTROPHIL footnote % LYMPHOCYTE footnote % MONOCYTE footnote % EOSINOPHIL footnote % BASOPHIL footnote % NEUTROPHIL ABS 0.29 1.80-7.80 10e9/L LYMPHOCYTE ABS 0.50 1.00-4.00 10e9/L MONOCYTE ABS 0.12 0.20-0.80 10e9/L EOSINOHIL ABS 0.51 0.00-0.45 10e9/L BASOPHIL ABS 0.02 0.00-0.20 10e9/L RDW-SD 44.5 38.4-53.1 MANUAL DIFFERENTIAL: POLY 5 21-85 % BAND 13 0-12 % LYMPHOCYTE 32 12-60 % MONOCYTE 8 0-17 % EOSINOPHILS 33 0-8 % BASOPHILS 1 0-2 % ATYPICAL LYMPHS 8 0-5 % VACUOLATED POLY PRESENT   LARGE PLTS PRESENT   METABOLIC / chem 14: GLUCOSE 97 70-100 MG/DL BUN 11 5-19 MG/DL CREATININE 1.04 0.50-1.00 MG/DL SODIUM 138 135-145 MMOL/L POTASSIUM 4.4 3.5-5.5 MMOL/L CHLORIDE 104 96-108 MMO/L BICARBONATE 23 18-30 MMOL/L ANION GAP 11 5-16 MM/L CALCIUM 9.7 8.5-10.5 MG/DL PROTEIN TOTAL 8.1 6.7-8.2 GM/DL ALBUMIN 4.3 3.9-4.9 GM/DL BILIRUBIN TOTAL 0.9 0.1-1.0 MG/DL ALK PHOS 77 28-114 U/L AST (SGOT) 20 0-40 U/L ALT (SGPT) 13 0-40 U/L LIPID GROUP: CHOLESTEROL 198 100-200 MG/DL TRIGLYCERIDE 166 30-150 MG/DL HDL CHOLESTEROL 35 40-125 MG/DL LDL CHOLESTEROL 130 0-130 MG/DL CHOL/HDL RATIO 5.66 0.00-4.44 RATIO     TSH 5.512 0.300-5.000 uIU/ML FREE T4 1.18 0.80-1.80 NG/DL Cholesterol — Discussed diet/excersise Thyroid — 12/4/08 started Synthroid 25 mcg. Finally! TSH and CBC re-check in a few weeks. WBC — Very scary, since no insurance. I wondered if this was due to sarc in my spleen. I talked to my former PCP who said that given my history of sarc, it could be my bone barrow. Don't worry about spleen unless bone marrow biopsy comes out ok. Suggested a 2nd lab, then to get on medicaid, and to get with a hematologist for a bone marrow biopsy. May not qualify for medicaid because of unemployment checks. Will try to not get sick	BLOOD
01/19/09 TEST RESULT REFERENCE RANGE GENERAL HEALTH PANEL: WBC 1.4 4.3-11.0 10e9/L RBCx10e12 5.36 3.79-5.25 /L HEMOGLOBIN 14.5 11.5-16.0 GM/DL HEMATOCRIT 44.5 34.5-47.0 VOL% MCV 83.0 80.0-100.6 FL MCH 27.1 25.0-33.4 PG MCHC 32.6 32.3-36.5 GM/DL RDW-CV 14.2 11.0-16.0 % RDW-SD 42.4 38.4-53.1 PLATELET COUNT 130 150-480 10e9/L MEAN PLT VOLUME 10.3 9.3-12.9 FL DIFFERENTIAL: NEUTROPHIL 28.3 % LYMPHOCYTE 23.2 % MONOCYTE 29.0 % EOSINOPHIL 18.8 % BASOPHIL 0.7 % NEUTROPHIL 0.39 1.8-7.8 10e9/L LYMPHOCYTE 0.32 1.00-4.00 10e9/L MONOCYTE 0.40 0.20-0.80 10e9/L EOSINOPHIL 0.26 0.00-0.45 10e9/L BASOPHIL 0.01 0.00-0.20 10e9/L LIPID GROUP: TSH 0.738 0.300-5.000 uIU/ML FREE T4 1.74 0.80-1.80 NG/DL Thyroid much improved! White Blood Count still freaky low, but since I'm not sick or have any chronic infections and feel great then no worries. Besides I couldn't afford a bone marrow check if I was sick.	BLOOD
5/2/09 Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE GENERAL HEALTH PANEL: GLUCOSE 92 65-100 MG/DL BUN 11 8-25 MG/DL CREATININE 0.9 0.6-1.3 MG/DL CALCULATED BUN/CREAT 12 6-28 SODIUM 138 133-146 MEQ/L POTASSIUM 3.8 3.5-5.3 MEQ/L CHLORIDE 103 97-110 MEQ/L CARBON DIOXIDE 23 18-30 MEQ/L CALCIUM 9.4 8.5-10.5 MG/DL PROTEIN, TOTAL 8.0 6.0-8.4 G/DL ALBUMIN 4.3 2.9-5.0 G/DL CALCULATED GLOBULIN 3.7 2.0-3.8 G/DL CACULATED A/G RATIO 1.2 0.9-2.5 BILIRUBIN, TOTAL 0.8 0.1-1.3 MG/DL ALKALINE PHOSPHATASE 92 30-132 U/L SGOT (AST) 16 5-35 U/L SGPT (ALT) 7 7-56 U/L CBC: WBC 1.5 4.0-11.0 K/UL RBC 4.96 3.80-5.10 M/UL HEMOGLOBIN 13.1 11.5-15.5 G/DL HEMATOCRIT 39.2 34.0-45.0 % MCV 79.1 80.0-100 fL MCH 26.4 27.0-34.0 PG MCHC 33.4 32.0-36.4 G/DL RDW 15.5 11.0-15.0 % NEUTROPHILS 30 40-74 % SEGMENTED NEUTROPHILS, MANUAL DIFF. LYMPHOCYTES 37 19-48 % MONOCYTES 17 3-11 % EOSINOHILS 14 0-7 % BASOPHILS 2 0-2 % PLATELET COUNT 174 130-400 K/UL RBC'S ARE NORMOCHROMIC/NORMOCYTIC PLATELET COUNT CONFIRMED BY REVIEW OF THE PERIPHERAL SMEAR. NO MORPHOLOGIC ABNORMALITY OF PLATELETS IDENTIFIED. LIPID GROUP: TSH < 0.1 0.3-5.1 K/UL Dr. said he will refer me to a hematologist for my blood and to a rheumatologist for my sarcoid. He didn't mention the TSH and I had just filled a prescription from him for a year's worth of Levothyroxin 150 mcg. I should probably get an adjusted dosage.	BLOOD
Rheumatologist He did an exam where he noticed splenomegaly. Referred me to a pulmonologist and new primary care. Records pending.	SPLEEN
5/20/09 Opthalmologist: Attempted transcription of "impression" section of notes. (see hard copies) 1. Sarcoidosis without ophthalmic involvement 2. Allergies - 2nd syle 3. Sinus - at'er Doc said no sarcoid was visible.	EYES
5/19/09 Hematologist notes: Initial consult Billing/coding diagnosis: Leukocytopenia, unspecified - 288.50 Diagnosis: xx is a 45-year-old lady with significant neutropenia History of present illness: xx has a pretty involved medical history. She has a longstanding diagnosis of sarcoidosis. She has had manifestations in her lung, skin and eye. xx has also suffered from hypothyroidism and hypercholesterolemia. However, xx has floated between jobs and insurances and has not been able to undergo any treatment for her problems. Recently xx moved to Tulsa and then to Oklahoma City a few months later. In Tulsa she was able to have some blood work done in the clinic. That demonstrated a significantly low white count but no further investigation could be undertaken at that time. However, xx was able to start on some thyroid repletion. After moving to this area, xx once again had some blood work which confirmed a low white count of 1.5 with only 30% neutrophils. xx is now referred over for additional investigation. She notes that she was also able to visit with her rheumatologist last week. It was felt that her spleen was a little bit enlarged at that time. However, so far no treatments have been initiated. xx has no real additional complaints today. She does note that some recent infections have taken a long time to heal but she has not really had any severe illnesses. She does not have any fevers, sweats or chills either. Past Medical History: As noted in HPI. Surgical procedures include mediastinoscopy in 2001 when the diagnosis was made. Apparently a skin biopsy has also confirmed the diagnosis. Medications: Levothyroxine 150 mcg. Allergies: Penicillin and Cephalosporin Family History: Noncontributory Social History: The patient is single. She has had a variety of jobs over the years and has had exposure to hair dye and acrylic. She does have history of smoking. No significant alcohol. Review of Systems: General: Energy level and appetite are pretty steady. No fevers, sweats, or weight loss. HEENT: Sinus congestion. Co acute complaints. Respiratory: Wheezing with exertion. No resting shortness of breath or productive cough. No severe respiratory infections. Cardiovascular: Without excertional chest pains or palpitations. Gastrointestinal: Without nausea, vomiting, diarrhea, pain, or bleeding. Genitourinary: Without hematuria or dysuria. Musculoskeletal: New new bone pain. Neurologic: No focal problems or severe headaches. Dermatologic: Active rash from sarcoidosis. Physical Examination: xx is in acute distress. Vital Signs: BP 129/81, pulse 88, temp 97.1, weight 202 lbs. she is 5 feet 5 inches tall. HEENT: Normocephalic, atraumatic. Negative pallor. Negative thrush. No mouth sores. Neck: Neck supple without venous distention. Lymph Nodes: Negative throughout. Lungs: Clear to auscultation and percussion bilaterally to the bases. Hearth: Regular S1, S2. No murmurs, rubs, or gallops. Abdomen: Positive bowel sounds. Spleen tip is just palpable but without masses, hepatosplenomegaly. Extremeties: Without clubbing, cyanosis, or edema. Neurologic: Alert and appropriate. Grossly nonfocal. Skin: Some scattered faintly erythematous plaque. Labs: Recently white count was 1.5 with only 30% segs, hemoglobin normal at 13.1, and platelets normal at 174. Creatinine and LFT's well within normal limits. TSH was suppressed at less than 0.1. Impression: xx is a 45-year-old lady with long standing history of biopsy proven sarcoidosis. For several months she has had neutropenia and she is now able to pursue additional evaluation to see if this problem is related to her prior diagnosis. We will pursue bone marrow examination to confirm that and rule out the small possibility of an additional disorder. At the same time we will also check B12 and folate levels. Finally since it has been quite some time we will repeat a CT of the abdomen for an additional look at the spleen. Depending on the findings, xx might benefit from a course of treatment for her systemic illness. In addition we could pursue a brief course of white cell growth factor in setting of any severe infections or planned procedures. xx, M.D.	BLOOD
5/22/09 Bone Marrow Aspiration: Operative Notes: PROCEDURE: Bone marrow aspirate and biopsy. INDICATIONS: Leukopenia The patient was placed prone. The area over the right posterior superior iliac crest was prepped and draped in the usual sterile fashion. Licocaine 1% was infiltrated. Jamshidi was inserted. The patient experienced some additional pain when the Jamshidi touched the periosteum. So, additional Lidocaine was infilatred through the Jamshidi needle. Three attempts at removing aspirate were performed. Unfortunately no aspirate was obtained. However, there was a clot section which will be sent for cell count and differential and morphology. After the additional Lidocaine the patient tolerated the procedure adequately. xx, M.C. Radiology Notes: CT ABDOMEN WITH AND WITHOUT CONTRAST: CLINICAL HISTORY: Sarcoidosis. Splenomegaly. The spleen is enlarged measuring 17.3 cm in length. There are multiple splenic, gastric, and esophageal varicosities present. There also does appear to be varicosities in the para-aortic region. It is difficult to distinguish some of these from lymphadenopathy. There is only a small amount of oral contrast in the duodenal sweep region. There is a soft tissue density seen in the right upper abdomen which measures 4.7 x 2.2 cm. This is seen close to the region of the gallbladder. The liver is not enlarged. A few liver cysts are seen. No hydronephrosis is apparent. IMPRESSION: Splenomegaly. Multiple varicosities in the para-aortic region, gastric and splenic region. In the right upper abdomen there is a 4.7 cm density which is difficult to determine whether this is soft tissue mass, varicosities, adenopathy, or part of the duodenal sweep. Recommend ultrasound of the abdomen with dedicated attention to the region just deep to the gallbladder. Also ultrasound of the abdomen could help determine that the para-aortic densities are varicosities rather than adenopathy. There appears to be a prominent esophageal varicosity. Labs: Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE VITB12, FOLIC ACID, RA VITB12 369 193-982 pg/mL FOLIC ACID 9.2 3.0-17.0 ng/mL RA <20 <= 20 U/mL ANA ANA NEGATIVE NEGATIVE ISR CBC WBC 1.3 4.8-10.8 K/mm3 Repeated Result 1.2   RBC 5.07 4.20-5.40 M/mm3 HGB 13.2 12.0-16.0 gm/dL HCT 39.4 37.0-47.0 % MCV 77.6 81.0-99.0 fL MCH 26.1 27.0-34.0 pg MCHC 33.6 31.0-37.0 g/dL RDW 14.6 11.5-14.5 % PLATELET 134 130-400 K/mm3 GRAN % (auto) 26.1 48.0-70.0 % LYMPH % 29.1 22.0-45.0 % MONO % 25.1 4.5-10.0 % Monocytosis noted Repeated Result: 21.6   EOS 19.4 0.6-6.0 % Eosinophilia noted Repeated Result: 20.6   BASO % 0.3 0-1.6 % GRAN # 0.3 2.9-7.5 K/mm3 LYMPH # 0.5 1.4-3.4 K/mm3 MONO# 0.3 0.4-0.8 K/mm3 EOS # 0.2 0.0-0.5 K/mm3 BASO # 0.0 0.0-0.5 K/mm3 COMMENT: Abnormal Detected Smear is available for WBC and/or RBC morphology review or Manual Differential by a Technologist upon receipt of order. WINTERGREN ESR WINTERGREN ESR 13 0-20	BONE Marrow SPLEEN BLOOD
5/28/09 Hematologist Notes: Follow-up Diagnosis: xx is a 45-year-old lady with history of sarcoidosis and leukopenia. Interval History: xx was able to undergo bone marrow examination, however, the study was difficult and only a minute sample was obtained. The material was actually pretty unremarkable with normal maturation and relatively normal cell ratios. The results showed no evidence of granulomatous disease, however, more tissue would definitely be helpful. xx also underwent CT scanning. That confirmed the splenomegaly which was known but also showed extensive varicosities in the splenic, gastric and esophageal blood vessels. There was also a question of soft tissue density in the right upper abdomen. Despite this xx continues to feel pretty well. She is not experiencing abdominal pain and has good energy with no enexplained fevers. <leaving out symptoms and physical - was not examined> Labs: Bone marrow and imaging as noted. ANA is negative as is the rheumatoid factor. B12 and folate are within adequate ranges. Impression: xx is a 45-year-old lady with history of sarcoidosis and now found to have profound leukopenia. Workup for that shows no obvoius evidence of sarcoid as the etiology but unexpectedly there is evidence of portal hypertension as well as vague abnormality in the right upper quadrant. To get to the bottom of this we will need to repeat the bone marrow exam which will probably be best done by interventional radiology at this point. In addition, if feasible, I would like them to consider biopsy of the right upper quadrant area if confirmed or possibly just the liver to try to assess why there is significant portal hypertension.	LIVER BONE Marrow BLOOD
06/09/09 Retuned to the hospital for 2nd bone marrow aspiration as well as biopsy of the mystery "density". Pathology notes (liver): REQUISITION INFORMATION: 1) Liver biopsy 2) Liver biopsy 2. 3) Lymph node next to liver Pre: Liver - hepatitis versus periportal fibrosis. Lymph node - sarcoidosis History: Previous diagnosis of sarcoid and has had splenomegaly. Also received is additional material for hematology. DIAGNOSIS: A. Liver - Needle Biopsy: Granulomatous inflammation B. Liver - Needle Biopsy: Granulomatous inflammation; Steatosis, focal C. Lymph Node - Biopsy, Next to Liver: Granulomatous inflammation. COMMENT: Sections of the liver needle biopsies show well-formed noncaseating granulomas with expanded portal tracts consistent with the clinical history of sarcoidosis. The hepatic lobules show only focal mild steatosis. Iron stain is performed on both parts A and B and no iron is detected. Reticulin stain performed on both blocks shows intact hepatic architecture. The trichrome stains show expansion of the portal triads and possible early bridging fibrosis. Pathology notes (bone marrow): REQUISITION INFORMATION: Bone biopsy, red; CBC; peripheral smears (2+2); reports; bone marrow, EDTA, bone marrow, clot (red); bone marrow, green; bone marrow slides (x5). Preop dx: Sarcoidosis, leukopenia with neutropenia. History: Splenomegaly. Also received is additional material for surgical pathology. DIAGNOSIS: A. Peripheral Blood: leukopenia; thrombocytopenia B. Bone marrow aspiration and biopsy: Normocellular marrow with adequate numbers of megakaryocytes. COMMENT: Review of the peripheral smear, bone marrow biopsy and CBC show peripheral cytopenias with a normocellular marrow containing adequate numbers of megakaryocytes. The white cells do demonstrate a left shift. Labs: Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE CBC - drawn with bone marrow WBC 1.4 4.8-10.8 K/mm3 Repeated Result 1.5   RBC 4.64 4.20-5.40 M/mm3 HGB 12.7 12.0-16.0 gm/dL HCT 37.3 37.0-47.0 % MCV 80.3 81.0-99.0 fL MCH 27.5 27.0-34.0 pg MCHC 34.2 31.0-37.0 g/dL RDW 14.3 11.5-14.5 % PLATELET 127 130-400 K/mm3 GRAN % (auto) 39.3 48.0-70.0 % LYMPH % 21.7 22.0-45.0 % MONO % 24.3 4.5-10.0 % Monocytosis noted Repeated Result: 23.5   EOS 14.4 0.6-6.0 % Eosinophilia noted Repeated Result: 15.2   BASO % 0.3 0-1.6 % GRAN # 0.6 2.9-7.5 K/mm3 LYMPH # 0.3 1.4-3.4 K/mm3 MONO# 0.3 0.4-0.8 K/mm3 EOS # 0.2 0.0-0.5 K/mm3 BASO # 0.0 0.0-0.5 K/mm3 COMMENT: Abnormal Detected Smear is available for WBC and/or RBC morphology review or Manual Differential by a Technologist upon receipt of order.	LIVER BONE Marrow BLOOD
06/19/09 Hematologist Notes: Billing/Coding Diagnosis: Leukocytopenia, unspec. - 288.50 Diagnosis: xx is a 45-year-old lady with history of sarcoidosis and recent diagnosis of neutropenia. Interval History: xx was able to go for additional bone marrow examination which produced more material. She also had biopsies of a lymph node in the right upper quadrant as well as liver biopsy. Both the lymph node and the liver demonstrated granulomatous inflammation. There was some incipient bridging fibrosis in the liver but no extensive scarring. Interestingly, there were no granulomas in the bone marrow and only a minimal shift in the white cells. There is no evidence of any other infiltrative process or disorder maturation. xx actually has established care with a rheumatologist and will be following up next week to discuss a treatment plan in light of the most recent results. <leaving out symptoms and physical - was not examined> Impression: xx is a 45-year-old lady with extensive sarcoidosis, now demonstrated in lymph nodes and liver, though interestingly not in the bone marrow. The leukopenia could be due to concentration at the sites of inflammation as I would expect more of as a pancytopenia if the etiology were hypersplenism, otherwise, the blood work abnormalities are almost certainly related to the extensive sarcoidosis. Therefore, xx was encouraged to proceed with treatment with Dr. xx.	LIVER BONE Marrow BLOOD
07/23/2009 Pulmonologist Labs: Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE CBC w/ DFF/PLT WBC 1.8 3.8-10.8 Thousand /uL RBC 5.09 3.80-5.10 Million/uL HGB 14.1 11.7-15.5 g/dL HCT 40.8 35.0-45.0 % MCV 80.1 80.0-100.0 fL MCH 27.6 27.0-33.0 pg MCHC 34.5 32.0-36.0 g/dL RDW 14.9 11.0-15.0 % PLATELET clumped 140-400 K/mm3 NEUTROPHILS ABS 324 1500-7800 cells/uL BAND NEUTROPHILS ABS 288 0-750 cells/uL LYMPHOCYTES 468 850-3900 cells/uL MONOCYTES ABS 378 200-950 cells/uL EOSINOPHILS ABS 342 15-500 cell/uL BASOPHILS ABS 0 0-200 cells/uL NEUTROPHILS 18 % BAND NEUTROPHILS 16 % LYMPHOCYTES 26 % MONOCYTES 21 % EOSINOPHILS 19 % BASOPHILS 0 % COMMENT: Evaluate results with caution. The white blood cell count and platelet count may be altered due to interferences caused by the presence of significant numbers of platelet clumps. METABOLIC GLUCOSE 92 65-99 mg/dL UREA NITROGEN (BUN) 14 7-25 mg/dL CREATININE 0.94 1.59-1.07 mg/dL eGFR AFRICAN AMERICAN >60 > or = 60 mL/min/1.73m2 BUN/CREATININE RATIO n/a 6-22 (calc)L SODIUM 138 135-146 mmol/L POTASSIUM 4.0 3.5-5.3 mmol/L CHLORIDE 103 98-110 mmol/L CARBON DIOXIDE 23 21-33 mmol/L CALCIUM 9.9 8.6-10.2 mg/dL PROTEIN,TOTAL 8.1 6.2-8.3 g/dL ALBUMIN 4.4 3.6-5.1 g/dL GLOBULIN 3.7 2.2-3.9 g/dL (calc) ALBUMIN/GLOBULIN RATIO 1.2 1.0-2.1 (calc) BILIRUBIN, TOTAL 0.8 0.2-1.2 mg/dL ALKALINE PHOSPHATASE 95 33-115 U/L AST 20 10-35 U/L ALT 12 6-40 U/L SED RATE BY MODIFED WESTERGREN, MANUAL 35 < or = 20 mm/h ANGIOTENSIN CONVERTING ENZYME (ACE) ACE, SERUM 150 9-67 CALCIUM, 24 HOUR URINE CALCIUM, 24 HOUR URINE 574 <250 mg/24 h HISTOPLASMA ANTIGEN URINE HISTOPLASMA ANTIGEN URINE < 2.0 < 2.0 EIA Units FUNGAL PANEL 2, id AND cf ASPERGILLUS FLAVUS AB negative negative ASPERGILLUS NIGER AB negative negative ASPERGILLUS FUMIGATUS AB negative negative BLASTOMYCES ANTIBODY, ID negative negative COCCIDIOIDES ANTIBODY, ID negative negative YEAST PHAS ANTIBODY <1:8 <1:8 MYCELIAL PHASE ANTIBODY <1:8 <1:8 Dr. started me on hydrochlorothiazide for the high urine calicium.	BLOOD KIDNEYS
11/02/2009 Primary Care Went to primary care to ask about my constant sweating. She checked estrogen and FSH levels and said I wasn't menopausal. She said that if the sweating was happening around the time of my periods then it would likely be parimenopause related, but since mine happens all the time she said it might be sarcoidosis related. However, in her notes she wrote that it could be perimenopausal. TEST RESULT REFERENCE RANGE ESTRADIOL 61 pg/mL Follicular phase 11-212 Mid-cycle 18-480 Luetal phase < or= 247 post-menopausal < or = 27 FSH 9.9 mIU/mL Follicular phase 2.5-10.2 Mid-cycle peak 3.1-17-7 Luetal phase 1.5-9.1 post-menopausal 23.0-116.3 She also did a blood work up TEST RESULT REFERENCE RANGE CBC w/ DFF/PLT WBC 1.9 3.8-10.8 Thousand /uL RBC 4.81 3.80-5.10 Million/uL HGB 13.9 11.7-15.5 g/dL HCT 41.4 35.0-45.0 % MCV 86.0 80.0-100.0 fL MCH 28.8 27.0-33.0 pg MCHC 33.5 32.0-36.0 g/dL RDW 15.5 11.0-15.0 % PLATELET 152 140-400 Thousand/uL NEUTROPHILS ABS 657 1500-7800 cells/uL LYMPHOCYTES ABS 494 850-3900 cells/uL MONOCYTES ABS 386 200-950 cells/uL EOSINOPHILS ABS 342 15-500 cell/uL BASOPHILS ABS 21 0-200 cells/uL NEUTROPHILS 34.6 % LYMPHOCYTES 26.0 % MONOCYTES 20.3 % EOSINOPHILS 18.0 % BASOPHILS 1.1 % COMMENT: Evaluate results with caution. The white blood cell count and platelet count may be altered due to interferences caused by the presence of significant numbers of platelet clumps. METABOLIC GLUCOSE 98 65-99 mg/dL UREA NITROGEN (BUN) 12 7-25 mg/dL CREATININE 1.02 1.59-1.07 mg/dL eGFR NON-AFRICAN AMERICAN 59 > or = 60 mL/min/1.73m2 eGFR AFRICAN AMERICAN > 60 > or = 60 mL/min/1.73m2 BUN/CREATININE RATIO n/a 6-22 (calc)L SODIUM 140 135-146 mmol/L POTASSIUM 4.0 3.5-5.3 mmol/L CHLORIDE 105 98-110 mmol/L CARBON DIOXIDE 23 21-33 mmol/L CALCIUM 9.5 8.6-10.2 mg/dL PROTEIN,TOTAL 7.7 6.2-8.3 g/dL ALBUMIN 4.2 3.6-5.1 g/dL GLOBULIN 3.5 2.2-3.9 g/dL (calc) ALBUMIN/GLOBULIN RATIO 1.2 1.0-2.1 (calc) BILIRUBIN, TOTAL 0.8 0.2-1.2 mg/dL ALKALINE PHOSPHATASE 85 33-115 U/L AST 17 10-35 U/L ALT 12 6-40 U/L	BLOOD
02/04/2010 Primary Care Thyroid check: Levels are finally good. Now on 150 mcg 5x a week. TEST RESULT REFERENCE RANGE TSH, 3rd GENERATION 1.28 > or = 20 years: 0.40-4.5	BLOOD
01/21/2010 Pulmonologist Ran comprehensive blood work (compare to last July): TEST RESULT REFERENCE RANGE METABOLIC GLUCOSE 89 65-99 mg/dL UREA NITROGEN (BUN) 12 7-25 mg/dL CREATININE 0.98 1.59-1.07 mg/dL eGFR NON-AFRICAN AMERICAN >60 > or = 60 mL/min/1.73m2 eGFR AFRICAN AMERICAN >60 > or = 60 mL/min/1.73m2 BUN/CREATININE RATIO n/a 6-22 (calc)L SODIUM 138 135-146 mmol/L POTASSIUM 3.8 3.5-5.3 mmol/L CHLORIDE 102 98-110 mmol/L CARBON DIOXIDE 25 21-33 mmol/L CALCIUM 9.7 8.6-10.2 mg/dL PROTEIN,TOTAL 7.9 6.2-8.3 g/dL ALBUMIN 4.4 3.6-5.1 g/dL GLOBULIN 3.5 2.2-3.9 g/dL (calc) ALBUMIN/GLOBULIN RATIO 1.3 1.0-2.1 (calc) BILIRUBIN, TOTAL 0.8 0.2-1.2 mg/dL ALKALINE PHOSPHATASE 80 33-115 U/L AST 17 10-35 U/L ALT 8 6-40 U/L SED RATE BY MODIFED WESTERGREN, MANUAL 27 < or = 20 mm/h ANGIOTENSIN CONVERTING ENZYME (ACE) ACE, SERUM 125 9-67 CALCIUM, 24 HOUR URINE CALCIUM, 24 HOUR URINE 281 <250 mg/24 h	BLOOD
04/07/10 Emergency Room Went to the ER because I was coughing up blood (hymoptysis). ER Notes: The patient presents with cough and Patient with intermittent cough over the past 2 days. Patient with slight amount of bright red blood. Patient states that the blood it was not mixed with sputum. Patient states that she felt "liquid" coming up her throat and this caused her to cough to clear it. Patient with a history of sarcoidosis. The onset was 1 days ago. The course/duration of symptoms is fluctuation in intensity. Character productive: bloody. The degree at onset was minimal. The degree at present is minimal. Exacerbating factors consist of none. The relieving factor is beta agonist. Risk factors consist of Sarcoidosis. Prior episodes: none. Therapy today: none. Associated symptoms: denies shortness of breath, denies chest pain, denies sore throat, denies rhinorrhea, denies nasal congestion and denies hoarse voice. Labs: Abnormal test findings are in bold with the numbers in red: TEST RESULT REFERENCE RANGE CBC w/ DFF/PLT WBC 2.09 3.8-10.8 X 10^3 RBC 5.19 3.80-5.10 X 10^6 HGB 14.6 11.7-15.5 g/dL HCT 41.1 35.0-45.0 % MCV 79.2 80.0-100.0 fL MCH 28.1 27.0-33.0 pg MCHC 35.5 32.0-36.0 g/dL RDW 14.2 11.0-15.0 % PLATELET 149 150-450 X 10^3 NEUTROPHILS ABS .900 1.500-7.800 X 10^3 LYMPHOCYTES ABS .51 .85-4.10 X 10^3 MONOCYTES ABS 0.40 0.20-0.95 X 10^3 EOSINOPHILS ABS .270 0.050-0.550 X 10^3 BASOPHILS ABS 0.01 0.00-0.20 X 10^3 NEUTROPHILS 43.1 34-66 % LYMPHOCYTES 24.4 12-48 % MONOCYTES 19.1 1.0-13.0 % EOSINOPHILS 12.9 < = 3 % BASOPHILS 0.5 < = 2.0 % METABOLIC GLUCOSE 93 65-99 mg/dL BLOOD UREA NITROGEN (BUN) 13 7-25 mg/dL CREATININE 0.86 0.5-1.20 mg/dL BUN/CREATININE RATIO 15.1 6.0-25.0 (calc) SODIUM 137 135-146 mmol/L POTASSIUM, SERUM 3.9 3.5-5.3 mmol/L CHLORIDE 101 98-110 mmol/L CARBON DIOXIDE 28 21-33 mmol/L CALCIUM 9.1 8.5-10.4 mg/dL C1Cr Calculated 81.00 mL/min Osmolality 273.6 273.0-304.0 mOsmo COAGULATION D-Dimer Quantitative 2.4 0.0-2.5 mg/L FEU Radiology X-ray: Two views of the chest demostrate the lungs are clear. Prominence of the mediastinum and axilla consistent with lymphadenopathy. Heart size is normal. Visualized osseous structures are grossly intact. Impression: 1. Mediastinal and axillary lymphadenopathy 2. No acute cardiopulmonary disease  [See x-ray] CT Chest w/ Infusion PE: There are no filling defects to the level of the segmental pulmonary arteries. No consolidation, effusion or pneumothorax. Extensive mediastinal, hilar and axillary lymphadenopathy. Enlarged subcarinal nodes and nodes adjacent to the esophagus. Calcified right hilar lymph node. The largest nodes are in the prevascular region and measure up to 4.0 x 2.5 cm. Thoracic aorta is normal size. Extensive retroperitoneal lymphadenopathy. Subcentimeter cyst the left of the liver. Impression: 1. Negative for PE 2. Extensive mediastinal lymphadenopathy which may be seen with lymphoma or sarcoidosis given the clinical history.  [See CTs: 1 | 2 | 3 | 4 ] Patient with evidence of bronchitis, exacerbation of "sarcoid induced asthma" Patient with very non-toxic appearance here aside from mild wheezing. Patient comfortable, no heavy hemoptysis or recurrent cough here. Patient with x-ray showing no obvious infiltrate. Case discussed with [pulmonologist] with CT-PE discussed. Patient with initial D-dimer positive so CT-PE ordered to rule out pul infarct, occult pneumonia. If no PE or other abnormality dictating inpatient admission, patient may be DC'd. Patient looks very good from clinical standpoint. Patient will followup with xxx or his PA in 2 days, call for appt. Impression: Acute bronchitis, hx of sarcoid	BLOOD LUNGS LYMPH NODES LIVER

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