Lab Order List v1 — Hand to Dr Ambrose or Lab Tech
Patient: Ben Wilson, DOB 1990-06-02 (age 35). Context: Most recent panel 2025-03-18 (14 mo old). Active surveillance: MASLD (2021 dx), gout (4 flares 2022-2026, urate 7.9), pre-prediabetic glucose trajectory, borderline LDL. Goal: Refresh stale labs + add never-run high-leverage markers + characterize MASLD + cardio risk before age 40.
Section A — Standard labs to REFRESH (previously done, now outdated)
| Lab | Last value | Last date | Rationale |
|---|---|---|---|
| Comprehensive Metabolic Panel (CMP) | AST 46 (HIGH), ALT not in panel | 2025-03-18 | AST jumped from 20-29 baseline. Need ALT context to interpret. |
| Add ALT if not in CMP | 34 IU/L | 2021 | Pair with AST |
| Add GGT | not in record | n/a | Complementary liver marker for MASLD activity |
| Add CK (creatine kinase) | not in record | n/a | Rule out muscle-source AST elevation |
| Lipid panel (TC, HDL, LDL, TG, non-HDL) | LDL 108 / HDL 45 / TG 116 | 2025-03-18 | LDL drift up; want fresh number |
| HbA1c | 5.4% | 2025-03-18 | Trajectory 4.9 → 5.0 → 5.4 over 7 yrs; want current point |
| Fasting glucose | 105 (HIGH) | 2025-03-18 | Confirm fasting status, recheck |
| Uric acid | 7.9 (upper-normal) | 2025-03-18 | Gout monitoring. Target <6 if ULT (allopurinol) started. |
| CBC with differential | normal | 2025-03-18 | Routine refresh |
| TSH | 0.945 (normal) | 2025-03-18 | Refresh + add free T4 + free T3 (see Section B) |
| Bilirubin (total + direct) | 0.5 total | 2025-03-18 | Hepatic panel complement |
| Alkaline phosphatase | 63 | 2025-03-18 | Hepatic panel complement |
| Albumin + total protein | Albumin 5.0 | 2025-03-18 | Hepatic synthesis function + nutritional |
Section B — NEW labs (never run, highest-leverage adds)
Cardiovascular risk refinement
| Lab | Why now |
|---|---|
| Lipoprotein(a) [Lp(a)] | 2025 ACC/AHA dyslipidemia guideline: ONCE-IN-LIFETIME measurement for all adults. Genetically determined; if elevated changes the entire risk picture. Cost ~$30-100. |
| Apolipoprotein B (apoB) | Better atherosclerotic-risk marker than LDL-C, especially with borderline LDL + low-normal HDL. Cuts through the LDL ambiguity. |
| hsCRP (high-sensitivity C-reactive protein) | Inflammation marker. Relevant given fatty liver + glucose drift. JUPITER trial baseline marker. |
| Homocysteine | Optional; folate-B12-cardiovascular axis. Add if convenient. |
Endocrine + nutritional
| Lab | Why now |
|---|---|
| Vitamin D 25-OH | NEVER tested in 7 yrs of records. Indoor-worker pattern + New England light. Almost certainly low. Baseline before supplementing aggressively. |
| Testosterone: total + free + SHBG (AM draw, 8-10am) | 35yo male baseline per Endocrine Society. Informs sleep/energy/training response. SHBG calculates free T accurately. |
| Ferritin + iron + TIBC + transferrin saturation | Iron status. Mediterranean diet shift = less heme-iron. Baseline now, recheck if energy declines. |
| B12 + folate | Optional baseline. Berberine may modestly affect absorption. Methylated-folate form preferred if status is borderline. |
Insulin resistance characterization (KEY for the glucose trajectory)
| Lab | Why now |
|---|---|
| Fasting insulin | Pair with fasting glucose to calculate HOMA-IR (= glucose × insulin / 405). HOMA-IR > 2.0 = insulin resistance, even if fasting glucose still <126. Catches the upstream driver before HbA1c crosses prediabetic. |
| 2-hour Oral Glucose Tolerance Test (75 g) | More sensitive than fasting glucose alone for catching impaired glucose tolerance (IGT). Some patients are normal fasting + impaired post-load. Given the trajectory (105 → wherever it is now), characterize the full curve. |
Thyroid (full panel since TSH alone misses some patterns)
| Lab | Why now |
|---|---|
| Free T4 + Free T3 (alongside refreshed TSH) | TSH 0.945 is normal but a one-data-point thyroid screen. Full panel rules out central / conversion issues. Especially relevant if energy / weight-loss response is sluggish. |
| Anti-TPO antibody (optional) | Screen for Hashimoto's if free T3/T4 borderline. Skip if all three normal. |
Section C — PRE-BLOOD-DRAW PROTOCOL (founder discipline + tech notes)
Founder discipline before draw:
- Fast 12 hours. Water only. Fasting status is required for lipids, glucose, insulin, OGTT.
- No vigorous exercise 48 hours prior. AST and CK can elevate 30-50 U/L from training and confound results. This is the most-likely confound for the prior 2025 AST 46 reading.
- Pause creatine supplement 5 days prior OR explicitly disclose creatine 5g/day to the phlebotomist (see tech note below). Creatine elevates creatinine 0.1-0.3 mg/dL via the same metabolic pathway → false-positive renal flag.
- AM draw (8-10 am) for testosterone (diurnal variation; AM is highest). Same draw should also work for fasting markers.
- Hold berberine 24 hr before draw — small effect on glucose interpretation, conservative choice.
- Hydrate well the day before (water, not just at the draw appointment). Sodium 146 in last panel suggested dehydration on draw day; want a clean reading this time.
Note for lab tech:
"Patient is taking creatine monohydrate 5 g/day (held for 5 days pre-draw). Please flag on chart if creatinine result is borderline so Dr Ambrose has supplementation context. Patient also on vitamin D3, magnesium glycinate, omega-3, berberine (held 24 hr). Asymptomatic, fasting, no vigorous exercise in the last 48 hrs."
Section D — IMAGING to discuss separately (not labs, separate orders)
| Imaging | Why now | Cost notes |
|---|---|---|
| FibroScan (transient elastography, vibration-controlled) | 2021 MASLD diagnosis has had no follow-up. AASLD 2023 recommends non-invasive monitoring; FibroScan is the gold-standard non-biopsy option. Measures both stiffness (fibrosis stage) and CAP (steatosis %). Takes 15 min, no radiation. | ~$200-400 cash if not covered. Some GI clinics offer. |
| DEXA scan (body composition) | Baseline lean mass vs visceral fat at 202 lb, before 22-lb loss begins. Single most informative body-comp measure. Also captures bone density baseline at 35. | ~$50-150 cash; not usually insurance-covered for body comp alone. |
| CAC (Coronary Artery Calcium) score | Per 2025 ACC/AHA: recommended for men age 40+. Founder is 35 (5 years away from age-based indication). DISCUSS with Dr Ambrose: any family CV history that would justify earlier? If yes, consider now; if no, bookmark for 2031. | ~$100-200 cash, no insurance typically needed. |
| Home blood pressure cuff (not imaging, but device) | 30-day twice-daily home BP log. Clinic BP has hit 142/90 once. AHA recommends home/ambulatory averages over clinic-only readings. | $40-80 OTC, validated cuffs only (e.g., Omron Platinum, Withings). |
Section E — Questions to ASK Dr Ambrose at the first visit
(Patient-side prompts, in priority order)
- "My fasting glucose was 105 and HbA1c 5.4 in March 2025, trending up since 2018. Can we add fasting insulin (HOMA-IR) and a 2-hour OGTT to characterize whether this is impaired fasting glucose, impaired glucose tolerance, or both?"
- "AST jumped to 46 in March 2025 with no ALT in the panel. Can we draw AST + ALT + GGT + CK to rule out muscle-source elevation vs MASLD progression?"
- "I was diagnosed with MASLD in 2021 with no follow-up imaging. Can we order a FibroScan to get a current liver assessment?"
- "I've had 4 gout flares 2022-2026 with serum urate 7.9. Per 2020 ACR guideline I appear to meet the urate-lowering-therapy threshold. Can we discuss starting allopurinol after the next flare resolves, with colchicine prophylaxis for the first 6 months?"
- "Per 2025 ACC/AHA, can we add Lp(a) once-in-lifetime + apoB + hsCRP + vitamin D 25-OH + AM testosterone + ferritin to the panel?"
- "I'm considering berberine 500 mg twice daily for glucose management while I work on lifestyle. Any contraindications you'd flag given my labs and the absence of prescription meds?"
- "Clinic BP was 142/90 in 2021. I'll do a 30-day home BP log. What threshold should trigger a follow-up conversation?"
- "I'm tracking retatrutide (LLY) Phase 3 readouts for the eventual MASH indication. Can we revisit annually whether I become a candidate once the indication lands (~2027-2028 expected)?"
- "What's your view on CAC now vs at 40? Any individual factors that move the date?"
- "Can you write a standing PRN script for indomethacin OR colchicine for acute gout breakthrough?"
Section F — How to use this document
Two ways to deliver to Dr Ambrose:
- Print this page (Section A + B + C + E fit on 1-2 pages). Hand it at the start of the appointment. Most PCPs appreciate organized patient prep.
- Email or patient-portal upload ahead of the visit so Dr Ambrose can review before walking in.
At the lab:
- Bring this document.
- Show the tech Section C ("PRE-BLOOD-DRAW PROTOCOL") and the note-for-lab-tech block. Most labs will paperclip it to the requisition.
- Confirm the draw is scheduled AM and fasting before you arrive.
After results return:
- Update [[2026-05-21-founder-health-assessment-v1]] with the new values.
- Ray writes a follow-up interpretation memo referencing the new data points.
- Plan v2 issued: nutrition / workout / supplement adjustments based on what changed.
Cross-references
- Full clinical picture + rationale for each lab: [[2026-05-21-founder-health-assessment-v1]]
- Diet + sleep changes happening in parallel: [[2026-05-22-nutrition-plan-v1]]
- Training discipline that affects AST/CK reading: [[2026-05-22-workout-plan-v1]]
- Supplement caveats (creatine, berberine): [[2026-05-22-supplement-plan-v1]]
- When this gets executed (quarterly cadence): [[2026-05-22-execution-system-v1]]
End of v1. Schedule first Dr Ambrose appointment week of 2026-06-01 (phData insurance effective 2026-05-26 + 1-week buffer for portal activation).