Medical records of a 21 year-old Iraqi male detainee held in the Hard Site at Abu Ghraib prison, Baghdad, Iraq. The report states the detainee was a passenger in a car that was in an accident ten (10) days prior to his detention. No additional details are known.
OUTPUT
URINE NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL -TIME AMOUNT TYPE ACCUM TOTAL
220=1) SU)
CHEST
EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT
ACCUM TOTAL
OTHER OUTPUT
TIME AMOUNT
TYPE
ACCUM TOTAL
GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical
facility) . • INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (1 oz/ .
( 30 HALF PINT MILK
) (to) -9
}240 120
LARGE SOUP BOWL }
240
SMALL FRUIT CUP }180
LARGE WATER GLASS ... 240COFFEE MUG }
180 PLASTIC OR PAPER JUICE CONTAINER }
180
DD FORM 792, JAN 74
Page 2
MEDCOM - 21041
DOD-034617
HIS FORM IS SUBJECT TO
TWENTY-FOU IVU' PATIENT INTAKE AND OUTPUT WORKSHEET
Cl ORAL
TIME TYPE AMOUNT
__.....
LC 0
A C/
MI
Rix) rrb
INTAKE
ACCUM TIME AMOUNTTOTAL STARTED
TWO b(c5 --&-,1
0 WOO WO
FROM
0}
HOURS TOTAL HOURS TO MI COVERED
im 'HOURS
INTRAVENOUS
TYPE
(Include Medications)
12CD MEM 0
I 00 CAROD
iqa,
257) 24o0 I DDa 1-)
•Ti
ME V
irrilnall 8-0
4r/0 CO. .. -..1.24
a 2c c20 NNW
lDEaik, ii L-K
r9-7-7.1q n,
AMOUNT
RECD
00
DATE
5OCT
((p
TIME ACCUM COMPL TOTAL
900
1 o U 0Q) 10 • • 1 to D
vir a . iiie tn
i
100 ot Iwo ,
00 /la liooe
ID o aix.)
fr•-•.
IRRIGATIONS (N/G, Bladder, etc.)
.00 Ai
TIME TYPE . ACCUMULATIVE
AMOUNT
lb ri r: I
TOTAL -"'" ----• • •—•- .
I
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. Bl, TIME ACCUM .... _..
•AMOUNT
STARTED Alb, P. cells etc.) COMPL TOTAL OTHER INTAKE TIME TYPE ACCUMULATIVE
AMOUNT TOTAL
GRAND TOTAL INTAKE
DD FORIVI 799 _IAN 7A 1F0.1 ----.. --
OL E.
Designed using Perform Pro, WHS/DIOR, Jun 94
00) 1
MEDCOM - 21042
DOD-034618
OUTPUT
TIME AMOUNT URINE ACCUM TOTAL TIME AMOUNT ACCUM TOTAL . TIME AMOUNT NASOGASTRIC TYPE ACCUM TOTAL
62 V3 z) gr....) (1/67:'- SZ.,0 95--64 -' • _ ..
k-360 375 BT6 ...
t+ 27-0 25-$OO *u3 gDetb 40 -t Wsr-36 6160 AD-c .... _. ..„ _
C' e-Sictua0-coaa}.5(A. r6...-p-ibLc_---TIME AMOUNT ACCUM TOTAL TIME AM UNT ACCUM TOTAL al---3 c) 3cD OM (PIS 550 00 t'S-U (5— Ojp ib c A 9-00 -----} TIME AMOUNT EMESIS TYPE ACCUM TOTAL
215-
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
16 1 TIME AMOUNT
TYPE ACCUM TOTAL
6160 Ifrijr) &CID&C---
350
&= BYllv•fr-.) 11ovs°2_. 3-40 --, (1}o:.. ---
.._ -_...,
GRAND TOTAL OUTPUT
REMARKS
•
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical facility) . INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS Il ozl.}30}HALF PINT MILK }240
(L)(b)-1
120}LARGE SOUP BOWL }240 SMALL FRUIT CUP .160}
LARGE WATER GLASS ... 240 COFFEE MUG }
180}PLASTIC OR PAPER
• JUICE CONTAINER }180
DD FORM 797 _1AM 7d
Page 2
MEDCOM - 21043
DOD-034619
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974
FROM.HOURS TOTAL HOURS DIV0043
-
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET COVERED
TO.HOURS
INTAKE
ORAL
INTRAVENOUS ACCUM TIME
TIME TYPE TYPE AMOUNT TIME . ACCUMTOTAL STARTED (Include Medications) RECD COMPL TOTAL AMOUNT AMOUNT
LR6',9i'''--r Na0 C ° ie00 MU ,-1 t et) lad° fje qCD leCC -[-VD ckY' ea) Il P OLFD 1F/is9, gcbt 91 vu
kW "4601120 14°9 14°C) aLaAr&L• 0....,1 eftn-vi.
...
IRRIGATIONS (N/G, Bladder, etc.) TIME TYPE ACCUMULATIVE
AMOUNT
TOTAL , ._., ......_ .._.. .
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. Bl, TIME ACCUM
AMOUNT
OTHER INTAKE TIME TYPE ACCUMULATIVE
STARTED Alb, P. cells etc.) COMPL TOTAL
AMOUNT TOTAL
GRAND TOTAL INTAKE
nn rnDR/I 709.IA Al 7.4 icnt
ON OF 1 SEP 54 IS OBSOLETE..
Designed using Perform Pro, WHS/DIOR, Jun 94
cb) Lb) -1
MEDCOM - 21044
DOD-034620
OUTPUT
URINE
NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
eliar; LISO 115o
0c0 i_61-1..;0
al/CD AZO /FCGD - .° 3/9-67D to-vi icts-D ...__
055 de_
c c)coc-f,Q-db--D;
---_
..... _..
. _. ___
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
_.
12CC 2C° .. P c" 300
.......___......
--GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
411.11(6 ) (lca) —1.
MEDICINE GLASS (1 az) . 30 HALF PINT MILK 240
120 LARGE SOUP BOWL 240 SMALL FRUIT CUP 160
LARGE WATER GLASS ... 240 COFFEE MUG 180
PLASTIC OR PAPER
JUICE CONTAINER 180
MI FORM 717 1/1111 74
Page 2
MEDCOM - 21045
DOD-034621
HIS FORM IS SUBJECT
FROM (_)0 HOURS TOTAL HOURS
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET c l COVERED DATE
TO a HOURS
1 .7 0(A-63
INTAKE
ORAL
INTRAVENOUS
TIME ACCUM TIME TYPE
TYPE AMOUNT AMOUNT AMOUNT TIME ACCUM
TOTAL STARTED (Include Medications) RECD COMPL TOTAL
676/CD 80 We- /,rim— LIZ,
tS- 2— 04701
e..--);c.J.e.—
PD &LC( LP t 5 1) AR)
FWD /WO _4SO
..---"--------"------------
.ster
, 4,9,"6,---e_ --iiiit6Azialaauarshieitioe4-61,..4 TIME ACCUMULATIVE
TYPE AMOUNT TOTAL
.}......._
(‘--• c../ C.c._ 17(40Z' c •r--I SD Clo-4...q4J 5u ra,hI")
:,..„.5
1395— Vrtw / 0 0 cc f=e_g; Jc.I.,./
....--
BLOOD/BLOOD DERIVATIVES
/t
TIME PRODUCT (i.e. BI, TIME ACCUM
AMOUNT
STARTED AM, P. cells etc.) COMPL TOTAL OTHER INTAKE TIME TYPE ACCUMULATIVE
AMOUNT TOTAL
GRAND TOTAL INTAKE nri Fnann 7C19 IAM 7A IC121
1 SEP 54 IS OBSOLETE.
Designed using Perform Pro, WHS/DIOR, Jun 94
MEDCOM - 21046
DOD-034622
OUTPUT
URINE
NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT
TYPE ACCUM TOTAL
134/5-267)c..c . pub ,07.7 7.5-Dr_c_ ?IOD LoOD 1 -
9LIcC 36D l lacb
...
...._ _
• . ---__ -}
CHEST}
-}' '} EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE
ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL
OTHER OUTPUT
AMOUNT TYPE
AD UM/k SQ ) W ac TIME ACCUM TOTAL
--ircOlia)
GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last,
first, middle; grade; date; hospital or medical facility) .._ -
INTAKE EQUIVALENTS (Serving levels cc)
_.. MEDICINE GLASS 41 az) ..
30.HALF PINT MILK .240 120.LARGE SOUP BOWL .240 SMALL FRUIT CUP .160.
LARGE WATER GLASS ... 240 COFFEE MUG .180.
PLASTIC OR PAPER
•} JUICE CONTAINER .180
nn FrIPTI/1 7(47.IAM 7A
Page 2
MEDCOM - 21047
DOD-034623
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 19
FROMVO HOURS TOTAL HOURS DATE
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET COVERED
TO HOURS
(2.e/ C-74-
INTAKE
ORAL
INTRAVENOUS
ACCUM TIME
TIME TYPE AMOUNT AMOUNT TYPE AMOUNT TIME ACCUM
TOTAL STARTED (Include Medications) RECD COMPL TOTAL
• IRRIGATIONS (N/G, Bladder, etc.) TIME s up i.,6.. k) varcE_ ACCUMULATIVE
AMOUNT
06-IOOD I, 54,-4}-.tie_. I, t. c_.3 6100c-.
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. BI, TIME ACCUM . •••. _.,
AMOUNT
STARTED AM, P. cells etc.) COMPL TOTAL OTHER INTAKE TIME TYPE ACCUMULATIVE
AMOUNT TOTAL
GRAND TOTAL INTAKE DD FORM 7ci7 _IAM "TA 1FM --- -
IS TE.
Designed using Perform Pro, WHS/DIOR, Jun 94
MEDCOM - 21048
DOD-034624
OUTPUT
URI E NASOGASTRIC
,-L...,
V 01}D c c2-E6 DOP
TIME cuM TOTAL TI MOUN TOTAL TIME AMOUNT TYPE ACCUM TOTAL
1060 WOcc Loz2
.
C,00100 3o0 a ,s, . z icce___,
-------—
...
--.--
..—}__ .}_}...
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE
ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
.....}_ __ .......
_..........
---GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last,
first, middle; grade; date; hospital or medical facility) .
INTAKE EQUIVALENTS (Serving levels cc)
(10) Lb) — q --. MEDICINE GLASS (1 oz)}30}HALF PINT MILK }240 120}LARGE SOUP BOWL }240
lap
SMALL FRUIT CUP }160}LARGE WATER GLASS }240 COFFEE MUG }180}PLASTIC OR PAPER JUICE CONTAINER }180
Page 2
MEDCOM - 21049
DOD-034625 }
Ward/Section: ,,-.,„,( REQUESTIN '., IL CLX0 -7-}CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)
DATE -_ TIME k
SS/PEEUDO SS :
LAST, FIRS1',MI..
ta-b)-41 h-h
ct c—el
g.elaft} q chitty, 1Lmastly I „tii,i VP41.g..' wtit-vJetab -.-
:
TEST - - - - - - -PICCOLO }RESULT RBI: --TEST RESULT .REE RANGE
10/04/03}19:38 , RANGE
3.5-5.5 g/d1 73-118 ing/d1
Na.REFERENCE RANGE:}MALE GLU.
PATIENT #: es (b)/12)-/
K 26-84 u/1 7-22 mg/dl
BUN.
(fNERAL CHEMISTRY 12
CI.DISC LOT #:}10-47 u/1 CA .mg/d1
, z 3112AA4
pH.OPER #: fig. (4°6"-DR #: 000 14-97 u/1 CRE. 0.6-1.2 mg/d1
SERIAL #:
PCO2 11-38 u4 NA+.128-145 mmol/d1
P02.AL8}3.3}3.3-5.5}G/DL 0.2-1.6 mg/d1 K+ 3.3-4.7 nuno1/1
ALP}122*}26-84}U/L
TCO2 7-22 mg/di Cr. 98-108 nuno1/1
ALT}31}10-47}U/L
HCO3.ANY}152*}8.0-10.3 mg/d1 1CO2.18-33 nuno1/1
14-97}U/L
S02.AST}35}11-38}U/L 100-200 mg/d1
TBIL}0.8}0.2
1./DL
BEecf.6 MG 0.6-1.2 mg/d1 TEST RESULT REE RANGE
BUN}8}7-22}MG/DL
AnGap}73-118 mg/d1 ALB.
CA++}9.6}8.0-10.3 MG/DL 3.3-5.5 g/dI
Ca.CHOL}115}100-200}MG/DL 6.4-8.1 g/d1.. ALP. 26-84 u/1
BUN.CRE}0.8}0.6-1.2}MG/DL}' ''''''.! i- a1-4A644:441 ALT.10-47 nil
GLU}99}73-118 mG/Dt_ -}:...:4,11:,,,,
v.... z }-
GLU.RESULT REE AST. 14-97 u/1
TP}7.6}6.4-8.1}G/DL
RANGE
Creat.73-118 mg/d1 AMY. 11-38 u4
INST OC: OK}CHEM OC: OK
Hct.-EM 1 4 ,.LIP 0},}ICT 0 7-22 ing/d1 TBIL. 0.2-1.6 mg/d1
Hgb 0.6-1.2 nog/dl GGT. 5-65 u/I
' ., 39-380 /I (M) TP.
......44 30-190 /I (F)
.„ -- -. .,
TEST 128-145 nuno1/1 '' .4 ' (Piccolo) El .tii.
i ''}.,1r:it:-mk•L..._ '.../, , }:-}, ,,,
3.3-4.71=01/1”-TES RESULT REE RANGE
Tropoin-
Drug of 98-108 nanoUl NA' 1 ../.1211-145 mino1/1
Abuse tCO2 18-33 mrnoll1 K 33-4.7 minolA LL 0.
a-9}
98-108 mmo1/1
tCO2.
c.18-33 mmol
REMARKS:
REPORTED BYllp ( 6)1-6)1 DATE: LAB ID NO.:
MEDCOM -21050
DOD-034626
.I
LABORATORY RESULT FORM
REQUESTING PHYSICAN:
Ward/Section:
(Subject to the Privacy Act of 1974)
• .„ .-• ¦ ,
TIM.SSN/PEEU DO SSN:
LAST, FIRST,M1. DATE.
katitirtA.A. o 44
TEST REF RANGE
WBC RPR Negative
RBC Mono Negative
Hgb 14-18 g/dI(M) 12-16 g/d1(1') Negative tt, gy-6 6 10
Hct 42-52%(M) 37-47%(F) Negative Source
MCV 80-9411(M)81-99 ti(F) Negative Gram Stain
Plt 130-500 x 10' verified l„C)10 N/A Occ Bid Negative
Lymph °A 20.5-51.1% 5,,,,,631 I Negative II. pylori Negative
D N/A Micro
Parasites
Segs Malaria
Bands Eos O&P
Lymph Baso Other
Atyp Imm QE
RBC 5511.c-1 1 ‘Ned-Ve..c) Mec)ecc.
Morph kt,e.et as- 3 0 v„Prne. 60164,e- ?g.
Spun Hematocrit 42-52%(M) 37-47%(F)
Set Rate MUST suBmn SF 518 WITH EVERY UNIT REQUESTED
Other ABO/Rh
TYPE .CROSSMATCH
--TEST RE T REF RANGE .UNIT.
PT.ot.9.8-13.6 secs
APTT.T7 1 ei 21-34 SESS D d r 20 ug/ml FDP
10 '1g/rat
REMARKS:
REPORTED DATE: LAB ID NO.: Iv-LI-03 (,1.)110)
144.
_pe t:
MEDCOM - 21051
DOD-034627
0 0 -13 -9 r—
n) o.co a)
w
m
0
C)
.Z Z
CD
a. * 11 3CD
CTO0 p cc,
--s
Cn
co
z
r-
MEDCOM - 21052
DOD-034628
Name: NI
Specimen:
Patient ID:h(6)(6) -1
(IOW) Status: Final
Source:
Urine
Ward/Rm: W1/
Collected:Ward of Iso: Attd. Phys:
1
Escherichia coil
2 Status: Final
Pseudomonas aeruginosa Status: Final
1
E. coli
Drug MIC 2 P. aeruginosa
Interos
1:2'11 g
,
Amox/K Clay (c)
=8/4 S MIC Intems
Amp/Sulbactam (c)}AmoxjK Clay lc) 16/6
16/8 R
Ampicillin Amp/Sulbactam (c)
16 16/8
Aztreonam}R Ampicillin
=8 16
Cefazolin}16 S Aztreonam =8 S
Cefepime =8 I Cefazolin
16
Cefotaxime (c)}=8 S Cefepime =8
S S
Cefotetan}Cefotaxime (c)
=16 S 32 R
Cefoxitin Cefotetan
=8 32
Ceftazidime (a) S Cefoxitin
=8 16
Ceftriaxone (c)}S Ceftazidime (a)
=8 16
Cefuroxime (b)}S Ceftriaxone (c) R
=4 32
SI
Cephalothin Cefuroxime (b)
16 16
Chloramphenicol}=8 R Cephalothin 16
Ciprofloxacin}=1 S Chloramphenicol
16
ESBL-a Scm}=4 S Ciprofloxacin =1
ESBL-b Scrn}ESBL-a Scrn S
=1 4
Gatifloxacin ESBL-b Scm
=2 1
Gentamicin}=4 S Gentamicin 8
Imipenem (c)}=4 S Imipenem (c) R
=4
Levofloxacin}=2 S Levofloxacin S
=2
Meropenem (c)}S Meropenem (c) S
=4 =4
S S
Moxifloxacin Nitrofurantoin
=2 64
S
Nitrofurantoin Norfloxacin
=32 =4
Norfloxacin Pip/Tazo (d)
=4 64
Pip/Tazo (d)}=16 Piperacill in (a) R
64
S R
Piperacillin (a) Tetracycline ›8
64
Tetracycline}8 R Ticar/K Clay (a)
=16
Ticar/K Clay (a)}R Tobramycin S
64 8
Tobramycin}I Trimeth/Sulfa R
=4 2/38
S
Trimeth/Sulfa}2/38
R
s
. Susceptible
1 N/R
= Intermediate = Not Reported
R —
= Resistance = Not Tested Blank = Data not available, or drug not advisable or tested
MIC = mcg/ml (mgIL) TFG = Thymidlnedependent strain ESBL = Extended spectnim beta-lactamase
S
Slat = Beta-laclamase positive
Fr
= Resistant due to extended spectrum beta-lactamases (ESBL)
EEL? = Suspected ESBL Confirmatory tests needed to differentiate ESBL from other beta-laclamases.
IB = Inducible Beta-lactamase. Appears in
place of Sensitive with species known to possess inducible beta-lactamases; potentially they
Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.
may become resistant to all beta-lactam drugs.
For
blood and CSF Isolates, a bett•lactamase test is recommended for Enterococcus species.
(a)
Use maximum doses of drug
(b)
with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.
(c)
Breakpoints based on parenteral dose. For cefuroxime meld (PO) use (8=s, 8-16=1, 16=R). Footnote (c) applies to this drug.
For streptococci refer to penicillin Interpretations. For amoxicillin
(d)
.
K clavulanate or empicilrin/sulbectam with enterococcl, refer to the penicillin interpretation.
For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100,S12 Jan 2002. Sparfioxacin (for Gram Negative isolates) and moxifloxacin
For S. pneumoniae, cefotaxime and ceftriaxone breakpoints are based on isolates from pa are based on FDA approved breakpoints.
Name: -¦
• .. - rigltis. For non-meningitis infections, use 2=S, 2=1, 2=R.
Specimen .}(t
Patient ID : Cb)--,../
Ori 04(10) -} Status: Final
Source: Collected:
Ward W1/ Urine
Ward of iso:
Req. Phys: Printed 10/9/2003 9:44:06 AM Page 1 of 1
6 ,40a)-2
Tech: -
MEDCOM - 21053
( t)(6) -Z
DOD-034629
LABORATORY RESULT FORM
s_
(Subject to the Privacy Act of 1974)
Ward/Section- GP C)0.Lb)
/6
SSN/P.a SN:
• TIME.
DATE.
LAST, FIRST,MI. e
77;111 -;',1:410,1111,!„!tit
TEST RESULT REF RANGE
REF. RANGE
3kk• REE RANGE
NegativeRPR
N/A
4.8-10.8 xlb NegativeN/A Mono. 4.74.1 xln
yA4S1,.,
Negative
14-18 g/d100 ,54 of.A 12-16 g/d1(F) Negative Source
42-52%(M)
37-47%(f)
Gram
Negative
81-99 (1(F)
80-94 fi(M) Stain Negative
Occ Bld
130-500 x10 N/A
verified
H. pylori Negative
Negative
20.5-51.1% NIA Micro Parasites
Negative Malaria
O&P
0.2-1.0
Negative Other
v
V,443,
Negative 1
,.„
Negative S;11 If 2 ç.-3 we ttg
5-2 H 1; Li7f
0
MUST SUBMIT SF 518 WITI1 EVERY UNIT REQUESTED
ABO/Rh
CROSSMATCHTYPE .
UNIT
TEST RESULT REF RANGE .
PT. 9.8-13.6 secs
21-34 SESS
APTT.
20 ug/ml
D dimer.
10 ug/mlFDP.
REMARKS:
DATE:.I LAB ID NO.:
REPORTED BY:Am
092115 1111-11.
MEDCOM - 21054
DOD-034630
I SPECIMEN/LAB RPT. NO.(616D )
HEMATOLOGY UlyNCY PATIENT STATUS BED}. AMB
ROUTINE OUTPATIENT .
TODAY . NP.. DOM
. PRE-OP SPECIMEN SOURCE
VEIN
. CAP
STAID Et
OTHER (Specify)
Enter in above space.PATIENT IDENTIFICATION-TREATING FACILITY-WARD NO.-DATE I REQUESTING PHYSICIAN'S SIGNATURE
(REPORTED BY MD DATE
LAB. ID. NO.
TECH 615Cr10.
]5
REMARKS
if
iv
Z o
0 a g
O Q n0
O
zz -§-g
8 U g O
Z4 2 a 0
a }v 3 ae
0
I WBC DIET AND 8100D CELL MORPH 0 o
.....
0. Vde V U
Qt
.r 1111 • , •
NL
HEC 16.6 H x10-'3/ILL
RK
3.90 Y.10'6,iui_
Hgb
11.3 gldl.
Hct 35.3 Z
90.4 ft.
H 29.1}P9WIC 32.2 L gid1Pit 608.
H}x10'37tIL
LY7. 13.8 44_ X
Ln}
2.3 * x10'3/id..
. 06-10-0.3
03:55
Patient,
LiBitE.
4.5 10.5
1..X? 6.00
11.0 18.0
35.0 60.0
80.0 99.9
27.0 31.0
33.0 37.0
150. 450.
20.5 51.1
1.2 3.4
MEDCOM - 21055
(10110)-f 04-10-03 14D 19:37 Patient
• Limits la 15.4 H x10'3/m. RIC 3.99 L x10'6/u1 4.00 6.00
Hgb 11.3 g/dL 11.0 18.0
Hct 36.7 Z 7.0 60.0 ITV 91.9 ft 80.0 99.9 MB 28.3 pg 27.0 31.0 MK 30.7 L 33.0 37.0 Plt 549. H x10"3/111 150. 450. LYX 20.0 *I. X 20.5 51.1 LIP 3.1 * x10"3/(11. 1.2 3.4
RAP1OP}ANALYZER V4.54 SERIAL 1.0/07/03 05:06 6.6V 1,)•
Patient ID:.-v
a)10
Test Name
Test Result:= 11,4 sec.
***RESULT-OUT OF RANGE***
Ratio = 0.9
Calculated INR ='0.90
Sample Type:citrated wh. blood
Test Date :10/0/03
Test Time ;05:05
Card Lot.L4)66 ) -
Operator.C6) /k.)): 1-
RAPIDPO.
ANALYZER V4.54
SERIAL}10/07/03 05:09
H-Patientj0}-6%)/ y.}•
.!TestNaM Tr,}
Test Restilt:= 49.8 sec.
'.'***RESULT OUT OF RANGE***
Sample Type:citrated wh. ood
Test Data '00/07/03
Test Time :05:06
.Card LaJ.64/ 4)
4}
Werati.CW/A4)--i
.
77,0L0
10/06/03
REF ERLNCE
PATIENT #:
METLYTE 8
DISC LOT #:
OPER #:
SERIAL
OW 108 BUN 8 CRE 0.6
04:21
MALE
0.3141AA4
00
)"u
DR #: 000
73-118 MG/DL
7-22 MG/DL
0.6-1.2 MG/DL
CK.
30* 39-380 U/L
NA4
130 128-145 MMO&L Kih4,0
3.3-4.7 MMOL.L
CL-.
94* 98-108 MMOvL
tCO2 25
18-33 MMU/I_
RAPIDPOINT AG ANALYZER V4.54 SERIAL ORM10/06/03 09:20
Patient ID:.(,I)(6)-/
fest Name :PT
Test Result:= 13.1 sec.
***RESULT-NOT RANGE CHECKED***
Ratio = 1.1
Calculated INR = 1.12
Sample Type:citrated wh, blood
Test Date :10/06/03
Test Time :09:19
1.0,4119)'Y
Card Lot.
INST QC: OK.Operator.
CHEM OC: OK M/19) -7-
HEM 0 , LIP 0.
ICT 0
4-WIL) -Y
06-10-03
09:15 Patient Emit
15,8 H x10"3/uL 4.5 10.5 RK 3.87 L x10"6/aL 4.00 6.00 11gb 11.0 L ghil. 11.0 18.0 Hct 73.0 Z 35.0 60,0 IV 90.5 n 80.0 99.9 ra 28.4 pg 27.0 31.0 KM 31.4 1 g/d1. 3.3.0 37.0 Plt 615. H x10'31111 150. 450. LYl 15.5 k X 20.5 51.1 iffit 2.4 * x10"37u1 1.2 3.4
RAPIDPOINT}ANALYZER V4.54 SERIAL 10/06/03 09:24
16)- cf-
Loa.) iliTT
Patient ID.V
Test Nam.
Test Result:= 29.9 sec.
***RESULT NOT RANGE CHECKED***
Sample Type:citrated wh. blood
Test Date :10/06/03
Test Time :09:21
Card Lot 4
Operator Ltam„)-2.
_ -
(a4)-V 07-10-0,3 LIE 0506 Patient
Limits Ids 14,4 H x10'3/11L 4.5 10.5
3.87 L x10"6/11 4.00 6.00 Hgb 11.1) 11.0 18.0
gidi..
PA-A 35.4 1 35.0 60.0 IICV 91.4 A. 80.0 99.9
28.5 pg 27.0 31.0 Mt 31.2 L 33.0 37.0 Plt 600. H x10'3/uL 150. 450. LYX 16.9 k X ;.5 51.1 LYfi 2.4 * xW3/uL}1. 2 3.4
•, .
Yr •
MEDCOM - 21056
DOD-034632
RBC Hgb
RBC
Morph
Spun
Hematocrit
Set Rate
Other
RESULT
D dimer
REMARKS: REPORTED BY:
(
LABORATORY RESULT FORM
REQUESTING
(Subject to the Privacy Act of 1974) SSN/PEEUDO SSN:
) b ) -
4.7-6.1 x16 4.8-10.8 x10 Mono. Negative
Negative
42-52%(M) Negative
37-47%(1) Negative Gram Stain
20.5-51.1% 130-500 x 10' verified SG Bid Negative Occ Bid H. pylori Negative Negative
"•'•*';'"er, PH N/A Micro Parasites
Negative
0.2-1.0
Negative
Negative
Negative
42-52°A(M) 37-47%(F) MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
A:,•5,'
CROSSMATCH
REE RANGE
9.8-13.6 secs 21-34 SESS
10 ug /m1
DATE: LAB ID NO.:
46.
MEDCOM - 21057
DOD-034633
Ward/Section: REQUESTING PHYSICAN:
CHEMISTRY RESULT FORM
LAST, FIRST,MI.
$.4:445:---is '},, , ,,,, zrof
. 501104`,:vt,
garafte 14
w`t it.
TEST RESULT
Na
K
Cl
pH
PCO2
P02
TCO2
HCO3
SO2
BEecf
AnGap
Ca
BUN
GLU
Creat
Hct
Hgb
--..,
.21 t+-1/4 4 li,*::,,.
,.k',..KA. -: ,oNw.,.It..
TEST RESULT
Thpoin-1
Drug of
Abuse
REMARKS: REPORTED BY:
ect,..M...1V ,
REF. RANGE
138-146 nunol/dL
3.5-4.9 nunol/L
98-109 nunol/L
7.31-7.45
35-45 mmHg (art)41-51 mmHg (yen) 80-105 mmHg (art)
N/A (ven)
23-27 nunol/L (art)24-29 minol/L (ven) 22-26 Irani:JUL (art) 23-28 mmol/L (art)
95-98%
(-2) -(+3)
nunol/L 10-20 nunol/L 1.12-1.32 mmol/L 8-26 irw/d1
70-105 mg/dl
0.7-1.5 mg/di
38-51% PCV
124701
,,,P 4'.." '''
'""v''' lmi
'4-, 4v.".°}.
REF. RANGE
DATE.i TIME
tata"-Ikpitt. 6
rfc
v,,,,KP.,,, —}o' Itt
, „ },--..z-–}1 , %, Ar
4:',.*Wia.t.:Ses-,z, ."-p t', A v, ' 4,, ,t?',',.*~(.,,.
TEST RESULT REE RANGE
ALB 3.5-5.5 g/d1
26-84 u/1
ALP
ALT 10.47 u/1
AMY 14-97 u/1
AST 11-38 WI
TE
0}, .}.
_
.... piccol n.::-----...:
c 1 0/07/03 0,5 : 02 REF-ERE NU.
RANGE .
C.
PA T I ENT # : IIIII (wt 6 _MALL tat404400L
).y
C METLYTE 8 1;T
c opER tt au. ..
DISC LOT #: B
et,,) thyl 3141M4 DR #: 0O .P
SERIAL
# &0(0111111111111 LT ............ 7.77:77.7.
GLU
117
73-118
BUN
8 7-22 t.CRE 0.8 0 .G-1 .2
4
f
CK
24*
39-380
NA t.127*
128-145 K+ 4.2 3.3-4.7
CL-
93x-108
tCO2
24 18-33
ST
MG/DL - -
MG/DL
MG/DL .MY
wt._ BIL
MOM-;GT
MMOi/L MOW rP Mr1QM._
' •
INST QC: OK Cl_EN QC: OK !'EST
HEM 0
LIP 0
, ICT 0
NA+
K+
CL
tCO2
(Subject to the Privacy Act or 1974)
SSN/PEEUDO SSN:
.,..,.. ..,,:...
.4.......v
'''''. 4 , 9..P e . 'v ,},.,;,
.}:..rot.}-,-},..},M.:?-ssAW0--,,,,,,,, . t.4,,,I.,,, -v" —,
TEST RESULT 1 REE RANGE
GLU
BUN
CA++
CRE
NA
—
:02
RESULT
buys!,
lifiejrajW7A10RESULT REF. RANGE
128-145 mmo1/1
3.341 mmolti
98-108 mmol/1 18-33 mmol/1
73-118 mg/dl 7-22 mg/d1
8.0-10.3 mg/d1
0.6-1.2 Ing/d1
128-145 nmol/d1
3.347 mmo1/1
98-108 mtno1/1
18-33 mmo1/1
i''0 .' '
RE . RAN GE
3.3-5.5 g/d1
26-84 WI
10-47 u/1
14-97 till
11-38 u/I
0.2-1.6 mg/di
5-65 uA
6.4-8.I ell
„
MEDCOM 21058
-
DOD-034634
RAPIDPOINT COAG ANALYZER V4.
10/08/03 04:44 .
PICCOLO .
(6 .04:29
0g/10/03.Patient ID: 111111 (b) MALE
REFERENCE RANGE:.
Test Name :PT Test Result:. 12.6 see. ***RESULT OUT OF RANGE*** Ratio = 1.0 Calculated INR = 1.05 Sample Type:citrated wh. blood Test Date :10/08/03 Test Time :04:42 Card Lot 0.)/4 ) -4, Operator.00) 10-7.-RAPIDPO.' ANALYZER V4.54 SERIAL.10/08/03 04:47 Patient ID (6)/0 Test Nam.PTT Test Result:. 28.5 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh, blood Test Date :10/08/03 Test Time : ,, Card Lot.6.jlec,)-7 Operator.ao.)/i) -Z- 3•11111(b)/b)-r PATIENT #: r 049/6) -Y METLYTE 8 DISC LOT #: c ou,)/-. 3151AA4 OPER #: DR #: 000 SERIAL GLU.97 73-118 MG/DL BUN 11.
MG/DL CRE 0.9 0.6-1.2 MG/DL CK.26* 39-380.U/L NA+.13 8-145 MMOVL K+.4.2 3.3-4.7 MMOVL CL-.94* 98-108 MMOVL tCO2 26 18-33.MMOVL INST OC: OK.CHEM 01C: OK HEM 0 , LIP 0 1 ICT 0 66)02
. f V
RAPT ir? ROg Ai4ALY-Ir; V4,1,4 10409203 05:39
patient ID 'tat NaMe:,.„,„„, 1;,...aSt14ir.rn-712.1 sec. TiRESULT OUT OF RANGE*** Ratio = 1,0 Calculated INRA.Sample Type:citrated wh. blood 'Of: Test Date :10/09/03 Test Time ...05:37 '11. Card Lot.( 1402)-Y Operator.(h)L6./ - 2
1_491.0-y Goei) -2 VAPItt.ANALYZER V4.54t. • OERIAL 0,. 10/09/03 05:41 V-Ak.116)Y Oatient I.(.6)/19) --Test Nalil ,TT ‘•Tet Result:. 33.7 sec. Type:citrated wh. blood, Test Date :10/09/03 Test Time :05:39 Card Lot Operator 15C, 454,. .5 51.1 1.2 14
MEDCOM -21059
DOD-034635
7-22.
09)60 ) -1,
• REQUESTING PHY LABORATORY RESULT FORM
Ward/Section:
(Subject to the Privacy Act of 1974) SS.UDO SSN:
.LAST, FIRST,MI. 611111111 (&)/b)-1/
lig 4
TEST TEST RESULT REF RANGE TEST RESULT REF RANGE
WBC Color.N/A RPR Negative
RBC App. N/A Mono Negative
Hgb Hct 14-18 g/dI(M) 12-16 g/dI(F) 42-52%(M) 37-47%(F) Bili. Negative !Negative Source 1
MCV 80-94 fi(M)81-99 fi(F) Ket. Negative Gram Stain
Pit. 130-500 x10' verified SG. N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld. Negative H. pylori Negative
;." 141- pH Micro
Parasites
;$1 ,}. •}... ekt4I-1," •
Malaria
Sega Mono Bands Eos O& P Lymph.Baso Other
AstiagarWrai.
Atyp.Imm asw
RBC Morph
Spun 42-52%(M)Hematocrit 37-47%(F)
•
MUST SUBMIT SI? 518 WITH
Set Rate EVERY UNIT REQUESTED
ABO/Rh
Other
TYPE .CROSSMATCH
TEST RESULT REF RANGE .UNIT.
PT 9.8-13.6 secs APTT 21-34 SESS D dimer 20 ug/ml 10 ug /ml
FDP
REMARKS:
REPORTED BY: DATE: J LAB ID NO.:
MEDCOM 21060
-
DOD-034636
}
04)L(0) -1-
LABORATORY RESULT FORM
REQUES
Ward/Section: VivOifit ' (Subject to the Privacy Act of 1974)
1210:,),1 DATE SSN:
LAST, FERST,M1..
c
1,5. -,--a-}..0}..}a}:}44
7, POTSr' : }4, „,}.,,„ ,,,,,,.„,ek'} :f,
, ,k,4,-
qa,me,.1f,Ve's•".:,....4 ` -',.:0}-}I .,:-.,,, ge,}--.
.,:=, .4.w'
`4"zet',:e4 .Ae '
TEST .RESULT .REF. RANGE TEST .RESULT
WBC. 4.8-10.8 xlil Color App
RBC. 4.7-6.1 xl Hgb.
1111ERMilia
Hct. MCV.
Pit.
42-52%(M) 37-47/e(F) Bill
80-94 fi(M)81-9911(1) Ket
130-500x10 3 verified SG
Bill
Lymph %.20.5-51.1% .
4.,11 1 1 ?4,}7 }IMF. I 1
*„,4 ' 9 .a. ,5; .-1:1
Segs Mono
Bands Eos
Lymph Baso
Atyp.Imm
RBC Morph -Spun 42-52%(M)
Hematocrit 37-47%(F) Set Rate
Other
40(W r97..}7,91
. .-.,:`},.4".,.4..‹ ,
,,,.1.',: v,,40
KR.,pre' sa, '.'.,:. ..,
K. e..-As..,s.-., i-.
TEST .RESULT .REP: RANGE
PT. APTT.
D dime r.
FDP.
REMARKS:
REPORTED BY:
9.8-13.6 secs 21-34 SSSS 20 ug/ml 10 ug /ml
pit
Prot
Urob
Nit
Lenk
HCG
,,,e
1.1-.
"'
Cell
Count
Diredigeo
-**w ,,, '''' B
v, c}.}.,..,. I.'.,,.1.'
-...
4 tvw: g ti , .}-1..,, ,1
a 4,..
7..
,,,.'04'4.
, . „.,.....''f.,
UNIT
(.6)(10) -9
Pt!-RD
4' :},40--}-`-'},
,
REF. RANGE
N/A N/A Negative
Negative
Negative N/A Negative N/A
Negative
0.2-1.0
Negative
Negative
Negative
,L.-..---.--k.a
Negative
, ..
DATE: LAB ID NO.:
.e a ...4 a,}' d'}'w
,.,:.,
• z.t.t"
TEST .RESULT .REF. RANGE
RPR. Negative
Mono Negative ,,:v.,- - ' , 6 6 z44.. -,..1i.'., ..'tkz..giAa....-s.,......:.?:.,. Source
Gram Stain Occ Bld. Negative
H. pylori. Negative
Micro Parasites
Malaria
0 & P
Other .
ta.Or 6itl. nfgri,
, ,
4 :s. .‘',, ..,,a- a.•C*}•}, MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
ABO/Rh
,}— —}zig,
• !!?!.rt. ...7,4., se ._
,},}te ,., }f/ ,,.Z. &g
r;
rg,..
'4.
..c.4
CROSSMATCHTYPE.
MEDCOM - 21061
DOD-034637
Ward/Section: REQUESTING PHYSICAN:
CHEMISTRY RESULT FORM (b)(10)-11 (Subject to the Privacy Act of 1974) DATE TIME SSN/PEEUDO SSN:
LAST, FIRST,MI.
'. *Rig a ' 7.,41,-Wik',.e,0% ii! (11, .. Vheput '}'" ''' "VA' ' e4}
,.,. ..N, ,}4 k ..0,' imi ‘-''' 1 ,, to ..}•1,,,
}-}a, 40ki.:;:,
Nth ., ..:... ',.' lthVg ,:-001.0'}ab§10.41i ta.01
TEST RESULT REF: RANGE TEST RESULT REF TEST RESULT REF RANGE
RANGE
Na 138-146 mmoUdL ALB 3.5-5.5 g/dI 73-118 mg/dl
GLU
K 3.5-4.9 rrimon ALP 26-84 u/1 7-22 mg/dl
BUN
98-109 mmol/L Al . 8.0-10.3 mg/d1
CI A++
pH 7.31-7.45 Al. 0.6-1.2 mg/dl
RE
- - - - - - -.PICCOLO -----—
PCO2 35-45 mmHg (art) A.. 128-145 tomoUtil
4+
41-51 mmHg (yen) 09/10/03}05 : OJ
P02 80-105 outing (art) TI REFERENCE RANGE :}MALI:}+ 33-4.7 itimo1/1N/A (yen)
PAT I ENT # : all 00)00) - -/
27 o(a
TCO2 )B1 98-108 =non
21-29 inml/Len)
mtnoifL (yrtMET L.Y TE 13 HCO3 22-26 trunoUL (art) C DISC LO1 # : 1,004-1-3151 AA• }D2 18-33 immol/1
23-28 mmol/L (art) opER #h:insL
DR #: 000
+-.
SO2 95-98% a} '4 ' . 71#1ffireitr • ?.}
1 •I•e,',
_RI AL grin} : • ,,..4.0-:: ,,..:-!,::-.10.p....
A.:h• • .., .., . -
BEecf (-2) - (+3) RESULT REF RANGE
CI .(W( b) -- aj 'ST
mmol/L AnGap .. 10-20 nimoUL G GLU}107 73-118}M(.3/ DI_}[3 3.3-5.5 01
Ca 1.12-1.32 mmol/L T1 BUN}10}7-22}MG:11.}?' 26-84 till
CRE}1.3*}0.6-1.2}MG/PA.}r
^^e
f"-1
8-26 mg/d1.
BUN
10-47 u/I
r
CX}20* . d9-380 U/L
T
70-105 mg/d1
14-97 u/I
GLU
2 NA +}1-20* 'el 28-145}NOM_}
K+}4.1}3.3-4.7}NNOM_ Creat 0.7-1.5 mg/d1 G] CL }92*}98-108}MMOR_}IY 11-38 u/I Hct 38-51% PCV BI tCO2 2.5 18-33}MMOfit}IL 0.2-1.6 mg/d1
Hgb 1 12-17 g/dl CI irrrar,!*4 i. -,., .."...W 0,M.-41.:04114,, INS/. oc. OK}CF-EM oc . HEM 0 ,}LIP 0 ,}I CT 0 0,6„..[T 5-65 u/I 6.4-8.1 Oil
TEST RESULT REF. RANGE N) "I ,, ' 0 ,..„,}.:,.......,............,,,.„5„....„,,,,,or,,-,-
Tropoin1 IC ST RESULT REF. RANGE
Drug of Abuse CI f 128-145 truno1/1
to 3.3-4.7 tnmoI/1
• 98-108 nuno1/1
'2 18-33 mmol/1
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
MEDCOM -21062
DOD-034638
I
LABORATORY RESULT FORM
REQUESTING PHYSICAN:
(Subject to the Privacy Act of 1974)
DATE.TIME
LAST, FIRST,MI
1) 0}3 ,SI D
TEST REF RANGETEST REF RANGE TEST RESULT
RPR Negative
4.8-10.8 x16 Color Negative
App
RBC 4.7-6.1 x16
Negative
Htb
42-52%(M) Negative Source
37-47%(F)
80-94 0(M) Negative
81-99 fi(F)
PICCOLO .
130-500 x10'
05:50
ver 10/10/03.
Negative
Lymph Vo 20.5-51.1% REFERENCE RANGE:.MALE PATIENT #: Ill/ 041,0-y METLYTE 8 Negative DISC LOT #:.3151AA4 OPER #.#: 000 -
Urob
Bands SERIAL
601
Negative
Lymph Nit.
GLU 102 73-118 MG/DL
Negative
BUN 5* 7-22 MG/DL E
-
Negative CRE 0.9 0.61.2 MG/DL
RBC CK 16* 39-380 U/L
Morph NA+ 130 . 128145 MMOVL
--MMOt'L
K4 4.5 3.3-4.7
Spun CL-95* 98-108 MMOVL fi
Hematocrit
tCO2 26 18-33 VMOVL
Cell
Set Rate
Count
CHEM OC: OK -Directigen Negative HEM 2+, LIP 0 , ICT 0
INST OC: OK.
t2
3, 3
• l tr.;‘
REF RANGE
9.8-13.6 secs
21-34 SESS
20 ug/ml
D dimer
10 ug /m1
FDP
REMARKS:
DATE: LAB ID NO.:
REPORTED BY:
MEDCOM -21063
DOD-034639
Ward/Section• REQUESTING PHYSICAN: CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
i&R)I __
DATE TIME SSN/ • EEUD •
LAST, FIRST,
Lto )07) -Y /00, , osip (10)“)-/
a:}
wok
7 .e . .; ,
Noe; --4:. 5%04 ,}, -nora ,}- ,},,,,,,,-TA,.k
.4w., ,, e. „,, },„,, ,,,,,,,A,,,,,,,
: y*}ic+.1,,,,* IA, .44.„,4sols:
,., wiaI ?,' A -4 ,,,,,,
TEST
Na
K
pH PCO2 P02 TCO2 HCO3 SO2 ' BEecf
'AnGap
,:.
Ca
BUN
GLU
Creat
Hct
Hgb
w4.1.". ...p....,,,, CK
, , i
Pr }
TEST RESULT REF RANGE NA+
K+
Tropoin-I
Drug of Cc
Abuse
tCO2
•
REMARKS:
..
REPORTED BY: DATE:
RESULT REF RANGE TEST RESULT
138-146 nunol/dL ALB 3.5-4.9 nunol/L ALP 98-109 mmoUL ALT
7.31-7.45
AMY
35-45 mmHg (art) AST
41-51 mmHg (yen) 80-105 mmHg (art) TBIL N/A (yen)
23-27 mmol/L (art)
BUN
24-29 mmol/L (ven)
22-26 mmol/L (art)
CA++
23-28 mmol/L (art) 95-98% CHOL
CRE
(-2) -(L)
nuno 10-20 mmol/L GLU 1.12-1.32 mmol/L TP 8-26 stg/d1 lagi: L : 70-105 mg/dl TEST RESULT
0.7-1.5 mg/d1
GLU 38-51% PCV
BUN 12-17 g/d1 CRE
.h
REF
RANGE
3.5-5.5 g/d1
26-84"n
10-47 u/I 14-97 u/1 11-38 u/I
0.2-1.6 mg/dl 7-22 mg/di 8.0-10.3 mg/di
100-200 mg/d1 0.6-1.2 mg/d1 73-118 mg/dl 6.4-8.1 g/di
,
REF.
RANGE
73-118 mg/dl
7-22 mg/dl 0.6-1.2 mg/dl
39-380 /I (M)
30-190 /I (F)
128-1asinmo
3.3-4.7 mmol/1 98-108 mmol/1 18-33 mmol/1
LAB ID NO.:
,,
TEST RESULT REF RANGE
73-118 mg/dl
GLU
7-22 mg/dl
BUN 8.0-10.3 mg/dl
CA++
0.61.2 mg/d1
CRE
128-145 nunol/d1
NA+
K+ 3.3-4.7 mmol/1
CL 98-108 mmol/1 . 18-33 mmol/1
tCO2
..,,,, . 1*
TEST RESULT REF RANGE
ALB 3.3-5.5 Oil
ALP ~ 26-84 u/1
ALT 10-47 u/I
—
AST 14-97 un
AMY 11-38 u/1 TBIL 0.2-1.6 mg/d1 GGT 5-65 u/I
TP I.6.4-8.1 g/dl
i:,... ttorstarcapi
4z
le}4 g
RESREE RANGETEST RESULTULT
NA+ 128-145 mmolli K+ 3.3-4.7 mmol/J
CI: 98-108 mmol/1
tCO2 18-33 mmol/1
MEDCOM -21064
DOD-034640
APIDP
HANALYZER V4.54
04ERIAL.
'10/10/03 05:55
ao(b)-((
ipaient ID: IIIII (1,)14) -Test Name—71 Test Result:= 11.8 sec. '= ***RESULT OUT OF RANGE*** atio = 1.0 ['Calculated INR = 0.95 Type:citrated wh. blood Vest Date :10/10/03 -" est Time :05:53 Mrd Lot.(WW-Y , Operator
COAG _IAA=
y -
-
'Al4T'
e-1.17.38.2 sec.
trated wh. blood
seR-
ef:11 Y4:'cl
;10/ 10/03
ro
e 555. f54;f5-4
, ----- PICCOLO 11/10103 05:22 REFERENCE RAAV MALE PATIENT II:hOOLW4
METLYTE 8 DISC LOT #: L, )•z 3151AA4 OPER #:41111P DR #:. 000 SERIAL #:h1111111111.
NC9-/
GLU 104 73-118 MG/DL BUN 5* 7-22 MG/DL CRE 0.8 0.6-1.2 MG/DL CK 24* 39-380 U/L NA+ 132 128-145 MM0f/L K+ 4.0 3.3-4.7 MMOVL CL-99 38.108 MMOVL tCO2 25 18-33 MMOF/L
INST-OC: OK CHEM oC: OK HEM 0 , LIP 1+, ICT 0
r,)
RAPIDPO NT CO ANALYZER V4.54
SERIAL..
10/11/03 05:25
Patient TOME tf,) 01
Test Namr"..15T
Test Result:= 11.1 sec.
***RESULT OUT OF RANGE***
Ratio = 1.0
Calculated INR = 0.93
Sample Type:citrated wh. blood
Test Date :10/11/03 •
Test Time :05:2
Ll.)/6)"'i
Card Lot Operator L10)/6) •
RANDP#Iii ANALYZER V4.54 1 SERIAL 10/11/03 05:28
cb)-1,
Patient ID_ (.10.19)-Lt
Test Na : PTT
Test Result:= 32.8 sec.
Sample Type:citrated wh. blood
Test Date :10/11/03
Test Time .
-
Card Lot Lb)}Operator (0/0 -Z
411111
101.0-
•..;;;;;: 3. &3 L
'6;7•;: 10.1 L
?0. 3
27;1:
Z05 33.0 7%0
4,711 ,ta-.
25.0
0;-:. •
MEDCOM - 21065
REQUESTING PHYSICAN: LABORATORY RESULT FORM
Ward/Section:
(Subject to the Privacy Act of 1974)
TEST
WBC 4.8-10.8 xld
RBC 4.7-6.1 x16
Hgb 14-18 011(M)12-16 gidl(F) s"riv,
Hct 42-52%(M) 37-47%(F) Source
MCV 80-94 fi(M) 81-99 fi(F)
Pit 130-500 x10' verified
Lymph Vo 20.5-51.1%
. t4
Segs Mono
Bands
Lymph
Atyp
440::
•
~.4.44
,
Cell MUST SUBMIT SF 518 WITH
Set Rate
Count
EVERY UNIT REQUESTED
Directigen
Other
TEST RESULT REF RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APTT 21-34 SESS
D dimer 20 ug/ml
FDP 10 ug /ml
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 21066
DOD-034642
Ward/Section: REQUESTING PHYSI CAN: CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)
IA.)
( (2
DATE TIME SSN/PEEUD SN:
LAST, FIRST,MI
coo,)-y tfoq-03 roeig5 (14(6)-V " tiv( -STAT) '.°. lifagt"OVSida'I ffilit ' ntaft pogp(Pti'.coloTNlitabollc P
.55*..t ,p,_:.:,,,,:::', ,-,
• , ? . ,k , lc ,1,` ...., ,,,,, ", ''''‘ ;,..75.t-gl,,,,o,,,,,,td, toN51*--,4:0,41:trmit--0:Som: 4,0#tio -:.."
TEST REE RANGE
TEST RESULT REE RANGE TEST RESULT REF RESULT
RANGE
3.5-5.5 g/d1 73-118 Ing/d1138-146 mmoUdL ALB
Na GLU
K 3.5-4.9 nunol/L my 26-84 u/I BUN 7-22 mg/d1
mg/dI
98-109 nunol/L ALT 10-47 u/1 CA
CI
0.6-1.2 mg/d1
pH 7.31-7.45 AMY 14-97 u/I CRE 128-145 nunol/dI
PCO2 3545 nunllg (art) AST 11-38 u11 NA+
41-51 mmHg (ven)
P02 80-105 nunlIg (art) TBIL 0.2-1.6 mg/dI K+ 3.3-4.7 nuno1/1
N/A (yen)
23-27 mmo1/L (art) BUN 7-22 mg/dl CL 98-108 mmol/1
TC 02
24-29 menol/L (ven)
22-26 mind& (art) 8.0-10.3 mg/111
18-33 nuno1/1
HCO3 CA++ tCO2
23-28 mnsol/L (art) , SO2 95-98% CHOL 100-200 mWdl 47:040:1C'itAtigiaa: 4$1.5c
-
. BEecf (-2) - (+3) CRE 0.6-1.2 mg/du TEST RESULT REE RANGE'
?ninon
AnGap 10-20 mmol/L GLU 73-118 mg/Ell ALB 3.35.5 g/dI
Ca 1.12-1.32 nunol/L TP 6.4-8.1 g/d1 ALP 26-84 u/I
BUN 8-26 mg/dI 1.„"vii, ALT 10-47 u/I
y*.itie...
GLU 70-105 mg/dl TEST RESULT REE AST 14-97 u/I
RANGE
73-118 mg/d1 AMY 11 38 ul
Creat 0.7-1.5 mg/d1
GLU 3851% PCV 7-22 mg/d1 TBIL 0.2-1.6 mg/d1
Het BUN
0.6-1.2 an/d1 GGT 5-650
Hgb 12-17 g/d1 CRE
39-330 /1(m) TP 6.4-8.1 g/d1
23l_eallm.112-CK 30-190 /I (F)
"—a.iWir ''''- itIt.laMSrelOVSe;#" ,_____, TEST. RESULT REF RANGE NA+ 128-145 nuno1/1 NM :,.. ' iatiT $14a.ifilo,l,
;;;•,.:,•..,,,v,i A. .,..; .... ,..1;1,45?-A ,25":d. . , 1...-ixm.:' '-:
3.3-4.7 mmot/i TEST RESULT REF RANGE
Tropoin-1 Ki-
. Drug of CI: 98-108 mmolA NA+ 128-145 nunoIll Abuse tCO2 18-33 nuno1/1 K+ 3.3-47 mmoUl
_
CL 98-108 mmoUl
I
tCO2 18-33 nunoUl
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 21067
DOD-034643
4.8-10.8 xlo
4.7-6.1 x16
14-18 ORM)
12-16 011(F)
42-52%(M)
37-47%(F)
80-9411(M)
81-991i(F) 130-500 x10'
verified
20.5-51.1%
LABORATORY RESULT FORM
(Subject to the Privacy Act of 1974)
.....,.*:,A.'".4,...:
) ;
44.4°:
Mono
W41.14417 14
*2,05:46;4,,
MEDCOM - 21068
DOD-034644
RAPIOPOINT COAG ANALYZER V4.54 SERIAL 10/12/03 03:43
(OW
Patient ID:401. ("("--Test Name :PT Test Result:. 12.3 sec. ***RESULT OUT OF RANGE*** Ratio = 1.0
Calculated INR = 1.01
Sample Type:citrated wh. blood
Test Date :10/12/03
Test Time : 3.41
Card Lot.b) (6) -X
Operator LOGO -2
RAPIDPOlaalii ANALYZER V4.54 SERIAL 10/12/03 03:45 (.6X6)
Patient Ili 6W/t,) --7 Test Name : PTI Test Result:= 35.1 sec. Sample Type:citrated wh. blooci Test Date :10/12/03 Test Time:, :03:43
Card tot e),..)co -
-
Operdtbf
PICCOLO
13/10/03
I lt. F f kt .141. RANGE :
PATIENT #
4-1LYIE 8
Di sc LOT #:.
3151,v,4
OPER # .4/..DR # : 000
SERIAL #:
lk)
GLU 134* 73-118 ruirl BUN 9 7-22 MG/OL CRC 0.9.
0.6-1.2 M6/DI
CK. 20* 39-380
NA-1 VRIPP6128-145 MMOi/L
3.9 3.3-4.7 MMOLL
CL-96* 98-108 MMOLC
- - - - - - PICCOLO --.
12/10/03.03:38
REFERENCE RANGE : , MALE
PATIENT #:.totiky
ME TLY TE 8
DISC LOT #: 04/,6) 3151AA4
OPER #11,.
DR #: 000
SERIAL
GLU 106 73-118 MG/DL
BUN.MG/DI _
6* 7-22.
CRE.0 .6-1 .2 MG/DL
0.7.:Z•K 174
CK.U/L
22* 39-380.NA + WO*13E1 28-1 95 Mkt K+.
4.2 3 .3-4 .7 MMOM_
CL-.P,M
93* 98-108 MMOM _
tCO2 25 MOM_
18-33.
7 !;.51.1
INST GC: OK.
CHEM GC: OK
HEM 0 , LIP 0.
ICT 0
Rk.1! . 11 0,111 LOAGANALYZER V4.54
SEPIA:. am 10/13/03 03:54
ca)Lio -y
Patient ID:11111 (49(e) -Test Name :PT Test Result:. 13.4 sec. Ratio = 1.1 Calculated INR = 1.16 Sample Type:citrated wh. blood Test Date :10/13/03 Test Time :03:53 Card Lot (W/b) -Operator 00)1 b) _ z
RAPIDPOINT COAG ANALYZER V4.54 SERIMAIN 10/13/03 03:57
(0/g.
Patient ID :ea (-1') 11,) Test Name :APTT Test Result:= 33.5 sec. Sample Type:citrated wh. blood Test Date :10/13/03 Test Time •03:54
Card Lot 4 04 Lb) Y Operator-
ewo- z-
tCO2 25 18-33.
MOM_
INST GC: OK.
CHEM GC: OK
HEM 0.
LIP 1+, ICT 0
-
MEDCOM 21069
DOD-034645
Ward/Section: REQUESTING PHYS CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
ICLAJI
SSN/PELAST, FIRST,MI.
6010-11
. • •
Wetagred
RESULT REF. RANGE
TEST RESULT REF RANGE TEST
138-146 mmol/dL ALB 3.5-5.5 g/dI 73-118 mg/dl
Na GLU
K 3.5-4.9 inmol/L ALP 26-84 u/I 7-22 mg/d1
BUN CI 98-109 mmol/L ALT 10-47 u/I CA ++ 8.0-10.3 mg/ill
pH 7.31-7.45 AMY 14-97 u/I CRE 0.6-1.2 mg/ill
35-45 mmHg (art) AST 11-38 u/I 128-145 nunol/dI
PCO2 NA
41-51 nunlig (ven) P02 80-105 mmHg (art) TBIL 0.2-1.6 ing/dI K 3.3-4.7 mmoVI N/A (ven) 23-27 nation (art) BUN 7-22 mg/d1 98-108 mmol/1
TCO2 CL
24-29 mmol/L (ven)
22-26 mmo1/1. (art) 8.0-10.3 mg/ell 18-33 inmolll
HCO3 CA+
23-28 mmol/L (art)
SO2 95-98% CHOL 100-200 mg/d1
mitt-BEecf (-2) - (+3) CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE
mmol/L AnGap 10-20 mmol/L GLU 73-118 mg/di ALB 3.3-5.5 g/dI
Ca 1.12-1.32 mmol/L ALP 26-84 u/I
BUN 8-26 mg/di ALT 10-47 u/I
70-105 mg/dl AST 14-97 u/I
GLU
0.7-1.5 mg/ell 73-118 mg/di AMY 11-38 till
Creat GLU
Hct 38-51 % PCY 7-22 mg/ill TBIL 0.2-1.6 mg/ill
BUN
0.6-1.2 mg/dI
Hgb 12-17 011 CRE GGT 5-65 till
39-380/I (M) 6.4-8.1 g/dI
CK TP
he
.
30-190 /I (F)
TEST' RESULT fREE RANGE NA+ 128-145 mmoUl (Phcok)
Al ^4r
3.3-4.7 mmol/I TEST RESULT REF RANGE
Tropoin.:1
Drug of CL 98-108 mmol/1 NA+ 128-145 mmol/I Abuse
1CO2 18-33 moon K 3.3-4.7 mmo[/1
CL 98-108 mmol/1
tCO2 18-33 mmol/I
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 21070
DOD-034646
REQUESTING PHYSICAN: CHEMISTRY RESULT FORM
Ward/Section:
(Subject to the Privacy Act of 1974)
nag
akz
TEST
ALB
ALP
ALT
AMY
AST
TB1L
BUN
+ +
CA
CHOL
CRE
GLU
TP
NA+
K
CL
1CO2
DATE:
SSN/PEEUDO SSN:
DATE TIME
4 40.440 ItX
'4AN
RESULT TEST RESULT REF. RANGE
REF.
RANGE
73-118 mg/di3.5-5.5 g/dl
GLU 26-84 u/1 7-22 mg/dl
BUN 8.0-10.3 mg/dl
10-47 u/I CA ++ 0.6-1.2 mg/di
14-97 u/I CRE 128-145 mmol/d1
11-38 u/I NA 3.3-4.7 mmot/1
0.2-1.6 mg/411 K 7-22 mg/d1 CL 98-108 mmo1/1 18-33 mmol/I
8.0-10.3 mg/d1 tCO2
100-200 mg/dl WM'
t?4,V3r,r.4. N,
RESULT REF RANGE
0.6-1.2 mg/d1 TEST 73-118 mg/dl ALB 3.3-5.5 g/d1 26-84 u/1
6.4-8.1 g/d1 ALP ALT 10-47 u/I
mw"-....,044411:46"1
14-97 u/I
11-38 u/1 0.2-1.6 mg/d1 5-65 u/1
6.4-8.1 01 128-145 mmo1/1 1 :OA 3.3-4.7 mmo1/1 TEST RESULT REF. RANGE
98-108 mmol/1 NA+ 128-145 mmo1/1
18-33 nirno1/1 3,3-4.7 mmo1/1
98-108 mmoUl
tCO2 18-33 mmo1/1
LAB ID NO.:
LAST, FIRST,M1.
TEST RESULT REF: RANGE
Na
K
pH PCO2 PO2'
TCG2
HCO3 SO2 BEecf AnGap Ca BUN
GLU
Creat
Hct
b
TEST RESULT
Tropoin-1
Drug of
Abuse
REMARKS:
REPORTED BY:
138-146 nnol/dL
3.5-4.9 nunol/L
98-109 nunol/L
7.31-7.45
35-45 mmHg (art)
41-51 mmHg (ven)
80-105 mmHg (art)
N/A (yen)
23-27 nunol/L (art)
24-29 mmol/L (ven)
22-26 nunol/L (art)
23-28 mmol/L (art)
95-98%
(-2) - (+3)
mmol/L
10-20 nunol/L
1.12-1.32 mmol/L
8-26 mg/d1
REF. RANGE
MEDCOM - 21071
DOD-034647
Z
LABORATORY RESULT FORM
(Subject to the Privacy Act of 1974)
.anTow.,7177
Niivagkdi
MEDCOM - 21072
DOD-034648
CW L b 1
LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
IISection• T, FIRST,M1 •
MEDCOM - 21073
DOD-034649
CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)
MEDCOM - 21074
DOD-034650
LABORATORY RESULT FORM
(Subject to the Privacy Act of 1914)
tiSection: ( 7, FIRST,MI•
MEDCOM - 21075
DOD-034651
• iDPOINT COAG ANALYZER V4.54
10/14/03 05:58
-= : PICCOLO ==== /0/0"
PICCOLO .
.
05:16 iti ent ID:41//a
14/10703.05:56 15/ 1 0/03. Od6)'
lest Name :PT
REFERENCE RANGE:.REI- ERE NEL RANGE : MN
MALE
Test Result:- 13.8 sec.
PATIENT #:.PATIENT #: 1110 0409) ' y
(19/1) - y
Ratio = 1.1
METLYTE 8 METLYTE 8
Calculated INR = 1.22
3152A NI
DISC LOT 14: 3151AA4 DISC LOT #:.
Sample Type:citrated wh. blood
DR #:
OPER #11111rul DR It: 000 OPER # .Test Date :10/14/03
SERIAL :.41111/111111111, SERIAL. #: Test Time :05:56
(4.)teo
.(b.0) -Y Card Lot 211(11;)1 (0) GLU 107 73-118 MG/DL GLU 95 73-118 MG/O1" Operator./00-1
.
MG/D1.
BUN.7-22 MG/DL BUN 7 7-22
7
1.1 MG/DL 0.6-1.2 Mt3/01.
CRE.0.6-1.2 CRE 0.9
.
39-380 OIL RAPIDPOINUlaANALYZER V4.54
CK.19* 39-380 U/L CK 28*
.MIANt-SERIAL 10/14/03 06:02
MOW 128-145
NA+ 129 128-145 NA+ 130
/ 1 )16)-y
.MOM.
4.1 MPKN/L 3.3-4.7
K+.3.3-4.7 4.4
K+ C4)(b)-y
Patient I.
.
98-108 MMOot
CL-.98-108 MMOUL CL-
96* 96*
Test Name :APTT
MMOR.
18-33
tCO2 23 18-33 MOW_ • tCO2 21
Test Result:= 37.5 sec.
Sample_Type:citrated wh. blood
CIEMOCOK
1NST GC: OK.CHEM OC: OK INST OC: UK.Test Date :10/14/03
HEM 0.HEM 0 , LIP 1+, 1CT 0 tgigi
LIP 1+, ICT 0 Test Time
Card Lot WWI (1)47;9-,
Operator -411111111 (0)-7
•
RAPIDIETIPT COA NALYZER
0/15/03::
..
/6)tb) -.•
Patient., ID OW L04.4)
Test Name • :PT • :,.
Test Result:= 12.4 sec:
***RESULT OUT OF RANGE**0-
Ratio = 1.0 --
Caculated INR = 1.03
Sample Type:citrated wh. blood
(WIN -
Test Date :10/15/03 (b)/6
Test Time nal
15-10-03
Card Lot 0502
Operator -2 • PAW
Wits
MC BA 1101/11. 4.515
FIC 3.511 210.1d. 4.00 6.0
1 RAPIDPOILWitiANALYZER V4.54
10.0 L gML 11.DI.0
SERIId.10/15/03 05:36
Ikt 31.6 I. 2 35.0 4/40
Gam) -y 010 91.9
Patient ID 4IIIPI 6944.,) -28.5 pg M0 31.0
ME31.7Lut ILO 37.0
Test Name :APTT
Pit 242. 110134 1581 450.
Test Result:= 36.3 sec.
VI 29.3 I MS 51.1
Sample Type:citrated wh blood
1.911 2.4 110!'3/11. 1.2 3.4
Test Date :10/15/03
Test Time :05:33
Card Lot c016)- y
Operator.
(4)/b) -
MEDCOM 21076
-
DOD-034652
CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)
MEDCOM - 21077
DOD-034653
SPECIM(N/LAB RPT NO.
4•1
HEMATOLOGY 0 URG CY
PATIENT STATUS.nal
0 AMB OUTINE rd0 BED
OUTPATIENT 0
TODAY 0 DNP P DOM ill
IE n
SPECIMEN SOURCE
PRE-OP 0 VEIN D CAP STAT
¦••
0 OTHER (Specify).¦C
e.
NO.-DATE
PATIENT IDENTIFICATION-TREATING FACILITY-WARE)
LAB. ID. NO.
Enter in oboe space MD
REPORTED BY
REQUESTING PHYSICIAN'S SIGNATURE
TECH
0
REMARKS
4. 5
°.
4 E
--ae 0
0 ni 3
0 LI 0 ¦-•
z LI WBC DIFF AND BLOOD CELL MORPH L). LI 411
2
161 ) 1U1'11 N._.. !.;[ k Ai 1 ¦.1/16/1.6.04:!31
(4)W-9
112)11,) -y
In. 16-1003 Patieut 1U
04:47 fe M. NàIIIt Patient 11.6 sec.
lest Rewit:.
Liiits
144,RESLO Y U01 Of RANGE4*A
VIC 10.3.
x101/oL '4.5 10.5,
1.0
Ratio.
PBC 3.67 L :10"6/01 4.00 6.00
HO 10.4 L g/dL.Calcuiated 1NR - 6.92
11.0 18.0
Hct 32.9 L Z35.0 6060 Sdmple lype:uitrated wit bluod KV 89.6 n..59.9 lest Date :10/16/03
NCH 28.5 pg.
V.031.0
Test Time :04:49
N:HC 31.8 L g/&.
33.0 37.0
Card Lot
Pit M..
x101/11L 150. 450.
LYZ 19.1 *L Z.Opelator
20.5 51.1
LI 2.0 * x10A3/1d..
1.2 3.4
IAI' IIIF'Ol NIJjà ANALVER V4.b4
.
SiR1Al 10/16/03 04:55
)7 7)T q
ao.)a) -
Pelen1 1D:0
Test Name .API1
lest Result:. 18.3
*t4RLSOLT Oil! OF kANGE344
Sample Type:L:11rated wh. blood
lest Uate :10/16/03
Lest Time :04:
Card lot
jperator
MEDCOM - 21078
SPECIMEN/LAB RPT. NO
MISC
URGENCY PATIENT STATUS DUD . AMB
calROUT
OUTPATIENT . TODAY 0
. NP .DOM 8
. PRE-OP SPECIMEN SOURCE
(Specify)
STAT .
Enter in above spate
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE a. REQUESTING PHYSICIAN'S SIGNATURE
REPORTED BY MD DATE
LAB ID NO.
TECH REMARKS_
T.T_ 0
4r1
O t7i
U
MEDCOM - 21079
SPECIMEN/LAB. RPT. NO.
CHEM I
URGENCY PATIENT STATUS
g
. BED . AMB U
\CuO
V2/10-UTINE OUTPATIENT .
TODAY . el
. DOM ILI
. NP
. PRE-OP
SPECIMEN SOURCE STAT .
. BLOOD OTHER (Specify)
.
Enter in above space_ PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE DATE LAB. ID. NO.
REQUESTING PHYSICIAN'S SIGNATURE REPORTED BY_ MD
TECH REMARKS
uS
a
CA-M
CHOLESTEROL
TRIGLYCERIDES
4
Cg.
9
O
z
REQUESTED
LI(
O
55
CREATININE
O
0
O
POTASSIUM
5
U
PHOSPHATE
5
4
Za
7i ,IL'
om
0 8 ik
§
9,
PICCOLO =::::7
"--Z
16/10/03 '.
04:57
REFERENCE RANUE: MALE
PATIENT #11111 tL)10-Y
METLYTE 8
DISC LO rwl-3152AA1
OPER #:.
DR #: 000
SERIAL #:.
111INIMINNO6
CL)iip)-1
GLU 98 73-118 MG/DL
BUN 6* 7-22 MG/DL
CRE 1.0 0.6-1.2 MG/DL
CK 30* 39-380 U/L
NA+ 132 128-145 MMOVL
K+ 4.3 3.3-4.7 MOM_
CL-98 98-108 MMM_
tCO2 22 18-33 MMOVI
INST QC: OK.
CHEM OC: OK
HEM 0 ) LIP 1+) ICT 0
MEDCOM - 21080
5 1 ?-301
NSti 7540-01-185-7294
RADIOLOGIC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
SSN (Sponsor) WARD/CLINIC REGISTER NO.
AGE SEX
EXAMINATIONS) REQUESTED
(b)lb) -Z_ ar
111111
PREGNANT
CT
FILM NO.
NOW -9 n YES (EINO
TELEPHONE/PAGE NO.
REQUESTED BY (Print).
c()„,, (6)lb)-
DATE REQUESTED.
TORE OFR u
SPECIFIC REASON(S) FOR REQUEST (Compiaints and findings)
/ ) 5,1 1-ti/
/1
6("Li
6L191 C-41‘1
Sir
DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year)
DATE OF E AMINATION (Month, day, year) RAD IOLO (
RLORT
(6)10
C,
iaLr
athArt
2‘-)Q/(
c-,e1.
Cb ) 2
1116 14/\)
PATIENT'S IDENTIFICATION (For typed or written entries give: LOCATION OF MEDICAL RECORDS Name — last, first, middle, Medical Facility)
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
STANDARD FORM 519-B (8-83)RADIOLOGIC CONSULTATION
Prescribed by GSA/ICMRREQUEST/REPORT FPMR (41 CFR) 101
.11.806-8 t — MEDICAL RECORD
MEDCOM - 21081
DOD-034657
HSN 7540-01465-7204
616-301
RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiol6gy/Nuelear Medicine/UI rasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED AGE SEX SSN (Sponsor) WARD/CLINIC REGISTER NO,
l'eto
FILM NO. PREGNANT
n YES.El NO
REQUESTED BY (Print) TELEPHONE/PAGE NO.
SI DATE REQUESTED.
(Complaints andSPECIFIC REASON(S) FOR REQUEST finding.)
R/0 4445 (6)C&-)-Z
DATE OF E3CAM 1 ATION
Month, day, year)
DATE OF REPORT (Month, day, year)
ATE OF TRANSCRIPTION (Month, day, year)
741 0 ?
RADIOLOGIC_RTRE
r//eeci
a.e/ce-ee,
Nu ,1-K9.-7
1lLp (L)1k)-'
PATIENT'S IDENTIFICATION (For typed or written anther glue:
LOCATION OF MEDICAL RECORDS
Name — last, first, middle. Medical Facility)
LOCATION OF RADIOLOGIC FACILITY
ti,)(b) -
SIGNATURE
RADIOLOGIC CONSULTATION STANDARD FORM 519-8 61 -83)
REQUEST/REPORT Prescribed by GSA/ICMR 1 — MEDICAL RECORD FPMR (41 CFR) 101-11.006-8
MEDCOM - 21082
DOD-034658
NSN 7540-00-634-4165
REQUEST FOR ADMINISTRATION OF ANESTHESIA
MEDICAL RECORD AND FOR PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES
A. IDENTIFICATION
1. OPERATION OR PROCEDURE
ae-t-f-e-ix
B. STATEMENT OF REQUEST
The nature and purpose of the operation or procedure, possible alternative methods of treatment, the risks involved, and the possibility of
1.
complications have been fully explained to me. I acknowledge that no guarantees have been made to me concerning the results of the operation or procedure. I understand the nature of the operation or procedure to be
(Description o op ration or pr • cedure in laym a n's language)
which is to be performed by or under the direction of Dr.
I request the performance of the above-named operation or procedure and of such additional operations or procedures as are found to be
2.
necessary or desirable, in the judgment of the professional staff of the below-named medical facility, during the course of the above-named operation
or procedure. A
4y peAnsidered,n:eceSsary or advisable in the judgment of the professional staff of the
I request the administration of such anesthesia as .rri .
below-named medical facility.
3.
Exceptions to surgery or anesthesia, if any, are
4.
(If 'none", so state)
I request the disposal by authorities of the below-named medical facility of any tissues or parts which it may be necessary to remove.
5.
I understand that photographs and movies may be taken of this operation, and that they may be viewed by various personnel undergoing training
6.
or indoctrination at this or other facilities. I consent to the taking of such pictOreg and observation of the operation by authorized personnel, subject
to the following conditions:
a. The name of the patient and his/her family is not used to identify said pictures.
Said pictures be used only for purposes of medical/dental study or research.
b.
(Cross oat any -parts above which are not appropriate) (Appropriate items in Parts A and B must be completed before signing)
C. SIGNATURES_
), attendant risks involved, andCOUNSELING PHYSICIAN/DENTIST: I have counseled this patient as to the nature of
1.
expected results, as described above.
(Signature of Counseling Physician/Dentist)
isks involved, and expected results, as described above, and hereby
PATIENT: I understand the nature of the proposed'procedUre(s
reques such procedure(s) be performed.
2.
•gnature of Patient). (Date and Time)mbers of operating team)
ent) I,
SPONSOR OR GUARDIAN: (When patient is a minor or un understand the nature of the proposed procedure(s), attendant
3.
sponsor/guardian of
risks involved, and expected results, as described above, and hereby request such procedure(s) be performed.
(Date and Time)(Signature of Sponsor/Legal Guardian)
(Signature of Witness, excluding members of operating team)
,.•
REGISTER NO. WARD NO.
(For typed or written entries give: Name - last, first, middle; grade;
PATIENT'S IDENTIFICATION
rank; rate; hospital or medical facility), ,, „..
REQUEST FOR ADMINISTRATION OF ANESTHESIA AND FOR PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES
(6J(6)9
-
Medical Record
STANDARD FORM 622 IREV. 7-91) Prescribed by GSAJICMR. F(RMR (41 CFR)
USAPPC V2.00
MEDCOM - 21083
DOD-034659
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LI T TI '
ORDER 4.--(SI NOTED AND
HOURS
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(4) - 2
PATIENT IDENTIFICATION
DATE OF ORDER TIME 0
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P% A_ a /al..an REPLACES EDITION OF t JUL 77, WHICH MAY BE USED.
1APR 79
MEDCOM - 21084
DOD-034660
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIMEDATE OF ORDER TIME OF ORDER
PATIENT IDENTIFICATION ORDER NOTED AND
HOURS
SIGN
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NURSING UNIT ROOM NO.
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PATIENT IDENTIFICATION
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NURSING UNIT
PATIENT IDENTIFICATION
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NURSING UNIT
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DATE OF ORDER_ TIME OF ORDER
PATIENT IDENTIFICATION
624
HOURS
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ng
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NURSING UNIT ROOM NO._BED NO.
10
REPLACES EDITION OF 77. WHICH MAY BE USED.
DA 1 FAO4256
PR
P 79
MEDCOM - 21085
DOD-034661
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LI T TIM ORDER PATIENT IDENTIFICATION NOTED AND SIGN
_
NURSING UNIT
ROOM NO.
OVV t&
TI • ORDER
DATE OF ORDER_
PATIENT IDENTIFICATION
HOURS
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NURSING UNIT
TIME OF ORDER
DATE • ORDER_
NTIFI TION ,
PATI cprs) -0
_ HOURS
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(OW-2-
NO. BED NO.
NURSING UNIT ROOM
TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
NURSING UNIT
REPLACES EDITION OF 1 JUL 71. WHICH MAY BE USED.
DA 1 FAO4256
PF:47 9
MEDCOM - 21086
DOD-034662