Medical Report: 25-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wound to Head and Craniotomy

Medical records of a 25 year-old Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with gunshot wound to the head with associated injuries. The medical records do not give any indication as to how the detainee received his injuries or what detention facility he came from. The medical report does not give any personal information on the detainee.

Doc_type: 
Physical (non-death)
Doc_date: 
Saturday, November 1, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

LAST NAME
FIRST NAME
MIDDLE INITIAL_ID NUMBER
I
DATE
NOTES
0 0(000 pi -1 -ucik6 '7 -(1-23 '' 1-Las. p032.. ?--fral.-2_
—yla../ R39 99 61 1 f 1-1(01 as 7 9.z._ q i
97 94
Ian I 2 Is
Ht -c_
3 ' 40
tivio 0-- 15-Y ILI
/1\, ,ano
STANDARD FORM 509 IREV. 6119991 BACK
USAPA MOO
MEDCOM - 22641
DOD-036217
¦
- •
E I 1-
RESULT FORM
LAST, FST. M1
A:et of 1974) r
TEST
RES ULT R_E F. RANG
TEST j RESCJIZ'
C
4.8-10.8 x IC' REF. RANGE
'csinr I
RPR
10'
Ugh 14-IS p, :al (N.f) Mono Ncfativc
Hct 12-16 g/11(7) 42-52%
MC V 37-47% 80-94 fl (M) S ource
81-99 fl
PlE 130-500 x 10 vaiticd 'N/A
Lymph % 20.5-51.1% NG VI/ Vr, H. pylori
Micro
Mono Parasites
0.2-1.0

Cell
Count
TEST 9.8-13.6 sccs TE F. R.4.NGE : . .Blood:13.112k. Unit Grosso:latch' : : -(NflUSiSUBM1T SF 5IS WITH EVERY uN.Tr OF BLOOD--- RE UTSTED JV/7 .. TIT E CROSS VITCH -
21-34 scm
1 .;)
10 g En!
FIE:VLARKS:

00-2-

MEDCOM -22642

DOD-036218

' I CHEATUTRY RESC1_,T FORM
(Subiect to the Privacy Azt of 1974.)
I TL\i
I SSNRSFLIDO SSN:
=====.

PIC 0

31/10/03

REFERENCE RAN

PATIENT #:

LIVER PANEL

DISC LOT #:

3153AA7

OPER #: 678

DR #: 000

SERIAL #:

0000100689

...............

...........

ALB 3.8 3.3-5.5 ..6/DL

PICCOLO .
31/.

3.

18:28

REFERENC NGE:.

MALE

PATIENT #
BASIC MET.

IC
DISC LOT #:

3203AA4

OPER #: 678

DR #: 000

SERIAL #:

0000100494

pH
PCO2
P02
TCO2
HCO3
s02
BEecf
AnGap Ca BUN
GLU
Creat Hct Hgb
35-45mullig(.c-0 41-51 nurdiz 80-105 mmHg (art) N/A (veul 23-27 mmol/L (art) 24-29 zorno1/1. (vea)
22-26 mmoVL (art) 7_3-78 mruoVL (vcn) 95-98%
(-2)— (+3) mmuL/L 10-20 mmoliL.
1.12-1.32 rnmol!L
8-26 mg/dl
70-105 mg/d1
0.7-1.5 mg/dl
38-51% PCV
12-17d.;.
•heitust
TEST 'RESULT REF. RANGE
Tropcnin-1
Drug of
Abuse
RE Ntk.RX S:
REPORTED BY:
ALP 93* 26-

84.GLU 96 73-118

U/L MG/DL

ALT.

10-47.BUN 9

37.U/L 7-22 MG/DL

AMY.

39 14-97.CA++

U/L 9.2 8.0-10.3 MG/DL

AST.

61* 11-38.CRE 1.3* 0.6-1.2

U/L MG/DL

TBIL 0.9.

0.2-1.6 MG/DL NA+ 136 128-145 MMOVL

GGT.

14 5-65 U/L K+ 4.5 3.3-4.7 MMOVL
TP 7.0.

6.4-8.1 G/DL CL-100 98-108 MMOVL

tCO2

21 18-33 MMOVL

INST QC: OK.

CHEM OC: OK

HEM 2+, LIP 0 , ICT 0 INST DC: OK.

CHEM OC: OK
HEM 2+, LIP 1+, ICT 0

tCO: Is-3) rr.,-no_.!
I
DATE:
J LAB TO NO.:
,.,?1 cic."--0?
MEDCOM - 22643
DOD-036219

Ward/Section: (1),.k\ REQUESTING PHYSI LABORATORY RESULT FORM (subject to the Privacy Act of 1974) LAST, FIRST,IVII. 4TT SSN/PEEUDO SSN:
0C3T
atti

Jrinafysis Misc. SeroiG
TEST RESULT REF RANGE TEST RESULT REF RANGE
TEST RESULT REF RANGE
4.8-10.8 xi() Color N/A RPR
BC Negative
R BC 4.7-6.1 x14 App N/A Mono

Negative
Hgb 14-18 g/c11(1‘1) Negative

12-16 g/11(1) Microbiology
42-52%(M)
Hct Bili Negative Source
37-47%(F)
80-94 Ii(M)

MCV K t Negative Gram
81-99 fi(I;)
Stain
Pit 130-500 x 10' SG

verified N/A Occ Bld Negative
Lymph °A,

20.5-51.1% Bld Negative IL pylori Negative entatology) i:Ianual Differeii ti p N/A Micro
Parasites
Segs Mono Prot Negative Malaria
Bands Eos ['rob

0.2-1.0 O&P
Lymph

Baso Nit Negative
Other
Atyp Imm Leuk Negative
HCG Negative

RBC
Morph

Spun
42-52%(M)
Hem atocrit
37-47%(F)
Set Rate Cell

MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED Other Directigen [Negative ABO/Rh nagiatirogg:.1"0:tga;0g014ttoilgSiiidjes..

.MrgsSROPY.WITHOEVERVUNtit'01t. 611
1Mwm nitgoimMEOM$Tx0).:'.11:6
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 /m1
REMARKS:
REPORTED BY: DATE:

LAB ID NO.:
)
MEDCOM 22644
-
DOD-036220

\V arsiLS,ecti on: REQ -' -ICIAN: LABORA ORY RESULT FORM
M1-- cAA. I LAST, F :, MI •c iro tology) CBC .... . DATE 6 iMitr4 TIME - • _Urinalysis_ . (Sub' ect to the Privacy Act of 1974) -SS P_•_ es • isc.-Serology: ..
T e'er' v LT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8x 10' Color N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb 14-18 d1 (M) 12- t6 .. dl (F) Glu Negative • Microbiology
Hct MCV 42-52% (M) 37-47% (F) 80-94 fl (M) 81-99 fl (F) . Dili Ket Negative Negative Source Gram Stain -
Plt 130,-500x103 SG N/A Occ Bld Negative
Lymph % verified 20.5-51.1% Bld Negative H. pylori Negative
(Hematology). Manual Difkrential pH • N/A Micro
Segs • Mono Prot Negative Malaria '
Bands . Eos Urob 0.2-1.0 0 & P
Lymoh. Baso Nit Negative Other
Atyp Imm Leuk Negative . . . . .•...Microscopic Urinalysis: -_ ._.,_:_ .._ ••_..,_._ .._,._ ._ ._.,•
RBC HCG Negative
Morph

Spun 42-52%(M) . CSF_• • Blood.Bank_, . 37L17% (F)
Hematocrit MUST SUBMIT SF 518 WITH
Sed Rate Cell
Count EVERY UNIT REQUESTED Directigen Negative ABO/Rh
Other oagulatioll••S;ii•. .. .. -: " .-• .Bload.Raitk Unit -Cross:I:latch' : • .-.'-• ..
,....
.._.. (MUST.SUBMIT SF,518.WITil EVERY UNIT OF BLOOD ..
• — .. ..-.... .....: . ...
-•'•_:-_._' :: RE I tstslip) : i, -
'_..'_' _._
UNIT TYPE CROSSIVL4TCH
TEST RESULT REF. RANGE
9.813.6 secs
-
PT
21-34 secs
AP-• 20 ug/m1
D dimer ,.
10 ug/ml
F DP 1 REMARKS: DATE: LAB m. NO.: .
REPORTED BY:_
MEDCOM - 22645
DOD-036221
WarcUSection: REQUESTING PHYSICIAN:
' CHEMISTRY RESULT FORM.5.--LCQ Sub'ect to thc Privacy Act of 1974)
LAST, FIRST, MI. DATE TIME SSN/PSEUDO SSN:
(:6)[ -L\
FVT or.orn-er, f ,,,,— /GE
TEST RESULT RE F. RANGE TEST RESULT REF. T.I.
RAN Na 138-!46 mmol/L ALB 3.5-5.5 g
iLt 0
PICCOLO
K 4 . Li 3.5-4.9 mmoL/L. ALP 26-84 u/1 31/10/03 22 : 02
CI 98-109 mmol/L ALT 10-47 u/1
REFE:RENCE RANGE: MALE 11 pH 7 1 i t) 7.31-7.45 ' AMY 14-97 lill PAT I ENT # : (6Y° .i* PCO2 5 D , j 4351 51:45 mmHg (art) AST 11-38 u/1 BASIC METABOLIC
DISC LOT # : 3325AA4
P02 TBTL 0.2-1.6 .
45 18:al?sempimFig (art) in‘ OPER # : 678 DR #: 000 TCO2 23-27 mmol/L (art) BUN 7 -22-Med SERI AL #: 0000100494g, t) 24-29 mmol/L (yen) HCO3 ,-,1 22-26 mmoVL (an) 8.0-10.3m
CA."
23-28 mmoVL (yen)
I 1 GLU 119* 73-118 MG/DL
s02 441 i LI 95-98% CHOL 100-200 mi
BUN 7 7-22 MG/DL
BEecf ,_, (-2) — (+3) CRE 0.6-1.2m1 CA+ + 6.7* 8.0-10.3 MG/DL bsH*. ramon
1 u CRE 1.0 0.6-1.2 MG/DL
AnGap 10-20 mmol/L GLU
73-118 mg NM 137 128-145 MMOtA_ Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/d K+ 4.9* 3.3-4.7 MMOtA_
-CL --112* 98-108 MMOVL
BUN 8-26 mg/di i--Ccilo)".1¦Iet1 _p-..s.:::::, ,,,4
tCO2 18 18-33 MMOtA_ 105 mg/d1
OW 70-1 TEST RESULT REF
RANG I NST DC: OK CHEM QC: OK Creat 0.7-1.5 mg/di GLU 73-118 rnE HEM 0 , LIP 0 , ICT 0 Het 3 LI 38-51% PCV BUN 7-22 mg/til
Hgb iel„ 12-17 g/c11 I CRE 0.6-1.2 mg
CR 39-380 oil
30-190 un
TEST RESULT REF. RANGE NA+ 128-145 m

,
Troponin-1 ; 3.347 mm
3E
Drug of _CL -98-108 Mil ' Abuse tC 02 18-33 mm

REMARKS:
4 -16.r_.1111. -9. 1
REPORTED BY: DA : / LAB ID NO.:
MEDCOM - 22646
DOD-036222

;-atient Limits
4.3 L x101,`,1 4,5 110V '
JO 6.00 gAL
1:.0 18.0 7Z.0 60.0 fL
30,0 99.9 4 PS 27.G 31„0 :1. girl 310 37.0 15). 450.
20.5 51.1
1. 7 ,,,101u1_ 1.2 3.4
RAPIDPOINT COAG ANALYZER p464
SERIAL #005485 10/31/03, 18:30

Patient ID: Test Name . Test Result:= 13.5 sec. Ratio = 1.1 Calculated INR = 1.18 Sample Type:citrated wh. hl Test Date :10/31/03 Test Time :18:28 Card Lot.
:080201
Operator.

: STILLWEL

RAPIDPOINT COAG ANO_YZER V4.54
SERIAL #005485 4131/03 18:38

Patient ID: 111111
Test Name :APTT
Test Result:= 27.1 sec.
***RESULT OUT OF RANGE***
Sample Type:citrated wh. blood

i Test Date :10/31/03

Test Time :18:35
1 .. Card Lot. : :030201
Opeqtqpi_ r: STEWART

..

.

Wri
1161: 14.5 H OK 4.96 63b 14.8 Ikt .46.5
93.6 NC?; 29.8
31-10-03
18:24 Patient
-"UL 4.5 10.5 x10'611. 4.00 6.00
gAL 11.0 18.0
Z 35.0 60.0
1; 80.0 99.9
pg 27.0 31.0

raj 31.8 L g/dL 33.0 37.0 Pit 16.
x10A3AL 150. 450. LYZ 3.5 aLl
20.5 31.1 LYN x1:1. '3AI 1.2 7.
RAPIDPOINT COAG ANALYZER V4.54
SERIAL 005485 10/31/03 22:07

Patient ID:
Test Name11r
Test Renit:= 17.3 sec.
Rat'.

= 1.4

culated INR = 1.76
Sample Type:citrated wh. blood
Test Date :10/31/03
Test Time :22:05
Card Lot.

:080201
Operator.

: JACKSON

RAPIDPOINT COAG ANALYZER V4.54
SERIAL #005485 10/31/03 22:09

---------.

Patient ID:

W1 3.5 L x10'3/uL
RBC 2.68 L x10'6/uL

Hgi 7.8 L g/dL
ct 25.3 L 1
Ni.V 54.3 19

tin; 29.2
pg Nc0­
2,• 31.0 L g/dL Pit 176. * xi0A3/..d. LYZ 29.3 * Z LYI 1.0 *L x103./t
Test Name l"' Test Result:= 34.3 sec. Sample Type:citrated MI, blood Test Date :10/31/03 Test Time :22:07 Ca rd Lot.
:030201
: JACKSON

31-10-03
Patient
4.5 10.5
4.00 6.00
11.0 18.0
35.0 60.0 GO. 0 99.7
27.0 31.0
33.0 37.0
150. 450.
20.5 51.1
1.2 3,4
MEDCOM 22647
-
Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM
(Subject to the Privacy Act of 1974)
LAST, FTRST,.MI.
DATE TIME
SSN/PSEUDO SSN:

HP 1 10-)1

(Hematology BC Urinalysis
. Misc. Serology • TEST RESULT REF. RANGE TEST •
RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10'
Color N/A

RPR Negative
RBC 4.7-6.1 x 109 App N/A

Mono Negative
Hgb 14-18 Wdl (M) Glu Negative

Microbiology

12-16 g/d1(F)
Hct 42-52% (M) Bili. Negative

Source

37-47% (F)
MCV 80-94 11 (M) Ket Negative

Gram
81-99 fi (F)
Stain

Pit 130L500 x10' SG N/A
Occ Bld Negative

verified
Lymph % 20.5-51.1% Bld Negative

H. pylori Negative (Hematology} Manual Differential_pH N/A . Micro
Parasites
Segs Mono Prot Negative Malaria

Bands Eos Urob 0.2-1.0
0 & P

Lymph Baso Negative
Nit Other

Atyp Imm Leuk Negative ..
.Microscopic Urinalysis '

RBC HCG Negative
Morph

Spun 4252% (M)
CSF. ' ::_. Blood Bank ,
-

Hematocrit 37-47% (F) --
Sed Rate
Cell

MUST SUBMIT SF 518 WITH ._, Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh I
COagulation"StUdiel: :_:- .BloOd:Ballk Unit Crossmatch -' , - --_
..: (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
. _

TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21-34 secs

-. D dimer 20 ug/m1
FDP 10 ug/ml
REMARKS:
MEDCOM - 22648

DOD-036224
if EMISTRY RESULT FORM (Subject to the Privacy Act of 1974) DATE TIME SSN/PSEUDO SSN: 00 R:7
b
1 1 11
1-15.% 1 0

lq 11
—10

LI D
TEST RESULT
Troponin-1
Drug of Abuse
REMARKS:

REPORTED BY:
REF. RANGE
138-146 mmol/L
3.5-4.9 mmol/L`
98-109 mmol/L
7.31-7.45
35-45 mmHg (art)
41-51 =OR (Yen)
80-105 mmHg (art)
N/A (yen/
23-27 mmol/L (art)
24-29 mmol/L (yen)
22-26 mmol/L (art)
23-28 mmoUL (yen)
95-98%
(-2) — (+3)
mmol/L
10-20 mmol/L

I.12-1.32 nunol/L
8-26 mg/dl
70-105 mg/dl
0.7-1.5 mg/d1 38-51% PCV
12-17 g/dl
REF. RANGE
TEST I RESULT REF. RANGE
ALB 3.5-5.5 g/dl
ALP 26-84
ALT 10-47 u/1
AMY 14-97 u/I
AST 11-38 u/I
TBIL 0.2-1.6 mg/d1
BUN 7-22 mg/dl
CA"" 8.0-103m01
CHOL 100-200 mg/dl
CRE 0.6-1.2 mg/d1
GLU 73-118 mg/di TP 6.4-8.1 g/d1 ( "Me I e
TEST RESULT REF. RANGE
GLU 73-118 mg/dl
BUN 7-22 mg/d1
CRE 0.6-1.2 mg/d1
CK 39-380 u/I (M)
30-190 u/I (F)
NA 128-145 mmol/1
33-4.7 mmol/1
_C 98-108 mrno1/1
tCO2 18-33 mmol/1
DATE: LAB ID NO.:

igc011i):MetabOlie,Papet
TEST RESULT REF. RANGE
GLU 73-118 mg/dl BUN 7-22 mg/d1 CA" 8.0-10.3 mg/di CRE 0.6-1.2 nag/d1 NA' 128-145 mmol/1
3.3 -4.7 mmol/1
CL 98-108 mmol/1 tCO2 18-33 mmo1/1
Picealti
TEST RESULT REF. RANGE
ALB 3.3-5.5 g/dI
ALP 26-84 u/I
ALT 10-47 till
AMY 14-97 till
AST 11-38 u/1
TBIL 0.271.6 mg/di
GGT 5-65 till
TP 6.4-8:1 g/dl
iccoloYglects6I
TEST RESULT REF. RANGE
NA . 128-145 mmol/1
3.3-4.7 mmol/1
CL" 98-108 mmoLl
tCO2 18-33 mmo1/1
MEDCOM 22649
-

DOD-036225

Vv'ard/Section: REQUES_
LAST, FIRST,,
0—
(HernatOlop) CBC .:

TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10'
RBC 4.7-6.1 x 10'
Hgb 14-18 Wdl (M)
12-16 g/d1 (I')
Hct 42-52% (M)
37-47% (F)
MCV 80-94 fl (M)
81-99 fl (F)

Plt 130L500 x 103
verified
Lymph % 20.5-51.1%

(HentatO ) Manual Differential .....
. :.. • . • • • . . ...

-•••• • •-•• Segs Mono
Bands Eos
Lymph Baso
Atyp Imm
RBC
Morph

I , C"f1 / •1, 11

Hematocrit 37.47% (F)
Sed Rate
Other
Coagulation Studies

TEST RESULT REF. RANGE
PT 9.8-1.3.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
FDP 10 ug/m1
REMARKS:
(4P
Lf ORY R. SULl" FORM
•-•...•-• ,....%
1.,./ us,. 1 Alva,. yrl.k..l 01 1714)
DATE TIME SSN/PSEUDO SSN:
I No ,./ C..)O -L-C,
._Urina._, _s* . Misc. Serology ,

TEST RESULT REF RANGE TEST RESULT REF. RANGE
Color N/A RPR Negative
App N/A Mono Negative
Glu Negative

Microbiology

Bili Negative
Source
-
Negative

Ket Gram
Stain
SG •N/A

Occ Bid Negative

Bld Negative
H. pylori Negative

pH_• N/A Micro
Parasites
Prot Negative

Malaria
Urob 0.21.0

-
0 &

Nit Negative
Other

Leuk Negative
..,. roscOpiC !Irina _.__s .

HCG Negative
Blood Bank

Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Directigen Negative
I ABO/Rh
-_:_Blood Bank Unit crossinitch" . (MUSTSUBMIT SF.518.WITHEVERy UNIT OF. BLOOD .
. ._•

:;. ,'REQUESTEDY
UNIT
TYPE CROSS1114TCH

REPORTED BY DATE:
LAB ID. NO.:.
MEDCOM - 22650

DOD-036226
'atcllSection: REQ
LABORATORY RESULT FORM .

1 k3uoject to tne rrivacy Act of 1974)

LAST, F1RST,..MI
DATE TIME • SSN/PSEUDO SSN:
6 r
etitatOogy) CB
_Urina_s'.
. Misc.' Serology :

RESULT . RANGE TEST RESULT REF. RANGE TEST
RESULT REF. RANGE

WBC 4.8-10.8 x 10'
Color N/A

RPR Negative
RBC 4.7-6.1 x 10 App N/A

Mono Negative
Hob 14-18

Glu Negative
• Microbiology

12-16 g/d1(F)
Hct 42-52% (M)

Bili Negative
Source

37-47% (F) . -.
MCV 80-94 fl (M) . ••

Ket Negative
Gram
81 99 fl (F)

. -Stain
Pit 130500 x 1O
SG 'WA
Oce Bld Negative

verified J
Lymph % 20.5-51.1%

Bld Negative

H. pylori Negative (Hematii ).Manual Differential . pH • N/A
Micro
Parasites
Segs . Mono Prot Negative Malaria

Bands .
Eos Urob 0.2-1.0
0 & P

Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative
MicrosCopi Uritin_s_'
._.

RBC
HCG Negative
Morph

Rnrin_ 19-.S1 0/- null
Blood.Bank .

Hematocrit 3747%
Sed Rate

Cell
MUST SUBMIT SF 518 WITH

Count
EVERY UNIT REQUESTED

Other Directigen Negative
ABO/Rh
Coagulation Studies
Bank Unit CrOssinatcl• - '• (MUST.SUBMIT SF . 518 WITH EVERY UNIT OF. BLOOD 1,11EQUESTED)

TEST RESULT REF. RANGE UNIT
TYPE
CROSSM4TCH

PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
FDP 10 ug/m1
REMARKS:
REPORTED BY:_
DATE: LAB ID NO.:.
MEDCOM 22651
-

DOD-036227

Ward/Section:
CHEM'S). tcY RESULT FORM1111111.1101111P (Subject to the Privacy Act of 1974)
LAST, FIRST, MI. DA TIME SSN/PSEUDO SSN:
IS. '. (91)-1 -CCOLO itabdiCTaie1.',17:. . TEST RESULT REF. RANGE 01 /11 / 03 01 : 08 TEST RESULT REF. RANGE REFERENCE RANC : MALE
Na 138-146 mmol/L GLU 73-118 mg/dl
/40 .PAT I ENT #: K 3.5-4.9 Inm°1/1; METLYTE 8 BUN 7-22 mg/dl DISC LOT # .
3151 AA4

Cl 98-109 mrool/L CA+1 8.0-10.3 roedl
DR #: 000

.OPER #: 678.

pH 160 7.31-7.45 CRE 0.6-1.2 mg/dI
0000100494

•, SERI AL #:.
PCO2 35-45 mmHg (arc) NA+ 128-145 mmoUl
qt, 6
41-51 rnmHs (yen)

GLU 122* 73-118 MG/DL

80-105 mrril-ig (art)

P02 K+ 3.3-4.7 mmol
1 a.N/A (veal 8 7-22.
BUN MG/DL
23-27 mmol/L (art)

CRE.CL" 98-108 mmol/1
1.3* 0.6-1.2 MG/DL

TCO2 2 0 .
24-29 mmol/L (vco) HCO3 1 7 22-26 mmoVL (art) CK.U/L tCO2 18-33 mmoUl
2647* 39-380.

23-28 mruol/L (yen)

125* 128-145 MMOVL s02 Cti K+.P:k6lOPLA,ei Pan e1P1u;:'
NA+.

4.6 3.3-4.7 MMOIL BEecf -1 D (-2) — (+3) CL-.MMOVL
112* 98-108.

TEST RESULT REF. RANGE

rumon, .
tCO2 15* 18-33.

MOW

AnGap 10-20 mmol/L ALB 3.3-5.5 g/dl Ca E 1 2-1.32 mmo1/L INST QC OK.ALP
CHEM QC: OK 26-84 u/I HEM 0 , LIP 0 , I CT 0
BUN 8-26 ing/d1 ALT 10-47 u/I GLU '70-105 mg/d1. AMY 14-97 u/I
Creat 0.7-1.5 mg/d1 AST 11-38 u/1 Het 38-51% PCV TBIL 0.2-1.6 medl Hgb 12-17 g/dl 5-65 u/I
GGT
13

ChemiLStry TP 6.4-8.1 g/dl
TEST RESULT REF. RANGE
Troponin-1
TEST RESULT REF. RANGE Drug of NA 1-128-145 uno1/1 Abuse 3.3-4.7 mmo1/1 CL" 98-108 mmoLl tCO2 18-33 rnmo1/1
DATE: LAB ID NO.:
MEDCOM - 22652

DOD-036228

RAPIDPOINl LOAG ANALYZER V4
SERIAL 4005485 11/01/03 18.

Patient ID:
Test Name rT iF\
Test Result:-10 sec.
Ratio = 1.5
Calculated IMP
Sample Type:citrated 41 1- 1 , (1
Test Date :11/01/03

Test Time.

:18:41
Card Lot.

:080201
Operator.

: DAVIS

RAPIDPOINT LOAG ANALYZER V4.!
SERIAL #005465 11/01/03 18:bi

Patient IDIOM
Test Name :APTT
Test Result: = 56.3 Se.
***RESULT NOT RANGE CHECKELJ***
Sample Type:citrated plasma
Test Date :11/01/03
Test Time :18:52
Card Lot.

:030201
Operator.

: DAVIS

PINIF.

01-11-0:

19:31
Patient LiNita
+.1 _.

J/d.L..

4.5 .11,, g5
920 L75. L

4.00 6.0

co-Pb.

g, e,.11.r, 18.0

o 'rk=7 17, 4L 3
35.0 60.0
35.0 60.0

71,7 4 1.•':•p..!:446 • 10.0 L g/dL
90.: 99.9 ri 94.0 fL
80.0 99. 9

MG; 52.1 H ''t-it 31.0 L
2 70 31.0 nch 49.3
a 27,0 31.0

t2RC 56.5 444 g/dL 92.3 fL
32.0 57.0 rE4C 52.4 # gidl.
32. 0

F1 l-122. 4-.37.0 21.is pg
Pi!. 92,
LY4 0.7 4L 1,1.0 5'uL

,

1111111111
4,

1432

4.7 003M FIC 4.87 x10'6/4! kqh 14.5 gAILH.Et 44.6 S
MCV 91,5 fL
•1CN 29.4 Pc! INC 32.1 L glaPlt 257. x10'5AL
;OS 13.2 L 1 !Y4 0.9 4L a103/eL
?APIDPOINT COAG ANA
V4.54
3ERIAL #005485 11/01/03 04:46

Patient I04111111,
Test Name :PT
Test tsult:= 16.3 sec.
Rat'o = 1.3

C. culated INR = 1.60

ample Type:citrated wh. blood
Test Date :11/01/03
Test Time :04:45
Card Lot.

:080201
Operator.

: JACKSON

RAPIDPOINT COAG ANALYZER V4.54
SERIAL 4005465 11/01/03 04:50

Patient
Test Name :APT1
Test Result:= 49.4 sec,
***RESULT OUT OF RANGE***
Sample Type:citrated wh. blood
Test Date :11/01/03
Test Time :04:48
Card Lot.

:030201
Operator.

: JACKSON

411111111r

18:37 01-11-03
patimt
12:51
Liallts
Patient
;IC
4.2'L A10'5/6L
4.5 10.5

902 2.07 *4_ i106,V,_ Likts
4.00 6.00
.„.3tC..

lipt, 7.5 * x10"3/L 4„S
10,2 4-L greL.
11.0 18.0
3.36 L x10'6/L 4.00 6.00

iict 19.5 ti Z
150, 4'

Pit 170, LW3ij 150. 450.
0,471.1t 32.1 L gidL20.5 51.1 In 10.7 44_ % 20.5 50.1

'.197. x10-'3/ti
3.4 1/1.
0.5 L 0. '3/11L.

1. 9 3,4
4go. 21.5 *5
1Y.it 1.64 x10'3/iii_

01-11-03

0443 Ari/A111111111.
01-11-03

Patient IC
01:10 Patient
4.5 10.5
Limita

400 6,00 2.9 L 410'5/..1L 4.5 10.5
11.0 18.0 RiC 4.72 (1.0"6/11L 4.00 6.00
35.0 60.0 Hgb 13.9 g/dL
11.0 18.0

80.0 99.9 lict 45.3 5
35.0 60.0

27.0 31.0 71.9.
FL.

80.0 79.9

32.0 37.0 rCH 29.4
a 27.0 31.0

150. 450. ¦ICHC 32.0 L gicIL
33.0 37.0

70.5 51.1 Flt 251.
x10'3/uL 150. 450.

1.2 3. LYS 37.3 ; %
20.5 51.1

LI
1.1 #1 t10'3/111
1.2 3.4
10.0 18.0 MO 60.0
60.1 99.9 27,0 31,0
33.0 37.0
150. 430.
20.5 51.1
1.2.

Z.4

-
• ,j
MEDCOM - 22653

DOD-036229
Ward/Section:
3ORATORY RESULT FORM
I
k..Ju ¦.,
,,t U./ 1.4.1c .r.iivat: Act OI .LY /4

LAST, FERST,.MI. 0,1,--ATE TIME SSN/PSEUDO SSN:
0 1 /Jai lci 3 -D .-.. alernatols ,,__) Urina_sis
Misc. Serology

TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST R.ESULT REF. RANGE
WBC 4.8-10.8x 10' Color N/A RPR Negative
RBC 4.7-6.1 x 10 App N/A Mono Negative
figb 14-18 g dl (M) 12-16 &I(I.) Glu Negative • Yficrobiology
Het 42-52% (M) 37-47% (F) Bili -- Negative Source
MCV Pit 80-94 fl (M) 81-99 fl (F) 130c500 x io' verified Ket SG Negative .N/A_. Gram Stain Occ Bld Negative
.. Lymph % 20.5-51.1% Bld Negative H. pylori Negative
ematolOgy).Manual Differential .-..:,• . ,--• . -• •-• - pH - N/A . Micro Parasites
Segs . Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 • & •
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative
r.MicrusOpic Urina_s
...

RBC HCG Negative Morph
A n couni ,n es

7 ---
o Blood.Bank •
Hematocrit 37247% (F)
I

Sed Rate
Cell
MUST SUBMIT SF 518 WITH

Count
EVERY UNIT REQUESTED

Other Directigen Negative
ABO/Rh Coagulation 'Studies :s ._. •_
.--(MUST..SUBMIT.SF,518.WITHyERy .UNIT OF. BLOOD •• 1. • • • '..:!ittOtitsrkp) • • •-• • -•-•

TEST RESULT REF. RANGE UNIT
TYPE CROSSNL4TCH

PT 9.8-1.3.6 secs APTT 21-34 secs D dimer 20 ug/ml
FDP 10 ug/m1
REMARKS:
REPORTED BY: DATE: LAB ID NO.: .

MEDCOM 22654
-

DOD-036230
Ward/Section:
ORATORY RESULT FORM
(51(.\2
SuFect to the Privac Act of 1974

LAST, FIRST.,M.I. TIME SSN/PSEUDO SSN:
(Hematology) CBC Urinalysis_ Misc. Serology
TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative
RBC 4.76.1 x109 App N/A Mono Negative
Hgb 14-18 g/dI (M) 12-16 g/dI (F) Glu Negative INEcrobiology
Het 42-52% (M) 37-47% (F) Bili Negative Source
MCV 80-94 fl (M) 81-99 fl (F) Ket Negative Gram Stain
Pit 130-500 x103 verified SG 'N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
ematology) Manual Differential pH WA Micro
Parasites
Segs Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 O&P

Lymph Baso Nit Negative Other Atyp Imm Leuk Negative
Microscopic Urina

RBC HCG Negative
1
42-52% (M)
. CSF • Blood Bank_•

Hematocrit 37-47% (F) ••_-_._
Spun Sed Rate
Cell
MUST SUBMIT SF 518 WITH

Count
EVERY UNIT REQUESTED Other Directigen itive
I NegaABO/Rh

oagulation Studies. . -_.Blood Bank Unit Crossmatch ._- ' -_:_:.
•'_-. (MUST,SUBMIT SF,518.WITH EVERY UNIT OF. BLOOD .
‘;-:.:,.. "
,' REQUESTED)._"_-.._. '_. •

TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT ' 9.8-13.6 secs
APTT 21-34 secs .
. D dimer 20 ug/m.1
FDP 10 ug/ml
REMARKS: c--, P '2 COQc-c3
D VIVA rvr-v-IN Tv_M .---• -
MEDCOM -22655

DOD-036231
Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM
J.
w Luc rfivacy itcE cn 1Y/4)
I

LAST, FIRST.,,M1-DATE TIME SSN/PSEUDO SSN:
mato!_-.1tr •_Urinalysis .....-_..Misc..Serology :
TEST RESVIT:.- —REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10 Color N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb 14­18 gFdL (M) 12-16 g/c11(F) Glu Negative -.• . Microbiology . .• -.
Hct 42-52% (M) 37-47% (F) Bili • - Negative Source
MCV 80-94 ti (M) 81-99 fl (F) Ket Negative Gram Stain
Pit 130:600 x103 verified SG 'N/A Occ Bld Negative
Lymph % 20.5­51.1% Bld Negative H. pylori Negative
,..gy)-•(IfematOlO..... Manual Differential ...:• .,:..• .• . ,•••.• -.•...... . ..... • pH_• N/A Micro Parasites ./ .
' Segs . Mono Prot Negative Malaria •
Bands Eos Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative Other Atyp Imm Leuk Negative
.• :.MicioscOptc iia lysis'_•
• ._•,__.•_.._• ._. ._,-.__
...__._._. ..... :_
...

RBC HCG Negative Morph
'

S pan 0
• Blood Bank_. ••:

Hematocrit 37.47% (F) -_• •••_
•_•_• Sed Rate
Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh
Coagulation Studies •BloOd:Baiik Unit Cross Watch' : •• UST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
• • -• .
•••• ..•

• ._REQUESTED) :

TEST RESULT REF. RANGE UNIT TYPE
CROSSA ,L4TCH

PT 9.813.6 secs
-

APTT 21 -34 secs
D dimer 20 nem]
FOP 10 tig/rn1
REMARKS:
REPORTED BY: DATE:

I

LAB ID NO.:.
MEDCOM - 22656

DOD-036232

Ward/Section: .,,__,JJESTING PHYSICIAN:
' CHEMISTRY RESULT FORM
-

77: C41, (Subiect to the Privacy Act of 1974)LAST, FIRST, MI. _ ....--,.
Dizt14 TIME SSN/PSEUDO SSN:*I
' S

cii5T,..., leotoych46, 5 . , -.1. ' -iogro:wtooiii!.:41iif..:.
TEST SULT EF. RANGE TEST RESULT
REF. TEST RESULT REF RANGE
II
RANGE

Na (try 138-146 mmol/L
(ALB 3 . 5-5 . 5 g/d1 GLU 73-118 mg/di K D _ is:, 3.5-4.9 inmoUL 26-84 u/1
-

ALP BUN 7 22 mg/dl
Cl 98-109 mmol/L ALT 10-47 u/1
CA+4. 8.0-10.3 mg/dl
// ?'
7.31-7.45

pH AMY 14-97 u/I CRE 0.6-1.2 n3g/dI
PCO2 35-45 mmHg (w1) AST 11-38 u/1 NAT 128-145 minoVI 41-5t mmHg, (yen)
80-10.5mmHg(2A)

P02 Kr 3.3-4.7 mmult1
N/A tveul TCO2 I ,243:,297 mmol/!-(0,arrca)) :.._ _ _ ._- = PICCOLO -- - — ' ' CL" 98-108 mmol/1
HCO3 22-26 mmoVL (art) 01/11/03 13 : 00
tCO2 18-33 mmoUl

23-28 mmoUL (yen) RANGE : MALE
REFERENCE
95-98%

SO2 PAT I ENT # : IMF •#0.140iir..of. gonel'Pl60:;
-.::: ...T..6.:...;.sh ,-.::.'...n3::::' ,i'.'. ---•
. :;,::,-.Y-c; 4

BEecf (-2) -(+3) METLYTE 8 (b)(0-1
TEST RESI)7,T REF. RANGE

mmoi/L DISC LOT # : 3151AA4 AnGap 10-20 mmol/L opER # : 777 DR # : 000 , ALB
3.3 -5.5 g/dl Ca L12-1.32 rnmon SERI AL # : 0000100194 • ALP 26-84 u/1
BUN 8-26 mg/d1 ALT 10-47 oil
GLU 130* 73-118 MG/DL '
1 7-22 MG/DL

GLU 70-705 mg/dl BUN
12.AMY 14-97 u/1

CRE 1.4*.
MG/DL

0.8-1.2.
CK 3159*.
U/L

39-380.

Creat 0.7-1.5 mg/di AST 11-38 u/1
NA+ 131 128-145 MMOVL Het . 38-51% PCV 3.3-4.7 MMOVL TBIL 0.27 1.6 algid'
K+ 3.3 Hgb 12-17 ydi CL-109* 98-108 MMOVL GGT 5-65 u/I
-tCO2 17* 18-33 Mal_
"--7.,gts.t.-Xb.prAriSAry:. TP 6,4•81 g/d1
TEST RESULT REF RANGE CHEM GC: OK
INST GC: OK.

cr61:9-4U041ibte
HEM 1+,.,.

LIP 0.ICT 0

Troponin-1
TEST RESULT REF. RANGE

Drug of NA' 128-145 mmol/1 Abuse 3.3-4.7 mmol/1
CL" 98-108 mmolll
tCO2 18-33 mmol

REMARKS:

REPORTED BY: DATE: LAB ID NO.:
.N2./33

i/
(c)(C1- L

MEDCOM - 22657

DOD-036233
WarcUSection: REQ• c . .
CHEMIS1 KY RESULT FORM C.)-f(--' Suliect to the Privacy Act of 1974)
LAST, FIRST, MI. DATE ip SSN/PSEUDO SSN:
' ' ;
.., ' 1,:5'llA:' 4ce,o4Ycli4=6 ico'16)'1*t4k4tirs4it' .-_
TEST RESULT REF. RANGE TEST RESULT REF. TEST
RESULT REF. RANGE RANGE

Na 138-146 mmol/L ALB 3.5-5.5 01 73-118 mg/di
GLU K 3_5-4.9 rnmoUL' ALP 26-84 u/1
BUN 7-22 mg./d1 98-109 mmol/L ALT
Cl 10-47 u/1 CA+1 8.0-10.3 mg/dl pH 7.31-7.45
AMY 14-97 u/I CRF 0.6-1.2 mg/d1
PCO2 35-45 mmHg ( 13n) AST 128-145 mmol
41-51 mmHg v.12)
80-105 mmHg (art)

P02 TBIL 3.3-4.7 mmol/l
A ( veil) -- - - - - -PICCOLO •=7==::77-TCO2 23-27 mmol/L WO BUN 01/11/03 04 : 20 98-108 mm01/I24-29 mmol/L (Inn)
: MALE
REFERENCE RANGE
22-26 mmoUL (art)

HCO3 CA+* 18-33 mmoUl
23-28 mmoUL (von) PATIENT # : Millirq(0 _Li s02 95-98%
CHOL METLYTE 8
ttr4110 Pliii:_;'i . -
3151004 ,::-. .', .'.:, .t . i:...-.
.,-,-;:;:'-
DISC I_OT #:

BEecf (-2) - (+3)
CRE
678 DR it: 000 " REF. RANGE

Imola, OPER # :
10-20 mmol/L it: 0000100684

AnGap GLU SERI AL 3.3-5.5 g/d1 Ca 1.12-1.32 mmol/L
TP 26-84 &I
GLU 124* 73-118 MG/DL 8-26 nag/c11 .
BUN 10 7-22 MG/DL ] 0-47 u/t
1CCOOYA BUN
1.1 0.6-1.2 MG/DL
-..r. .---CRE

GLU 70-105 mg/d1
TEST RESULT' 3517 * 39_380 14-97 &I
U/L
CK
NA+ 129 128-145 MMOtt.

Creat 0.7-1.5 mg/di
! GLU
K+ 4.6 3.3-4.7 MMO.PA_ 11-381.0 Hct 38-51% PCV
BUN CL-110* 98-108 WW1 0.271.6 mWdl Hgb 12-17 g/cli CRE tCO2 17* 18-33 MMOI/L 5-65 u/I --_.
:. •.;K*.TC.IieitiiSti-347.

. .' CK 6.4-8.1 g/d1
INST OC: OK CI-EM GC: OK , ICT 0 i‘eti.itti,.., , ,..,, ,

TEST RESULT REF. RANGE NA-' HEM 2+, LIP 0
Troponin-1
K+
REF. RANGE

Drug of _CL" 128-145 mmol/1 Abuse tCO2 3.3-4.7 mmol/1
98-108 mmoLl
18-33 mmo1/1

REMARKS:
.
I -

REPORTED BY: DATE: 1 LAB ID NO.:
MEDCOM - 22658

DOD-036234

0 Ca

Ward/Section: RF^TJESTING PHYSICIAN:
HEM S RY RESULT FORM
LAST, FIRST, MI
TEST RESULT REF. RANGE
Na 138-146 mmol/L
K 3.5-4.9 mmoUL-
Cl 98-109 mmol/L

7.31-7.45
pH 351 PC 02 35-45 mmHg (art)
)5. C
41-51 mmHg (Yen)
80-105 mmHg (art) N/A (yen)
P02
23-27 mmol/L (art)
TCO2 a-5
24-29 mmol/L (yen)
22-26 mmoL/L (art) 23-28 mmoUL (yen)
HCO3
s02 95-98%
3
BEecf (-2) — (+3) mmol/L AnGap 10-20 mmol/L
Ca 1.12-1.32 =OWL
BUN 8-26 mg/dl
GLU 70-105 mg/d1
Creat 0.7-1.5 mg/dl Het 38-51% PCV
.2(e
Hgb 12-17 g/d1 eli*t
TEST RESULT REF. RANGE
Troponin-1
Drug of Abuse
REMARKS:
REPORTED lig&
TIME
ATN

ALB TEST RESULT 0.2-1.6 mg/di 7-22 mg/di 8.0-10.3mg/d1 100-200 mg/dl REF. RANGE 3.5-5.5 g/d1 26-84 u/1 10-47 u/1 14-97 u/1 11-38 u/1
0.6-1.2 mg/d1
73-118 mg/d1
CRE CK NA+ GLU BUN 7-22 mg/dl 0.6-1.2 mg/d1 73-118 mg/di 39-380 u/I (M) 30-190 u/1(F) 128-145 mmol/1
334.7 mmol/1
_CL" 98-108 mmol/1
tC 0 18-33 mmol/1

DATE: LAB 11) NO.:

Al U
(Subject to the Privacy Act of 1974) SSN/PSEUDO SSN:
ieco16 . -itabOtier.:atie
TEST RESULT REF. RANGE
GLU 73-118 mg/di BUN 7-22 mg/dl CA' 8.0-10.3 mg/d1 CRE 0.6-1.2 mg/d1 NA" 128-145 mmol/1
KT 3.3-4.7 mmolul
98-108 mmol/1
tC 02 18-33 mmoUl
PthitiPhi
TEST RESULT REF. RANGE
ALT 10-47 u/1
AMY 14-97 u'I
AST 11-38 u/1 TBIL 0.2-1.6 mg/dl GGT 5-65 u/t TP 6.4-8.1 g/dI
iccolo).Electrobte
TEST RESULT REF. RANGE
128-145 mmol/1
3.3-4.7 mmol/1
CU 98-108 mmolll
tCO2 18-33 mmol/1
MEDCOM -22659

DOD-036235

** PRINT AHrELL7D **

i -31-RT EGt-
Pt: 1111111W

Pt Nam:

Ha.

151 mmol/L

.4.4 mmol/L
Tr:02 .

mmol/L
Hct .

48 ;PCs)
Hb*.

1 g/dL
*via Hct

Rt 370

pH.

7.410

P0A2.

3.0 mmH;
P02.

.,18 mmHg
HCO3.

25 mmol.
BEel:f .

0 mmol/L
s02*.

54 %

*calcu1atPd
1

At Patient Temp

Ph.

7.410
PCO2.

3,1.0 mmHq
P02.

68 mmtiq

Patient Temp: 98.6F

FIO2.

: 55

Sample Type_: ART

02H0V03 ..

11:31

Jper:111111„-----

Physician:

Ser# 42015

Ver: JAMSO4eR
CLEW A93

RAPIDPOINI LOAF ANALYZER V4.1)
SERIAL #005485 11/02/03 04:24

Paiient 113:111111,
Test Nam: :PT
lest Result: , 19.4 sec.
***WAPi 011 OF RANGE***
Ratio = 1.6
Calculated JNk - 2.12
Sample Type:citrated wh. blood
Test Date :11/02/03
lest Time :04:23.
Card Lot.

:80201
Operator

APTDPOINT WAG ANALY
V4.54

f',EklAL #005485 11/ /03 04:29
/ •

//katient ID fest Name :ANT lest Result:. 55.1 sec. ***RESULT OUT OF RANGE***
RAPIDPOIN COAG ANAL./ ER V4.54

SERIAL
#005. 5. 11/02/03 01:28
Patient .14111111, lest Name , :PT Test Result:. 20.4 sec. ***RESULT DOT OF RANGE***
Ratio = 1.7

Sample Type:citrated.

bloom

Test Date :11/02/03
Test Time :04:2
Card Lot.

:03020
Operator

RAPIOPOINT WAG ANALyMER V4.54
SERIAL #005485 11/02/03 01:53

Patient 7.: Test Name :APT1 Test Result:= 56.1 sec. ***RESULT NOT RANGE CHECKED*** Sample Type:citrated plasma Test Date :11/02/03
Test Time :01:49
Card Lot.

:030201
Operator :MUM

Calculated INR = 2.30
Sample Type:citrated wh. blood
Test Date :11/02/03
Test Time :01:25
Thrd Lot.

:080201

.?rator 411111111111111

MEDCOM 22660
-

DOD-036236

Ward/Section: AEQUESTING PHYSICIAN:
LABORATORY RESULT FORM I

=': ,l) *----' (4,)(0 :?--
(Subject to the Privacy Act of 1974)LAST, FIRST, MI. DATE TIME -SSN/PSEUDO SSN:

ra -I• . I k 02— 00
(Hen a _logY . ._Urinalysis• Misc: Serology :_..
TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative
RBC 4.7-6.1 x 104 App N/A Mono Negative
Hgb 14-18 dl (M) 12-16 g/d1(F) Gilt Negative . Microbiology
Hct 42-52% (M) 37-47% (F) Bili Negative Source
MCV 80-94 11(M) 81-99 fl (F) Ket Negative Gram Stain
Plt 130-;500 x 10 J verified SG N/A Oce Bid Negative
Lymph % 20.5-51.1% Bid Negative H. pylori Negative
• Iiemato )./41a.nual Differential pH . N/A Micro
- - Parasites
' Segs Mono Prot Negative Malaria
Bands Eos Urob , 0.2-1.0 0 & P
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative
.Microseivic If_alysis

RBC HCG Negative Morph
Spun 42-52% (M)
. Blood Bank , • •

Hematocrit 37-47% (F)
Sed Rate Cell

MUST SUBMIT SF 518 WITH
!

.__ Count EVERY UNIT REQUESTED Other Directigen Negative
ABO/Rh
.

Coagulation Studies:: .':. - • . '.. - .-_-. -Blood:Baal( Unit CrosSinatclf_.. -_-._:_:.... -_. (MUST SUBMIt. SF 518 WITH EVERY UNIT: OF BLOOD .
TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
FDP 10 ug/ml
REMARKS: _,_Lo a...,..
REPORTED BY: DATE: LAB ID NO.:._ '
MEDCOM - 22661

DOD-036237
Ward/Section:
-

---C__/,_---.\ LAST, FIRS
iiis.. .
TEST RESULT

Na i 5 1 K 3./
pH I.. 435 PCO2 ,-
34. -.. P02 ( 3 ( TCO2 ,2/ HCO3 (2 3
S02 79 BEecf
I

AnGap Ca
BUN
GLU
Creat
Het -Jr a.,...
Hgb t.3 ar.
Np-1
REF. RANGE
138-146 mmol/L
3.5-4.9 mmol/L'
98109 rnrnol/L
-
7.31 -7.45
35-45 mmHg (are 41-51 mml-IE (ven)' SO-70.5 mmHg art) N/A (vein23-27 rnmol/L (art) 24-29 rnrnol/L (yen) 22-26 mmoUL (art) 23-2S mmol/L (yen)
95-98%
(-2)— (+3) rnmon 10-20 mmol/L
1.12-1.32 nunol/L
8-26 mg/di
70-105 mg/d1
0.7-1.5 mg/di 38-51% PCV
12-17 eidi
4-,,g*.-kieniist . 1.—
TEST RESULT REF. RANGE

Troponin-1
Drug of Abuse
REMARKS: 0 t_b& .
REPORTED BY:
RE I.17: '^' PHYSICIAN:t
a.) RI) r?
DATE TIME

itt. ::. ,i'd.010-'010iiiJi. • TEST RESULT REF. RANGE
f
AL ; 3 75-5.5 edi
A T tr
L "L -. s = PICCOLO :---:=7:::::

-. -7-
01 :25

02/1 1/03

oar MALE

1-41FMLNCE RANGE:
PAT IENT It:
METLYTE 8

3151A M

DISC LOT #: DR # : 000
OPER # : 013 0000100684
SERIAL # :
73-118 MG/DL

GLU 91 7-22 MG/DL
BUN 10
1.0 0.6-1.2 MG/DL

CRE CK 5000* 39-380 U/L 138 128-145 MMOR.-
NA+
-4 .7 MMOUL

K+ 4.4 3.3CL-114* 98-108 MOM_ 18 18-33 MMOUL
tCO2 CHEM OC: OK
: INST QC: OK
4 HE_M 0 , LIP 0 , ICI 1 +

X
-C
1
tCO2

Cl.,esm (6 -.,..„,_ ''''''
,(3,), c tX) 'ail .'

DATE: LAB ID NO.: Q AA ki‘)
CHEMISI A Y RESULT FORM (Subject to the Privacy Act of 1974) SSN/PSEUDO SSN:
' k•Or6 . tal4Qi -,ilk
TEST RESULT REF. RANGE
l
GLU 73-118 mg/c11
Y
-
BUN 7 22 mg/dl
CA+ 8.0-10.3 Ing/d1 CRE 0.6-1.2 mg/d1 NA' 128-145 mmol/1 K-3.3-4.7 mmolil
CL 98-108 mrno1/1 tCO2 18-33 mmoUl ite00)%Nf.eii.!4n-el-pl6g,:;,
,....!:-....,,,::-:.,...--;.,,..:::,....::„:.:.....:.:::!!..a:
TEST
ALB
ALP
ALT

AMY

AST

rBri.
3GT
7F.
TEST
A'
,
,
RESULT REF. RANGE
3.3-5.5 g/dl 26-84 all 10-47 u/1 14-97 to
11-38 u/1
0.27 1.6 Ingi, I
. 5-65 u/1 6.4-3.1 Wdl
; ..• .... ... •
.
volo.I.X104011t0;,-,
RESULT REF. RANGE
128-145 mrnoVI 3.3-4.7 mmol/1
98-108 mmoL11 18-33 mmo1/1
.
MEDCOM - 22662

DOD-036238

Ward/S ion: REQUE ' • • • 'SICIAN:
CHEMISTRY RESULT FORM

1 Suliect to the Privacy Act of 1974)LAST, FIRST ,
-T.4. SS " -'' •• N:
r-A)60 -6

,.. ­
. --- --• - , ,.. .. ... : .
,i0610',01i014i.4 .. ' ' -',:: i.0 ' M-etabolic:Patiel..
;',',::,,..-:,--.:.:-
':.: is;::-7::;':,.it"::-.::..;::;•', : .•..-'; ei.,;::! .'', ',..:.' ..'.-
7:":',' •,' :•:,,i-;;:jf'-.j . :if::"-: -!':'' ::•::::- -.: .',:,;',.;',
TEST RESULT ". F. RANGE

TEST RESULT REF. TEST RESULT REF. RANGE RANGE
Na 1 5 -?. 138-146 na2o,RI/1.. ALB 3.5-5.5 g/d1 U 73-118 mg/d1
K 0 3.5-4.9 mmol./L . '".-I .m.sa,./1
t1UN 7-22 nag/d1
Cl 98-109 mrool/L A_

A+ 8.0-10.3 rog/d1

pH (Lqi
_-
Ll_

7 . ;1 7.31-7.45 A -- -PI COLO - - - - — RE 0.6-1.2 nag/di PCO2 L 11/03 (i : 04 : 17
A' 128-145 mmol/1
3 .7 43 15:5145 m TilFgrgZ)
REFERENCE MAI F

80-10.5 mmHg (art) T_
P02 3.3-4.7 mmolil
-7 ‘ N/A (veal PAT I ENT #' TCO2 5 ,234 :,279 mmolli.v B_frETLYTE 8 L. 98-108 mmo1 /1
i /L ((artn))
DISC LOT #• 3151M4
,4
1--12
32:2286 mmo
vULL avrten)) r

HCO3 ;0 18-33 mmolJl
-OPER #: 013 DR #: 000 2
_

s02 95-98% C SERIAI_ # : 0000100681 :`,...' .: .
.(giediilii)TLg'ii-Pdliil Pliii,';i:'-:::-
..7%7;.";;;;:',.,::.".:,:.: :::,,,;....::!!..::::::.?: '• ...:

5
'• k'.:),*:•.-::V.:; -...;,:
BEecf . (-2) - (+3)
C TEST RESULT REF. RANGE

nanol/L GLU 92 73-118 MG/DL AnGap 10-20 mmol/L a BUN 9 7-22
MG/DI-LB 33-5-5 8/c11 CRE 1.6* 0.6-1.2 MG/DL

Ca 1. 12-1.32 mmol/L LP 26-84u/1
CK 5000* 39-380 U/L8-26 ng/d1
BUN ' NA+ 140 128-145 MMOL LT 10-47 till
K+ 4.9* 3.3-4.7 MMOVL
70-105 mg/dt. :

GLU 14-97 un
CL-111* 98-108 MM0f/L MY tCO2 19 18-33 MMOIA_

Creat 0.7-1_5 mg/d1
-

G ST 11 38 u/1
Lf I 38-51% PCV

Hct .B INST QC: OK CF-EM 00 OK BIL 0.2-. 1.6 ro g/dl
-

Hgb I LA 1217g/dl 7 1-EM 0 , LIP 0 , ICT 1+
GT 5-65 tilt

...i7X!.Sijqh-einkifiy. 7_ . :, .!. C P 6A-8.1 g/dI
., :. -•i:,-, •7;:,-i,..% '.',,.;::. :1 ....: :.•:,—: .:*i '''

TEST RESULT REF RANGE N
_:.:.---Ota14Eletio6te...:-

Troponin-1
PEST RESULT REF. RANGE

Drug of . 128-145 mmolfl
-

Abuse
3.3-4.7 mmo1/1
-98-108 mmolll

1 I.0O2 18-33 mo1/1
REMARKS:
REPORTED BY: J DATE:_1 .AB ID NO.:
_I

MEDCOM - 22663

DOD-036239
Ward/Section: REQUESTING PHYSICIAN:
• CHEMISTRY RESULT FORM

IA) (Suliect to the Privacy Act of 1974) LAST, FIRST,
FIRST, MI. DATE TIME SSN/PSEUDO SSN:
(-7-PLZ) (D-2)
-Sm:

TEST RESULT REF. RANGE TEST RESULT REF.
TEST RESULT REF. RANGE RANGE

Na 138-146 intnol/L ALB 3.5-5.5 g/d1 GLU 73-118 mg/di
•3.5-4.9 mmoUL ALP 26-84 u/1 BUN 7-22 mg/d1
1 98-109 mrnol/L

CI ALT 10-47 till CAH 8.0-10.3 men
pH 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 ing/d1
PCO2 35-45 mmHg (art) AST 11-38 128-145 mmol/141 -5 1 mmilz (yen) P02 80-105 mmHg (an) TBIL 0.2-1.6 mg/dl K4 3.3.4.7 alma!
N/A (veal
23-27 Imola. (art)

TCO2 BUN 7-22 mg/di CI; 98-108 mmo1/1
24-29 mmol/L (yen) HCO3 22-26 mmol/L (art) CA 8.0-10.3mWdl tCO2 18-33 mmol/
23-28 mmol/L (yen) s02 CHOL
95-98% 100-200 mg/d]
BBecf (-2) — (+3) CRE 0.6-1.2 mg/di
TEST RESULT REF. RANGE

nunol/L AnGap 10-20 mmol/L GLU 73-118 mg/di ALB 3.3-5.5 g/d1
Ca 1.12-1.32 mmol/L TP 6.4-8.1 g/d1 ALP 26-84 u/1
BUN 8-26 mg/d1 etlyte; ALT 10-47 u/1
iicOYS
GLU 70-105 mg/di
TEST RESULT REF. AMY 14-97 un RANGE

Creat 0.7-1.5 mg/dl GLU 73-mg/dl 11-38 u/1
118
AST

Hot 38-51% PCV BUN 7-22 mg/dl TBIL 0.2-1.6 rng/d1
Rgb 12-17 g/d1 CRE mg/dl 5-65 u/1
GGT
CK 39-380 u/l(M) TP g/d1
30-190 u/l (F)
TEST RESULT REF. RANGE NA+ 128-145 mmo1/1 lecolo)-

40a.

Troponin-1 334.7 mmol/1
TEST RESULT REF. RANGE

Drug of CL 98-108 ramo1/1 NA+ 128-145 mmol/1 Abuse tCO2 18-33 mmol 3.3-4.7 mmol/3
CL: 95-108 mmol/1
tCO2 18-33 mmol/1
REMARKS: 7
-
5-5—x
3, o

REPORTED BY: DATE: LAB ID NO.:
MEDCOM 22664
-

DOD-036240
.

Ward/Section: /c."&( j---r. REQUES rNG
CHEMISTRY RESULT FORM
LAST, FIRST, MI.
TEST
Na
K
Cl
PH
PCO2
P02
TCO2
HCO3
s02
BEecf
AnGap
Ca
BUN
GLU
Creat
RI
Hgb ' ".-;,-.
TEST
Troponin-
Drug of
Abuse

.. ,
,,
RESULT REF. RANGE
138-146 nunol/L
3.5-4.9 mmoUl.;
98-109 mrnol/L
7.31-7.45
35-45 mmHg (art)
41-51 mmHg (yen) 8105 mmHg 010
(yen) N/A 23-27 mmol/L (art)24-29 mmol/1, (yen)
22-26 mmoll (arr)23-28 mruol/L (yen) 95-98%
(-2)-(+3)
rarnoUL
10-20 mmol/L
1.12-1.32 mmol/L
8-26 mg/d1
70-105 mg/d1.
0.7-1.5 mg/dl
38-51% PCV 12-17 g/d1
..4 •-_,
NA..: ..iiiiiji
Z1 .fi.7: "': "-...;f?
RESULT REF. RANGE
!
.
REMARKS:

TEST
ALB
ALP
ALT

AMY
AST
TBIL

BUN
CA-H-
CHOL
CRE

GLU
TP

•::.P..1:,:.icq: ;;;.•'
g;4 •:
TEST

GLU BUN CRE
:-.'' CK
, -t

NA+
+

_Cr
tCO2
(Subject to the Privacy Act of 1974) DA TIME SSN/PSEUDO SSN:
(914);1 / 0.7 AI ys'
-miooloY oin,-4..., -.' -
RESULT REF
RANGE

3.5-5.5 g/dl 26-84 u/1 10-47 u/1 14-97 u/1 11-38 u/I
0.2-1.6 mWdl 7-22 mg/di 8.0-10.3med1
100-200 mg/d1
0.6-1.2 mg/di
73-118 mg/c11 6.4-8.1 g/dl
&61:41i10,1ii ..4.
.i..v ---:;i ,:....
-
:i.; . 51,:. .; ,::: .k.:j-r........':-.: .::;.¦;-..

RESULT REF.
RANGE

73-1 1 8 mWdl
7-22 mg/d1
0.6-1.2 mg/dl
39-38011/1(M) 30-390 u/1 (F) 128-145 mmol/1
33-4.7 mmol/1 .
98-108 raino1/1
18-33 mmo1/1

.--....--
(Piccolo) 406lie.p.*40)„.,.
TEST RESULT REF. RANGE
GLU 73-118 mg/d1 BUN 7-22 mg/di CA+' 8.0-10.3 mg/di CRE 0.6-1.2 mg/d1 NA* 128-145 mmol/1
K+ 3.3-4.7 mmolil
CI: 98-108 mmol/1
tCO2 18-33 010101/1 (Piccolo) ii*it PAiit't..hi" .:„
TEST
ALB ALP ALT
AY
AST TBIL GGT TP

TEST
NA'
K
CL-
tCO2
RESULT REF. RANGE
3.3-5.5 g/dl
26-84 u/I
10.47 u/1
14-97 u/1
11-38 u/1 0.2-1.6 mg/d1 . 5-65 tilt 6.4-8:1 g/dl ,ect! O. 1ectroyte
RESULT REF. RANGE
-
128145 mmol/1
3.3-4.7 mmol/1
98-108 mmo1/1
18-33 mrno1/1
.

./413 G.f--/ 0,2.53" 4./ go_.-Ybeze-si s7/ifivr,
REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 22665

DOD-036241

RAPIDPOINi COAG ANALYZER V4.5

SERIAL 4005485 11/03/03 00:01

Patient ID:
Test Nameir
Test Result: 22.7 sec.
***RESULT OUT

RANGE•**

Ratio = 1,2

CalcuFated -NR =

73
Sample Typelocitrate wh. blood
Test Date :11/02/03
Test Time :23:58
Card Lot :180201
Operator

';)--
RAPIDPOINT COAG ANALYZER V4.54
SERIAL #005485 11/03/03 00:06

Patient ID:
Test Name :APT`T\
Test Result:= 96'9 sed,
***RESULT OUT OF RA ***
Sample Type:citrated wh. blood
Test Date :11/03/03
Test Time :00:02
Card Lot

:O208
Operator

.-RAPIDPOIN1 COAG ANALYZER V4,54
SERIAL #005485 11/02/03

Patient ID
Test Name :PT
Test Result:. 21.6 sec.
***RESULT OUT OF RANGE***
Ratio = 1.8
Calculated INR = 2.52
Sample Type:citrated wh. bloc
Test Date :11/02/03
Test Time :19:55
Card Lot

:080201
Operator

11111111111

EG6+ .
Pt
Pi NamP:

Ha 150 mmol/L
K 3.7 mmo 1 /L
TCO2 23 mmol/L
Hct %PCV

*via
At 37C
pH .
PCO2

45.1 mmHg
P02 55 mmHq
HCO3 22 mmol/L
BEecf , mmol/
s02* a4 %

te

Pa , lent TemP PH 7.308
PCn2

43.0 mmHg
P02 51 mmHg

Patient Temp: 94.eF
FIO2 ••

Sample Type_:
02H0V03 Op e r: 11111
Physician:
Ser# 42011

RAPIDPOINT COAG ANALYZE Ver: JAHSO4;A

V4.1)4

CLEW A5,3

SERIAL #00.5485 11/02/ 3 20 .0Y

Patient ID
Test Namr

-: TT
Test Result:=102.8 sec.
***RESULT OUT OF RANGE***
Sample Type:citrated wh. blood
Test. Date :11/02/03
Test Time :19:57
Card Lot pia

Or-

:

Z7. 7.2 27:C, 51.0 1,14C 31.6 L 91dL Pit 5. *. x10 L 150. 450, LIZ L.4 *1 20.5 51.1 LI 0,2 *L olO'3!uL 1.2 3.4
IR
5.1
x10"3/aL RBC 4.86
x1.0"6/uL 1/1-19b 14.5
gidt. Hct 44.8 try 92.1 fL it14 29.8 pgmit: 32.4 L g/dL
Pit 115. L x10'3/ii LIZ 8.6 *L. Z LIT
0.4 *1 x10'3AL
02-11-03 04:1'8 Patient Limits
4.5 10.5
4.00 6.00
11.0 18.0
.15,0 60.0 SILO 99.9
27.0 31.0
33.0 37.0
150. 450,
20.5 51.1
1.2 3.4
'N-11-03
01:2+ atient Limits
a S.: (1.031.L. +.5 10.5
. +-.)0 x10 4 6/uL 4.00 6.00
Hi 15.7 9/IL 11.0 19.0
. 42.9 1 35.0 60.0 rg 91.6 OL 80,0 99.9
• 2=.2 Pg027,0 31.0 117tC 31. 9 L g/dL 310 37.0 ell-115. L x1.0`3/aL 150. 450.
LIZ 8.4 4.X 20.5 51.1 LIT 0, 40X10:ik6.hO03.4
MEDCOM - 22666

DOD-036242

Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM
-•
v..,..),,t tv Luc I i vektt:y Pict 01 150 / 4)
'LAST, F. T„ .
DATE TIME -
SSN/FSEUDO SSN:

: ..... '. ....(Hen tOlogy) CBC .. • Urinalysis
_Misc. Serology:

TEST RESULT REF RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC ,—.. • 4.8-10.8 x 10 Color N/A RPR Negative
RBC 4.7-6.1 x 109 App N/A Mono Negative
Hgb Hct 14-18 g/d1(1vf) 12-16 wet' (F) 42-52% (M) 37-47% (F) Glu Bili Negative Negative Source • . IyUerobiology0..0.• •. :... . • .. • . . • — .
MCV 80-94 21 (M) 81-99 fl (F) Ket • Negative Stain Gram
Pit 130400 x10 verified SG •N/A Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
... (Hematology) Manual Differential .,.:-• pH0• N/A . Micro
. . -.. • • • - . • •• -• . • • ••• . : Parasites
Segs • Mono Prot Negative Malaria '
Bands . Eos Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative
Other

Atyp Imm Leuk 1 Negative
• •Microscopic Urinalysi

... ,-.. . .. • ....., ... .-. ..-.... . RBC HCG Negative Morph
.._ _...... .. _ I
p +,4-Jh7O -•
Blood Bank , •0.
Hematocrit 37:47% (F)

Sed Rate
Cell

MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other. Directigen Negative
I ABO/Rh

Coagulation Stu - Blood Bank Unit CrOssmatch . '0
• (MUST.SUB1I-IIT SF 518 WITH EVERY UNIT OF BLOOD
-.•• REQUESTED) • •0•-.0`'•0:

TEST RESULT REF. RANGE &WIT TYPE 9
CROSSMAI.TCH
PT 9.8-43.6 secs
APTT 21-34 secs
D dialer 20 ug/ml
FDP 10 ueircl
REMARKS: tc-‘ •

I REPORTED BY: DATE: LAB ID NO.: .
MEDCOM - 22668

DOD-036244

Z,MLSTRY RESULT FORM

(JESTING PHYSICIAN:Ward/Section:
(Subject to the Privacy Act of 1974)

(c10
SSN/PSEUDO SSN:DATE TIMELAST, FIRST, l'
)--
(Piecol)),Ch&nistry 1
TES RESULT REF. RANGE ,T. GE TEST RESULT 9REF.

TEST RESULT i ..../Z 1
RANGE
73-118 mg/dl3.5-5.5 g/dl GLU138-146 mmol/L
Na
7-22 mg/dl
26-34 u/1 BUN
3.5-4.9 mmol/L 8.0-10.3 mg/dl1047 u/198-109 mmoVL
Cl
' .2 roz/d1

7.31-7.45 AMY
PH
IILL 45 mmol/1
1 1

PCO2 P02 TCO2 HCO3 s02 BEed 35-45 mmHg (art) 41-51 mrnHz veal 80-105 mmHg (art) N/A (veul 23-27 mrnol/L (art) 24-29 mmol/L (yen) 22-26 mmoVL (art) 23-28 mmol/L (von) 95-98% (-2)— (+3) AST TBIL BUN CA CHOL CRE 7- PICCOLO ==-:---23:58 1M t02/11/03 RL1tRENCE R1 PATIENT #: BASIC METABOLIC DISC LOT #: 3325ml OPER #: 013 DR #: 000 SERIN #: 0000100684 )8 mmol/1 F. RANGE 7 mmolil 3 mmoVI
AnGap Ca BUN 10-20 mmol/L 1.12-1.32 mmol/L 8-26 mg/dl rumon GLU TP 7 6 GLO BUN rA+ 28* 14 7.7* i.5 73-118 MG/DL 4 u/1 7-22 MG/DL 7u/18.0-10.3 MG/DL
GLU 70-105 mg/dl TEST RESULT CRE NA+ 1.5* 144 0.6-1.2 MG/DL 128-145 MMOVL 7 tilL
0.7-1.5 mg/dl GLU L K+ CL­ 4.3 114* 3.3-4.7 MMOVL .8u/1 98-108 MMOVL
Het 38-51% PCV BUN tCO2 18 18-33 MMOVL
12-17 g/d1 CRE
CK INSI OC: OK CHEM OC: OK
RESULT REF. RANGE NAS HEM 0 LIP 1+, IC1 1+

tCO2
108 rr.mo1/1 33 mmol/1
REMARKS:

clk.\ vta, V-AJ
DATE: LAB ID NO.:REPORTED BY:
AntiV3
MEDCOM - 22669

DOD-036245
Ward/Section: REQUESTING PHYSICIAN: •
LABORATORY RESULT FORM

touojeet to me Yrtvacy Act of 1974)
I
LAST, FIRST,,MI.
DA TIME • SSN/PSEUDO SSN: t 0
1 CI

(Hematology) CBC :: yrina sis -
. : . , misc. Serology ... _ TEST R1fT i -.9
NGE TEST RESULT REF. RANGE TEST
RESULT 9REF. RANGE
NBC 4.8-10.8x 10
Color N/A

RPR Negative
RBC 4.7-6.1 x 109

App N/A

Mono Negative
Hgb 14-18 dl (M)

Glu Negative
l!ilierobiology
12-16 dl (I')
Hct 42-52% (M)

Bili Negative
Source
37-47%(F)
. •

MCV 80-94 11 (M) ..
Ket Negative
Gram
81-99 fl OD
Stain

Pit i 30-,500 x 10 SG N/A
Occ Bid Negative

verified
Lymph % 20.5-51.1% Bld Negative

H. pylori Negative (Ifematti ) Manual Differential : pH N/A
. . .. -Micro
•' . , -
Parasites
Segs Mono Prot Negative

Malaria
Bands Eos

.
-
Urob 0.21.0
0 & P

Lymph Baso Nit Negative Other
Atvp Imm Leuk Negative
:.Mkrpscopic UrinaysiS

RBC HCG Negative •
Morph

.

CrItIn ,t, S1.01_ (?AN0r
• Blood Bank .
Hematocrit 37.47%

Sed Rate
Cell
MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED

Other Directigen Negative
ABO/Rh

Coagulation Studies. . : - - ' . . .0
-Blood: Bank Unit Crossmatclf -0:0-(MIJST SUBMIT SF 5. 18.WITH EVERY UNIT OF BLOOD

, . '
. . . REQUESTED) ' :' : '
TEST RESULT REF. RANGE 9UNTT 9 TYPE 9 ': •
CROSSM4TCH
PT 9.8-13.6 sees
Am 21-34 secs
D dimer 20 tg/m1
FD.P 10 ug/m1

REMARKS: • -•40110‘...-P—t. PT REPORTED BY: DA1 E: LAB 103 NO.:
. .
MEDCOM 22670
-

DOD-036246

Ward/Section: (A.,,,( REQ
LAST, FIRST,,MI. ..-----•-,—.----,----­
(ilcmaOlogY) .
REF. RANGE
4:8-10.8 x 10'
WBC 4.7-6.1 x 10
RBC 14-18 &I (M)
Hgb
12-16 di (F) 42-52% (M)
Hct
37-47% (F)
80-94 t1(M)
MCV
81-99 fl (F)
130;500 x 10
Pit
verified
20.5-51.1%
Lymph % (Hematology) Manual Differential
Segs • Mono
EosBands Baso
Lymph
Atyp Imm
RBC
Morph
42-52% (M)
Spun
•Hematocrit

Sed Rate
Other
-
.:.-COagulation Studies., -
-.•0,0..........•-...0.0.,0...•••..

RESULT REF. RANGETEST 9
9.8-13.6 set:::
PT
21-34 secs
APTT
, 20 ug/m1
D dimer
10 ug/ml
FDP
REMARKS:
REPORTED BY:
LABORATORY RESULT FORM
Sub-ect to the Privac Act of 1974
SSN/PSEUDO SSN:

DATE v 3 TIME
C 0 16

.. Misc: Serology
•Urinalysis .
TEST RESULT REF. RANGE
TEST 9, REF. RANGE
Negative
N/A RPR
Color -
NegativeN/A Mono
App
Negative -• IYUCrobiology

Glu :. . • .. -. •
Negative Source
Bili
Negative Gram
Ket
Stain
Negative
.N/A Occ Bld
SG Negative
Negative H. pylori
Bid
N/A . Micro

. pH -
Parasites '
Negative Malaria
Prot
0.2-1.0 0 & P

Urob
Negative Other
Nit
Negative MIcinscopic Urinalysis;
Leuk . 0...0••0•0.0......
.
.
Negative
HCG
• Blood. Bank ...- .-
. CSF.
..

MUST SUBMIT SF 518 WITH
Cell EVERY 'UNIT REQUESTED
Count
Negative ABO/Rh .

Directigen
;!:. ' . ..-. .BloOrt Bank Unit Croisniatch--:0s.0-0.. --UNIT OF BLOOD ..
. (MUST SUBMIT sr518.WITH EVERY
CROSSM4TCH
TYPE
UNIT


------• I DATE:
LAB ID NO.:.
i _______
MEDCOM - 22671

DOD-036247
Ward/Section: REQUESTING PHYSICIAN:
CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)

.
LAST, FIRST, MI. DATE

TIME SSN/PSEUDO SSN:
.1.7 T , •
i0610)'PIi6iiiteY::1 !Ctilb). ,1WtabliiPa ail

• • -.--,...:::.D.:ic,•:., ::',..--•.::' , ., :f.,'' .:e: :"•:::,: 1,:::..,;:-.:?, ,
TEST RESULT REF. RANGE TEST RESULT
REF. TEST RESULT f REF. RANGE RANGE

Na 138-146 mmol/L ' 2 C-C i okli GLU 73-118 mg/dl
K 3.5,4.9 11=0UL- BUN 7-22 mg/di
Cl 98-109 mrool/L -PICCOLO - -
CA7f 8.0-10.3 mg/dl 03/11,03 00 : 52
7.31-7.45

PH CRE 0.6-1.2 rng/d1
REFERENCE RANGE: MALE PCO2 35-45 mmHg (gym pAT I ENT # : NA: 128 -145 miro1/1
41 -51 mrnffiz (ven)

IffikYC)-1
80-105 mmHg (art)

P02 ME:TLY I L 8 K' 3.3-4.7 mmo1/1
NM. (yell)

DISC LOT #:
23-27 rnrnol/L (art) 3151AA4
TCO2 98-108 mmol/1
24-29 mmol/L (ver OPER # : 013 DR # : 000 CE 22-26 mmoVL (art
HCO3 SERIAL # : tCO2 18-33 mmoV1
23-28 nuvol./L (vcr 0000100494 s02 95-98%
P:iciiiltION!4:-P. dite.f pli4-...]::;,-,.-:,

U21 * 73-118 MG/ -,(:;:,:j....;',;..'..-:; ,;.i.:.:,..'..:. f:..,,,•. ,.'..:z1 ,--. .:: BEecf (-2) - (+3) TEST
BUN RESULT REF. RANGE
13 7-22

runlon MG/DL
AnGap 10-70 mmol/L CRE 1 .6* 0.6-1.2 MG/DL ALB 3.3-5.5 g/dlCK 5000* 39-380
Ca 1.12-1.32 nun& U/L ALP 26-84 u/1N9+ 131
128-145 MMOVL BUN 8-267.301 K.f. 4 .8* 3.3_4.7 mmovt_ ALT /110-47 u
. CL -112* 98 108 MMOLL
GLU 70-105 mg/d1 -AMY 14-97 u/1. tCO2 16* 18-33 MMOVL
Creat 0.7-1.5 mu/d1 11-38 u/1
AST

INST QC: OK CFM QC: OK
Hut 38-51% PCV
TBIL 0.2 7 1.6 mg/d1

HEM 0 , LIP 0 1 ICT 1+
Hgb 12-17 g/cil 5-65 oil
GGT

,;..r. :11,4sC;TCIiixiiiit1 TP 6.4-8.1 g/d1 .:: -,
_ , ,

TEST RESULT REF. RANG .ccolo:) •peetTolyte :::.
Troponin-1
TEST RESULT REF. RANGE

Drug of l NA' 128-145 mmol/1 Abuse IC 3.3-4.7 mmol/1
CL: 98-108 mmol/1

tCO-. 18-33 mrnoUl 1 REMARKS:
REPORTED BY: DATE: 1 LAB ID NO.:
3AMV)3

Ma j

NOr-
MEDCOM - 22672

DOD-036248

k 14,R
NS 1$ . 'Po P-rT 2,7,1 WP SG3 ( kt-S
,..,

FIct_bi soo o ,.E. oNT.MEDICAL RECORD - ANESTHESIA0 itChit-`6.e.,..oktonstc.I.-. v0For use of this form, see AR 40-66; the proponent agency is the OTSG
th -OW --]::{Unita) :
TOTALS .7.,..;g0t.:::

" 3-1 ---...-.-... ( WS 0
D'z ---.. e 'Ir -Wee..
,cr: crS6-(1.3, raffiMIIMI IEMIEIMIIIIIPIIIIMII iDEISM G/1:11

t,' Uli,
WM

d 2 2 Mall11111CCM /.11111111
'• 2.0 i:folfg:f.00*
3 tt, 3 "BMW;
..,_ INKgarellM11 IK-
r 12,J, I 1111111111=1 411 /DO del ..„. .......
_, 8=6 VOL AT .. INEEIRIIIIIIIIIIMIRL9111/LIMIREVERIVAIII
Inialti

7',. 7 )-U AGE(i1T: -
111111111111111111111
CRx r LLOID-

k4 ° L. AIR L/Min G
Z 12
\O L-

z 0 Es) N20.L/Min
U ' 0ID-
cry 020L/Min 2..-----Z----2--2.,...-

w 7./ 2--7, '1--
z SINGLE DOSE DRUGS-MARK ON GRID
BLOOD-0
. •
WITH NUMBERS & ENTER IN REMARKS

4 r ,./...
toximrierimusrminzmin ..... 00 -ws Maill.11111111EN.GIIIMMIIII
4:0414.......................................n

, . Warm

IV sto /111, tY0 Mill 3241112111rEfill Iiii7111M1
Code drugs with numbers, ye is with lett!

P ram ft ..!4 warmed 1e MiziragiErame4.1111111111111.111111 s ‘
lTJ

LI Warmed I' Mili INN
, i-n ......---EST BLOOD LOSS 00 ..--------'2'00 .'-----___ DO -4,9 ..itzegA,..--- ‘.-
0., 4...
!S ES :

119.. pry.
:::::::,:%:::::::.:::::::::. URINE V, . / 5' ICA 00 ..-..•.¦
-.

4111Y :.i.STAT.':. TIME.1 40 ° • ID0•0 4;
tow0•0-500•021000'0300,
413 4 5 :.::---..:.:1.:..::::.:::
07_,0.0•
611/1B6LS'.

00074:V.E.101-1 .::::,::::':::-ii::.::.:.:::: zzo . eloiLX;•-e
'
my

• f1,BP by cuff if t-) 200 .....0•0, Z 2.Lib

imintmv-

..:::HgNiAr.r.ocfart. ?m..y253 r ' •
A
18 ...WgilTr-Vill0. t E,EME11.1. 'mPri
..... isrA

6. Heart rate NIS
160 MR OEM MIMI 1111111111111MOPAlbr
:'INITIAVPAW • &Tea PAM M11111111111111 ULT47.2/.
Resp rate 140 ¦11111•111021111M1111111111111 LW'..4 if 1 6455 1 2
BP-
21111111211,1•1¦11111NPANNIMINIIIIIIIIIN 1111=111111MLOW AI -44.6(..,
120 •• Mill•:11111INIMPFALEEZZEIll ••.v Mill 1117-'" AM
t 7 h i.ii ••

BR 111XXXINIRICSIEMPKIIIIIMINWIWAMICIL I._AI=
HR-(transduced) 100 mil1•11111111•El 1111111WAMINLVIRAWEammimmiumaim S.0C"-' 6t7er.-a

13 ) Illiill•MIIEFAIIIIIIIIIMI imply. ami3as-

ECNIR::cmcK0+ BO Amv„Pamm _tt-Ligu...,
010-.Illit

N TOURNIQUET 60

MrirAtin191. 11.111M111 14111111110M1111r1i 1
p4 reigNfr.:130i4tc1c: T—Ar
IMIIIVAIIIIMMITIMMIIIIIIMIIMMIPW,VN11 17.-
0

OK for 40 MINI IINNIIALWIPMFBMISILVILS/ILIMill ci0 0 t---14 ' fAJ ' ' !
PROCEDURE]
ANES- X-X 1111111111=111111•1111•11111111111111dLUMMINIIIIIIMMINIIIIIIIIMMIMMINI .;,,t.V122162. 1
TIME 01,gao 20 1=1111=11111111MIIIIIIIIIININNIMIII=111111MINIMIIMMINNIIIIIMME 0 .acv •

immiumummommommilimummummunissmemmitrems °.'
VT - ml

PR"-So • MIS" 81 inia 7( 0 0 ° P...
I 6 M giiiirai MEMO `..03rfl; '

i-f - breaths/min 0 ¦ tv• to..5
Z
¦ Nin-arispr ia

IM Peek In( pres I PEEP MilltiBlIallrakillnil • mum 0
MN.•

MODE • s( on). Alssist). C(on) Fin C C.-C_ c 1[411111=1111M1111111111
.

TAP/Auto Cuff C°2 ito") E11111EMPIllIMPIIIIMIE1111101111111EILMILW :0.70-"or'"" Vaal
ii BP/oth milPAC CP Specify)

I 102 (Frac or %I raCHIMMIMIIIIMIEVILMIarilMil
I ART fine 1 p020MS) 100 IIIMI o IMINtriligS1111Ta OTHER IL --CI .
oo %I.

ISteth' PC/ES 101•11111INICciLIVIMIESIIIIIVZILI'll s INVIIIBE CONDITION:009,
vi ii Gas analyzer COMMIYAMMI ­
IIIIMICIR11ESitlandlelniMINEMI RESP-1 ti0Sp02. 91... a'
i:). I IN-M Block (T/4) mg 0 now, 0 rennin irw-
Ariffi BP-i 07 5 HR-0ae,
rcCO I iiIIIMVIIMUffiliffinl NM 4tog.To g. ......0F.gpv0g:i:::.
0

P-al wStart Room End
6 IF 0161%. Loa PliiMmlimmilb¦JIMI

Women blkt ...72a11101.ri 1¦Itl
a Cony warmer .1.Y POEM
111=1
Merle with letters & symbols, EVENTS0II.Ta/.MN ' E.)0Ready In End
explain under REMARKS Position —4.6-1.f5 '

I N," 1 [ 44,.V! C3 a. lq0ri, 7.1 z
PROCEDURES and CPT Codes:0-- Colos.i.oiy‘

ANESTHETIC TECHNIQUES: Describe block technique under Remarks
.?(Ici,R :

st.9,,i4„.t::&Q,Q.0.0 ,k— E. 1 (I--
PATIENT IDENTIFICATION: Aiped or od/rte d enrries: Name, Grade/Rare, R0

AY MA0G MENT: Intubation route blade, techni ue, comments
liaical facility
1s".'.F' 01 I.?. D °4_.al: ,.at.12.-Tr°
SUR0
,0PROCEDURE0-7

Qrz i/
OCATION:0( _,..0
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aft 3er3a /41/rET PAGE0/0OF i

DA FORM 7389_ FFR 1998 .,..-r.,..,......................-.

USAPA V1.00

DOD-036249

0.
)-r

0.

M EDICAL RECWRD - ANESTHESIA

For use of this form, see AR 40-66; the proponent agency is the OTSG
o 0 . :iP01.../0 Mi.000):::: TOTALS
D 2 Z a/PiektilA ( ifs )
OD

:ii Fil 22
1760.0).1460:::
et-

w iccn 1---tr; 0 f•9 D Z VotAti. % del •-• D )"' 0 40EN:R:
t;',i Z1-..L..ii •.••.''''' % e.t. CRYST LLOID-
-.

uF.¦t: /- ii,=.) AIR.L/Min
Z 4_ •

•M C44 N20 L/Min
COLLOID-02.L/Min "7-'? _ 2-2.-
w.
..z SINGLE DOSE DRUGS-MARK ON GRID_I,
BLOOD-
WITH NUMBERS & ENTER IN REMARKS
LI NE site
0 Warmed

L40 :W.# 01.1A.
U: 11 /-.4.-e0il.. /0" 0 Warmed
— .. Code drugs with numbers,3 cc-0 Warmed events with !enters
-,....-....9EST BLOOD LOSS _/'
LOSSES..:i: (0(¦\ :
URINE -
1,5V
,..

14'..f:i. 4'1 ' TIME 411Frwe 24 6° _ - 2­2-
.;,..; vv., ..*,..,--,oft,.*0' amn r'',,... .. .SY, NIBOLS:'*i:x::::::,:*:::,:f:*:,:::,::::::::;.......... 220
G Elp by cuff 200 . •
14E-IVI-ATOCRITi.:::: : INITIAL700.1.0 BP- A Heart rate s Resp rate 180 160 140 ' . • :' . ..i'
0/0 120 i70e '
BR (transduced) + HR-M.PRPtigM:::. 100 BO A I 4-I i 4 • '1 .x °.• '.•.•..
OK? -0(v,i N TOURNIQUET 60 ... . . . .
PATIENTREOMK!: _OK for./ PROCEDURE? 3 T "NES- X-X 401 20 1.7 7 'THU i
TIME 1,03D PROC- 0_0 ' , •

VT-mi

lo.0) S.-69
5

f -breaths/min / (Cr.Pi/.a
i Peak Int pies / PEEP
kJ -316/0 .42 /D 3(, MODE - Sfpon). A(ssist), Clot)) C. 9
4 --IP Auto Cuff ---1 02 (tort) to.4.,c''.4••f • LtJ
PACU0ICU0Specify)

P/oth F102 (Frac or %) ,Z.....
Ii1E: ..Frr line .-Sr302.MI OTHER
4

o
Steth. PC/ES , (.S . CONDITION:
f

w Gas analyzer T MP-site
RESP-0Sp02-Block IT/4)
SP.RR-

VAMEsiA777emqptigu,

94.0k Ad

0
o.Start Room End 0 .....-6 arming Mkt /
2 1 ZDLY) 2L-4-1Z—Z
Cony warmer c, Ready Begin
Mark with let toss & syr Opts, EVENTS ifp End
1 .
explain under REMARKS Position
0 E.6.--Z1 CC Z:2-tf.
PROCEDURES and CPT Codes:.
ANESTHETIC TECHNIQUES: Describe block technique under Remarks

PATIENT IDENTIFICAT0: Typed or written entries: Name, Grade/Rare,
AIRWAY MANAGEMENT: lntugion route .e,technique, comments Medical facility I A-7-.164Pia t ,t ( C 0 46...Cir ..."i f ee9 r...,
1400((7.19 la_0
SURGEONS:
PROCEDURE( ./
LOCATION:
L6_10D) 1 .
DATE:
Z.drVO Y01-5 PAGE0
AGE /0OF /

0
IIIIIIIIIIIPIIIIIIIII
COPY 1 - PATIENT'S MEDICAL RECORD USAPA V1.00
M - 22674

DOD-036250
J:34 119 95 / 1g2 lug 1B

NIP TREND 11/03/03
11/03/23 .:32 119 95 I2g / p 8I (Ig 18 30 119 95 / 15X I2g 18
1:28 157 95

TIME HR/PR Sp82 SYS / DIA - MEAN RR 12d / ICU 122 OFF
FiME HR/PR Sp02 SYS / DIA - MEF RP ,3:26 120 96
HH:MM BPM X [SJ / 1C2 122 OFF
mmHg RPM
mm82 23:24 120 95 ITT / 36 OFF
RPM 12•

00:46 62 1U2 ERR 15 11 23:22 120 95 IT2 / P2 12u OFF
00:46 63 L ltd /0
Id2 14

00:41 100 Ig20/ 39 126 OFF 23:20 144 95 ITg /012d
00:44 63 OFF
argi/ 1B8 IFI 25

30:36 86 12d0
ERR 15 22 23:18 128 95 77 / 10.1
00:42 50 V-/ 67 OFF

ig 10

n / Ig0 ¦ • IAA 12 23:16 125 96 all / app pap
00:40 122 OFF
P= / is / ILki Egg 16
12U 18 23:14 MA 95 CCO / gab
00:38 1-1!ti4 j / 1g2 Igo 26 18A OFF
/ Mgg 111E1 18 23:12 121 95 16N / 36
00:36 89 Mrig0/ Idd Igg 12d OFF
00:15 Ugg 93 I2A /0122 16 23:10 120 96
18 00:34 117 86 itg / IC2 Igg 18 idg / 35 LJJ 23
00:10 gdg 94 igg /0122 23:08 120 96
18 00:32 119 89 12A / EN 18 Idg / 35 I2d 18
00:05 iigg 94 1dg / Igg 12A 18 00:30 ikil 23:06 TA 96 Idg / 35 126 19
00:82 ggy igg IQ 18
95 INg / 35 .-12A 18 00:2S il!,4 23:04 MNM 96 76 / 35 126 30
00:0B NI 95 ERR# 11 18 00:26 iAF 1dd WU 18 23:02 gal 96 80 / 36 ION 18

INA IAA 18

23:55 UNM 96 76 / 36 . Mb 18 23:00
BO:24 LINU 97 86 / 38 52 10
• ' INN9

23:50 LtU 96 76 / 37 • 52 18 00:22 4:0 18 22:58 86 97 96 lgg
59 OFF23:46 / IgN 18

ggg 96 77 / 36 . 51 18 00:20 22:56 i12 98 107 / 45 62 OFF
23:40 TA 96 81 / 39 . 54 18 00:18 • 1C8 21 22:54 LINA 96 143 / 64 87 OFF
23:35 188 IgA 18
ggg 95 79 / 40 . 54 18 22:52 120 94
00 :16 1.. Egg / IgNINA OFF
/ ig8 igd 18

23:30 119 95 75 / IgN 22:50 121 94
a 122 18 00:14 Ltb, 94 lAd / s Kg 21 I& / Egg P1 OFF
23:25 120 95 77 / 35
50 OFF WAt; 93 1_71 / s 22:48 itg 94 ISS! / Igg ICA OFF
23:21 120 96 160 / 35 126 OFF
30:10 ggg 94 IAN / Ogg 12A 22:46 LINg 94 IA2 / Igg 12N OFF
'3:15 106 96 162 / 38 22:44
51 OFF 18 Ugg 94 pg / igg OFF
30:08 j 94 IAN / ICU 128 18
`3:10 120 96 79 / 40 a 54 OF=
00:06 ggg 22:42 jJ 93 EA! / IgN Igtd OFF
3:05 my q994 IAA / Igg I2Y 18
82 / 38 i 55 20 22:48 ggg 94 IAN / P12 ad
00:04 ggg OFF
23:30 121 07 83 / 40 . 95 IA8 / p. 12g 18
55 1? 22:38 TUN g 93 IAN / IgN IgN OFF
??.R? 00:02 UM! 95 [1J / 1K1 I2g 18
n-dA3

00:00 22:36 NJ 93 IN /e le OFF
22:66 LIN:: /. L !AM 95 12E / Ig2 122 18
22:34 120 91 12 / PJ P2 OFF

23:58 MD 96
22:50 120 93 EU / INA Osi,0 ITU / ffq OUV 18
23:56 4D 95 om' 22:32 giNg ICU MAK / P2] Egd OFF
22:45 uNg /t12C 18
94 I2A /0128 OFF 23:54 22:30 Ugg 82 Iv / ggij gsz OFF
!}i 96 im / 35 lull 18

'2:40 Mdg 93 122 / lg lug OFF 23:52 22:22 120 :9NNU IAN / Igg 121 OFF

dgg 96

'2:55 120 92 126 / 1CW I2g I2g / Igg I2g 18
OFF 23:50 22:26 119 IA8 ICL] / IAN atir,!, OFF
?2:30 NNU WI 96 ITg / 1g2 122 18
IA4 ITU / INN l2g OFF 22:24 119 / ICU Igij 24
23:48 119 96 76 / 41
-:25 119 '41NON 53 18
/ igg P OFF 22:22 120 84
23:46 eij / itg 12
Li 96 12g / gtgj4

':20 LID 84 I213 / Ig21 -018 J 18 22:20 LINg on 1A2 / !Ng NB
23:44 ggg 18
:2:15 96 F.1.1 / Ig2 122 18
ggg [2I 84 /Igg 12U09 23:42 22:18 UNN II;An4
udg 96 le / 93 ICA 18

22:14 im 835 12A 18
ERR# 2

IgA023:40 J 96 le / 35 12g 18 22:16 WA P2] 12C ti56 1Y 98
'1 :38 22:14 WA AAAt 126 / J 12g 17
gtAg 96 )LTJ /
36 IM 18
22:12 46 :NNINI OFF OFF OFF OFF

3:36 ggd 95 162 / 36 126 18
ADULT 22:10 121 la OFF OFF OFF OFF
22:08 it2 OFF NOT ZEROED OFF
22:06 ggg OFF 126 / 56 75 OFF
22:04 gm OFF 84 / 39 53 OFF
22:02 LK] OFF 87 / 39 52 OFF
22:00 25 OFF NOT ZEROED
OFF
21:58 9FF 95 / 40 55 OFF

1P4747 ,7474:74:PL'
SYS-TEMS:

22:50 120 93 kAu / INA

ft OFF ADULT
22:45 94 E /
PAU El OFF
22:40 Lell 93 rffj / 1E4 ra OFF
22:35 120 92 ICIN / leg
IEN OFF

22:30 NJ EEEI FAN /4

Irkt4 OFF
22:25 119 MNII I
/ t P OFF
22:20 WA 84 ra / • RiN 18
22:15 WA gig 84 / Wig

rdri 9
22:14 LW
AIM ERRS 2 P21
ADULT
MEDCOM - 22675

DOD-036251

IBP TREND 11/81/03
NIBP TREND 11/01/03
TIME HP/PR Sp02 SYS / DIA - MEAN RR
HH:MM 5PM 7 01:25 142 ONO 103 / 52 70 14 01:21 140 ONO 96 / 48 67 18 01:15 141 ONO 95 / 48 66 16 01:10 143 4iN0U 95 / 54 69 14 01:05 141 ONO 100 / 52 73 17 00:55 141 ONO 92 / 48 66 14 00:50 141 ONO 92 / 48 66 15 00:45 141 99 88 / 47 64 14 00:40 144 1;Al 86 / 46 63 15 00:35 145 40qj 92 / 50 66 16 00:31 144 Mai 94 / 44 65 15 00:26 144 99 92 / 46 65 15 00:20 144 94 89 / 4? 64 15 00:15 SRCH 90 / 49 65 25 00:10 IN 91 92 / 51 69 27 00: 92 99 / 63 79 1E4 00:0 LV2 89 110 / 59 ?9 kg 6 it ti; 89 105 / 60 78 20 23:51 ! 91 113 / 71 • 83 21 23:45 ::;011 135 / 100 . 110 18 23:40 go 95 ERRt 15 19 23:35 ijal 90 117 / 59 83 13 23:30 On ONO 109 / 64 82 20 23:25 itki 90 99 / 66 . 76 21 23:20 WO 91 102 / 58 74 27 23:15 ONIC, 95 / 55 70 28 23:10 giR 96 103 / 56 76 126 23:05 144 97 105 / 63 • 79 3?CD) 145 77 la5 / 56 52 27 22:55 143 95 114 / 69 87 31 22:50 144 90 112 / 63 • 81 28 22:45 141 49 130 / 71 95 36 22:40 ilad 9? 132 / 6B 95 12 22:35 141 100 130 / 81 99 14 22:30 143 99 134 / 70 97 15 22:25 136 99 130 / 77 97 14 22:20 136 99 140 / 79 101 14 22:15 137 100 137 / 74 99 2B 22:10 131 100 126 / 77 97 22 22:05 ice'. 99 13? / 73 100 14Ort Mg! 98 138 / 69 97 14 21:56 On 97 120 / 62 86 14 21:50 UOU 94 108 / 56 76 18 21:46 On 88 128 / 56 85 14 21:40 j1 la 108 / 58 77 26 21:35 itIN 8[11 114 / 58081 14 21:30 it OFF 107 / 59079 OFF ADULT mmHg RPM HH:MH RPM X 9mmHg RPM 06:03 gn 89 87 / 49 66 2606:00 ij 91 89 / 42 . 62 20 05:56 Td6 98 ERR 15 17 05:48 !In 98 96 / 52 • 70 19 05:46 irgU1 98 84 / 49 = 63 2405:40 1E11 100 87 / 48 • 65 21 05:35 Ha/ 98 110 / 48 75 14 05:34 143 96 107 / 53 76 15 05:31 144 98 99 / 51 70 16 05:26 46.17 97 ERRS 15 15 05:20 141 93 107 / 61 79 26 05:15 154 95 105 / 62 80 20 05:10 144 98 109 / 62 88 2205:07 ii 86 ERR# 15 24 05:00 139 98 106 / 59 77 1604:55 .139 97 116 / 52 . 79 19 34;50 138 98 109 / 55 79 14 04:45 138 95 110 / 55 77 17 04:41 138 94 105 / 51 72 15 04:38 138 ONO 103 / 51 73 14 04:35 141 :1I) 101 / 49 71 15 .:30 140 # J 102 / 51 72 16 04:25 139 ONO 101 / 49 69 15 04:21 139 41N001 92 / 46 65 14 04:15 138 ;tin 89 / 46 63 1404:10 139 90 / 47 64 1404:06 139 .eNg 86 / 47 63 14 /04:03 139 AMU 86 / 47 62 1404:00 140 Agn 89 / 53 65 17 03:57 139 416001 84 / 46 61 1403:50 140 41011 88 / 49 65 1? 03:45 141 Mt 87 / 52 67 15 03:40 142 ma 95 / 54 71 16 03:35 144 ONO 93 / 55 77. 26 03:30 144 ONO 103 / 60 74 14 03:25 142 ONO 92 / 53 69 15 03:20 144 ONO 100 / 55 74 17 03:15 142 :!i j 95 / 56 72 16 03:10 142 .7;178 96 / 56 72 16 03:05 143 ONO 95 / 56 69 14 9:04 144 Mgt 92 / 61 71 14 3:00 144 .Agyt 95 / 53 70 14 02:56 144 41:10 ERRS 15 1902:50 146 1lia 98 / 60 76 18 02:45 144 ma 97 / 55 73 17 02:40 143 kat 95 / 57 73 15 02:35 144 ga 96 / 55 72 16 02:30 144 ONO 95 / 53 71 1702:25 144 gall 96 / 56 72 16 02:20 146 ONO 99 / 53 70 17 TIME HR/PR Sp02 SYS / DIA - MEAN RR 5 140 41:1011 102 / 52 73 15 40 139 92 101 / 52 71 14 ,-.36 140 ONO 98 / 51 70 18 01:30 141 99 102 / 53 71 16 01:25 142 ONO 103 / 52 70 14 01:21 140 4100 96 / 48 67 18 01:15 141 :gm 95 / 48 66 16 01:10 143 ONO 95 / 54 69 14 01:05 141 ONO 100 / 52 73 17 01:00 141 ONO 95 / 52 67 16 00:55 141 :W011 92 / 48 66 14 00:50 141 nNJ 92 / 48 66 15 00:45 141 99 88 / 47 64 14 00:40 144 :411:1 86 / 46 63 15 00:35 145 gMil 92 / 50 66 16 00:31 144 1INMIJ 94 / 44 65 15 00:26 144 99 92 / 46 65 15 00:20 144 94 89 / 47 64 15 00:15 S1J SRCH 90 / 49 65 25 00:10 ) 91 92 / 51 69 27 00:05 TA 92 99 / 63 79 ItO 00:01 0A 89 110 / 59 79 WIZ 23:56 ) 89 105 / 60 7B 20 23:51 O6.11 91 113 / 71 23 21 23:45 4,16 ga 135 / 100 ¦ 110 18 23:40 gjg 95 ERRt 15 19 23:35 TV 90 117 / 59 B3 13 23:30 ira ONO 109 / 64 82 20 23:25 irdl 90 99 / 66 . 76 21 23:20 Ug 91 102 / 58 74 27 23:15 Lui ONO 95 / 55 70 28 23:10 LEM 96 103 / 56 76 mad 23:05 144 97 105 / 63 • 79 32 23:01 145 97 103 / 56 82 27 22:55 143 98 114 / 69 87 31 22:50 144 98 112 / 63 . 81 28 22:45 141 99 130 / 71 95 36 22:40 101 97 132 / 68 95 18 22:35 141 100 130 / 81 99 14 22:30 143 99 134 / 70 97 15 22:25 136 99 130 / 77 97 14 22:20 136 99 140 / 79 101 14 22:15 137 100 137 / 74 99 28 22:10 131 100 126 77 97 22 ADULT +-WO TO C 0 5 E J N. CC.
PRO TO C 0 L' 3"6" T E AC 6', :V•:. 02:15 144 ONO 94 / 54 02:10 144 an 96 / 56 02:05 144 ONO 94 / 56 02:00 142 ONIV 99 / 56 01:56 143 Mgt 90 / 52 01:50 143 igal 99 / 53 70 18 74 19 72 16 72 17 66 15 72 17

MEDCOM - 22676

DOD-036252

.

11/83/03 0947:29 140­
cr; -61 ART/!D CUP=80/21(24) .80=11 SPIPigt. 24FT ESIFIFF
3 9 •
, -13 ION::
•• • ¦ •
.:. • • ... • ....

........

.... • .... .
......... .

¦ • • • • • • • • • • • .... • • •
. •

PACER DISPLAY ON

60
30 • -20 10

ii 3103 00:48:32 HR=61 flih CL01,32/23(26)

....

. " -"... •
E . ..

) . •." ".

-• • . . • ... -
PACER DISPIAY Eli -• • •


. •

: yu
60 pp'
30
20

10 : cup-
• • • • • • • ¦ • • • • •
• • •

RR--28 512=0 RIOMFF T1=OFF I24ICF eTOFF : : .1
. . . . . . • . . • a0.

MEDCOM - 22677

DOD-036253

)¦ 15 , 13 432NO EAD II }{1.9 HR=----

mmE--MEMIIIMEEMEa EME=MEME=
M

Warn Mira
IAIEEEMEEEMPIAMiEREEMINEEMIE. MMEHMEMEMMEMENMEMEEMEMEMMENESEEMEMME
MEMEMEEMEMEMEMEMEMEMEME MEEMEMMEMEM

MEMEEMEEMEEMEMEMEMMEEMEMEEMEME

EMEMEMEMEMEEMEMEM-EME ME" -ME

P/N 804700
PHYSOCONTROV
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P/N 804700
PHYSIOCONTROV

MEDCOM - 22678

DOD-036254

15: 16 02N LEAD II X1.0 HR=---

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P/N 804700

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P/N 804700

18 02NOV03 LEAD II X1 0 HR=-1211151,11. PRIM -11111ENINMEERIMINEMIPIIMMINMEMBRIMMINME5Wr:11101.11
MEDCOM - 22679
DOD-036255
4

518-123
NSN 7540-00-634-4158
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSI
Products are requested.)

RED BLOOD CELLS
FRESH FROZEN PLASMA [A" TYPE AND SCREEN
DIAGNOSIS OR 0

EDURE

PLATELETS (Pool of units) CROSSMATCH
CRYOPRECIPITATE (Pool of units) DATE REQUESTED terlit j I have collected a blood specimen on the belo
Rh IMMUNE GLOBULIN
named patient, verified the name and ID No. of th DATE AND HOURRE/UIRE13.7_ patient and verified the specimen tube label to b
1.11 OTHER (Specify) A, correct.
VOLUME REQUESTED (Ifplicable) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATU REACTION (Specify)
ML
I Ow,

REMARKS:
PATIENT IS FEMALE, IS THERE HISTORY OF: 7
lioc4.03

go
wurrei& /c/o RhIG TREATMENT? DATE GIVEN: 3/
TIME VERIFIED

HEMOLYTIC DISEASE OF NEWBORN?
SECTION II -PRE-TRANSFUSION TESTING
UNIT NO.
TRANSFUSION NO.

TEST INTERPRETATION
PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
RECORD tia....LIO RECORD

1111111. PATIENT NO.
RMING TEST v J
DONOR RECIPIENT
A ED DATE
ABO

REMARKS:

Rh ?C) h ­
6')/? 03, 1.)ov 03
s

SECTION III -RECORD OF TRANSFUSION
POST-TRANSFUSION DATA AMOUNT GI
TIME/DATE COMPLETED/INTERRUPTED
ML Oc--1-°3 24D

REAC ION PE ATURE PULSE BLOOD PRES URE
(AT NE
SUSPECTED
(g. J O

IDENTIFICATION
I reaction is suspected—IMMEDIATELY:
Y-) I have examined the Blood Component container label and this form and I find all
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item.
2. Notify Physician and Transfusion Service.
The recipient is the same person named Component Transfusion Form and
3. Follow Transfusion Reaction Procedures.
on the patient identification tag.
4. Do NOT discard unit. Return Blood Bag, Alter Set, and I.V. Solutions to the Blood Bark.
1st VERI
DESCRIPTION OF REACTION URTICARIA CHILL . FEVER E PAIN
OTHER (Specify)
2nd
OTH DIFFICULTIES (Equipment, clots, etc.)
PRE-TRA

NO YES (Specify)
TEMP. 2,— I PULSE 16)-3 B
DATE OF TRA

TIME STARTED

3i 0 c+ 03 2.030 (Aim-
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last rank; SEX
WARD 617/01
rate; hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSIOI
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.20-1

MEDCOM - 22680
DOD-036256
518-123
MEDICAL RECORD
COMPONENT REQUESTED (Check one) RED BLOOD CELLS O FRESH FROZEN PLASMA O PLATELETS (Pool of units) CRYOPRECIPITATE (Pool of units)
• Rh IMMUNE GLOBULIN
. OTHER (Specify)
VOLUME REQUEST \D\ (If applicable) U¦... ML
REMARKS:
UNIT NO.
11111111111101

DONOR
ABO A
Rh•cIOS

IDENTIFICATION
4::).S"
i q to
3to
TRANSFUSION NO. PATIENT NO. RECIPIENT ABO Rh ? s

(\.) I have examined the Blood Component container information identi fying the container with t The recipient is the same perso 1/4.42on the patient identif
VERIFI
DATE OF TRANSFUSION
31
NSF47§40-G0-634-4158
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell
Products are requested.)
TYPE AND SCREEN
CROSSMATCH
DATE REQUESTED
-
31 (-1'03
DATE AND H01111 REQUIRED
Itc5ik V

KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION ANTIBODY SCREEN
CROSSMATCH
NA ci)
CROSSMATCH NOT REQ UIRED FOR THE COMPONE REMARKS:
03,Nov o3
SECTION III - RECORD OF TRANSFUSION
AMOUNT GICiE
ML
ION ONE 0 SUSPECTED
REQUESTING PHYSICIAN (Print)
DIAG RATIVE PROCED
tiv
I have collected a blood specimen on th

below
named patient, verified the name and ID No.

f the
patient and verified the specimen tube label

be
correct.
SIGNATURE OF VERIF

VERIFIED
oc11 0
I
TIME VERIFIED
18
PREVIOUS RECORD CHECK:
RECORD

NO RECORD
TIME/DATE COMPLETE /INTERRUPTED
310c 3 t 1
PU SE BLOOD PR SSURE
label and this form and I find all nt matches item by item. ent Transfusion Form and

If reaction is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

4.
Do NOT discard unit. Return Blood Bag, Fitter Set, and I.V. Solutions to the Blood Bank.

DESCRIPTION OF REACTION
URTICARIA

LI CHILL FEVER

0 PAIN
OTHER (Specify)

OTHER DIFFICULTIES (Equipment, clots, etc.)
KNNO 0 YES (Spec,

it,SIGNA
/AO

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first rate; hospital or medical facility)
BLOOD .
OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 22681
DOD-036257
518-124
MEDICAL RECORD

COMPONENT REQUESTED (Check one) N.X,„.....RED BLOOD CELLS U FRESH FROZEN PLASMA

PLATELETS (Pool of units)


CRYOPRECIPITATE (Pool of units)


Rh IMMUNE GLOBULIN
OTHER (Specify)

VOLUME REQUESTED (If applicable)
ML

REMARKS:
UNIT NO. TRANSFUSION NO.
PATIENT NO.

DONOR RECIPIENT
ARO ABO
A
po-5

Rh Rh
PRE-TRANSFUSION DATA INSPECT
AT (Ho ON (Date) ID. IFICATION
OcT o3

have examined the Blood Component container label and this form and I find all
information identifying the container with the intended recipient matches item by item.
The recipient is the same person named on this Blood Component Transfusion Form and
ification tag.

DAT
TIME STARTED €.2.,., 740

NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN CROSSMATCH DATEREQUESTED .
VIACr A.
DATE AND HO R REQUIRED

KNOWN ANTIBODY FORMATI . N/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?

SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
REQUESTING PHYSICIAN (Print)
DIA E PROCEDURE

I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be
r
correct.
SIGNATURE OF VERIFIER
DATE RIFIED
ACC) \-D.-) 1
TIME VERIFIED
PREVIOUS RECORD CHECK: ag. RECORD
n NO RECORD RMING TEST

CROSSMATCH NOT REQUIRED FOR THE COMPONENT R
DATE 31 .O cr 0_3
REMARKS:

e 3 Nov 03
SECTION III - RECORD OF TRANSFUSION
POST-TRANSFUSION DATA AivicITTpIVEN TIME/DoECOMPLETED4112 UPTED ML 3( 2 REACT TEMPERATURE PT(E.47 BLOOD PqSSt.t E ONE SUSPECTED by!,
ction is suspected—IMMEDIATELY:

1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.

DESCRIPTION OF REACTION URTICARIA
CHILL 0 FEVER PAIN

0 OTHER (Specify)
0TH • DIFFICULTIES (Equipment, clots, etc.) NO
0 YES (Specify)

NAT RE
OVE

PATIENT IDENTIFICATIO
EMBOSSER (For typed or written entries give: Name—Last, fi
WARD) Cu
rate; or medical facility)

M(1)V?

BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

(9)Lt')H

MEDCOM - 22682 2N, Medical Record Copy
DOD-036258

518-124 NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN (Print)Products are requested.)
.REDRED BLOOD CELLS
FRESH FROZEN PLASMA • TYPE AND SCREEN
DIA


PLATELETS (Pool of units) • CROSSMATCH


CRYOPRECIPITATE (Pool of units)

DATE REQUESTED I have collected a blood specimen on the below


Rh IMMUNE GLOBULIN 03­

3

named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube label to beOTHER (Specify) correct.N vv
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION
SIGNATURE OF VERIFIER REACTION (Specify)ML
REMARKS:
PATIENT IS FEMALE, IS THERE HISTORY OF: RhIG TREATMENT? DATE GIVEN:
D vcD \c9.0
TIME yERIFIEDHEMOLYTIC DISEASE OF NEWBORN?

SECTION II - PRE-TRANSFUSION TESTING
TRANSFUSION NO.

TEST INTER PRETATION
PREVIOUS RECORD CHECK:
ANTIBODY SCREEN
CROSSMATCH
RECORD

0 NO RECORD PATIENT NO.
SIGN

C,6-fylp PERFORMING TEST
DONOR RECIPIENT
n CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ
IN ISPIP
DATE 31 ocr bj

ABO ABO REMARKS:
FO5 po5 ex :3 Nov 0
Rh Rh
SECTION III - RECORD OF TRANSFUSION
INSP AMOUNT GIVEN
TIME/DATE COMPLETED/INTERRUPTED ML
Mut oo :ic)

REACTION TEMPERATURE PUr
VRES SURE AT (Hour) . ON (Date) 3 bc_fi-NONE 0 SUSPECTED IDENTIFICATION 61 1)2._
If re 'on is suspected—IMMEDI TELY:
I have examined the, Blood Component container label and this form and I find all

77

1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item.
2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and

3. Follow Transfusion Reaction Procedures.
on the patient identification tag.
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1
DESCRIPTION OF REACTION
. URTICARIA
El CHILL 0 FEVER 0 PAIN OTHER (Specify)
OTHER DIFFICULTIES (Equipment, clots, etc.)
FellCoV

O NO YES (Specify) (°1/,&/S7
TEMP. I PULSE
IBP SIGNATURE OF PERSON NOTING ABOVE DATE OF TptQNSWSIO
TIME STAprp '1.7 i I) (4-PATIENT IDENTIFICATION—USE EMBOSSER For typed or written entries give: Name—Last, first, midd e; grade: rank; rate: hospital or medical facility)
kit
BLOOD OR BLOOD COMPONENT TRANSFUSION
11111PN(c 11
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 2014.202-1

MEDCOM - 22683
MPflirtal Rpr.orri C",nnv

DOD-036259

MEDICAL RECORD I
:;OMPONE IT REQUESTED (Check one) ED BLOOD CELLS
. FRESH FROZEN PLASMA
. PLATELETS (Pool of units) units)
. CRYOPRECIPITATE (Pool of
Ei Rh IMMUNE GLOBULIN
. OTHER (Specify)
VOLUME REQUESTED (If aptelic )
Lik/P

REMARKS:
ML

UNIT NO.ousai TRANSFUSION NO.
PATIENT NO. 11
DONOR RECIPIENT
ABO i1 ABO A
Rh Rh p o s
PRE-TRANSFUSION DATA
AT (Hour) ON (Date)
IDENTIFICATION

NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
TYPE AND SCREEN 00.---tiROSSMATCH DATE REQUVAD

1 Y v o L.) 0 '--'
DATE AND HOUR REQUIRED

rs A— j
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)

IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
TEST INTERPRETATION
ANTIBODY SCREEN

CROSSMATCH
Af 4 (0'
. CROSSMATCH NOT REQUIRED FOR THE COMPONEN REMARKS:
X? gAILA"

SECTION III - RECORD OF TRANSFUSION
AMOUNT GIVEN
ML

REACTION NONE . SUSPECTED REQUESTING PHYSICIAN (Print)
DIAL E PROCED (--
I have collecte ood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to be
correct.
SIGNATU E VERIFIER C..„
t'D -."
N.
DATE V ¦.1
TIME V r ED
PREVIOUS RECORD CHECK:
IQ! RECORD . NO RECORD
SI PERFOR MIN ST

DATE /A6
POST-TRANSFUSION DATA
TIME/DATE COMPLETED/INTERRUPTED

BLOOD PRESSURE
TEMPERATURE PULSE

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and
on the patient identification tag.
P
BPPULSETEMP.

TIME STARTEDDATE OF TRANSFUSION

If reaction is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
4.
.
URTICARIA . CHILL . FEVER . PAIN

.
OTHER (Specify)

./

ER DIFFICULTIES (Equipment, clots, etc.) NO . YES (Specify) SIGNATURE OF PERSON NOTING ABOVE
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility)
eme MEDCOM - 22684
SEX
"Thitc ki

BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-921 Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
Medical Record Copy

DOD-036260

NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION
MEDICAL RECORD
SECTION I - REQUISITION
YSICIAN (Print)

(Check ONLY if Red Blood Cell REQU
TYPE OF REQUESTCOMPONENT REQUESTED (Check one)

Products are requested.)

RED BLOOD CELLS
TYPE AND SCREEN OPERATIVE PROCEDURE
DIALFRESH FROZEN PLASMA CROSSMATCH

. PLATELETS (Pool of units)
6.51-u
units)

.
CRYOPRECIPITATE (Pool of

DATE REQUESTED I have collected a blood specimen on the below named patient, verified the name and ID No. of the
.
Rh IMMUNE GLOBULIN patient and verified the specimen tube label to be
DATE AND HOUR REQUIRED

correct.

OTHER (Specify) 0, jot?) tp"S
SIGNATURE OF VERX y

KNOWN ANTIBODY FORMATION/TRANSFUSIONVOLUME REQUESTED (If applicable)
REACTION (Specify)
ML

Q,

DATE VERIFI
REMARKS:

RhIG TREATMENT? DATE GIVEN: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II -PRE-TRANSFUSION TESTING
PREVIOUS RECORD CHECK:
UNIT NO.

TEST INTERPRETATION ANTIBODY SCREEN TRANSFUSION NO.
CROSSMATCH RECORD . NO RECORD RFORMING TEST
PATIENT NO.

RECIPIENT ES f I DATE
DONOR
)NOV

CROSSMATCH NOT REQUIRED FOR THE COMPONENT RE
REMARKS:ABOABO

es. 3 go, 03

Rh poS
Rh POST-TRANSFUSION DATA

PRE-TRANSFUSION DATA
AMOUNT GIVEN

TIME/DATE COMPLETED/INTERRUPTED
INSP

ML BLOOD PRESSURE
TEMPERATURE PULSEREACTION

. NONE . SUSPECTED
AT (Ho

ON (Date) 1 ked 0 5

If reaction is suspected—IMMEDIATELY:
IDENTIFICATION
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

I have examined the Blood Component container label and this form and I find all
information identifying the container with the intended recipient matches item by item.
3. Follow Transfusion Reaction Procedures.
The recipient is the same person named on this Blood Component Transfusion Form and
4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
on the patient identification tag.

DESCRIPTION OF REACTION 1st VERIFIER (Signature
.
URTICARIA . CHILL . FEVER . PAIN

.
OTHER (Specify)

OTHER DIFFICULTIES (Equipment, clots, etc.)
. NO . YES (Specify) SIGNATURE OF PERSON NOTING ABOVE
IBP

I PULSE
DATE OF TRANSFUSION

TEMP.
TIME STARTED
WI_
SEX

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; \ c.... L.i. )
rate; hospital or medical facility)

BLOOD OR BLOOD COMPONENT TRANSFUSION
N(C)--'1
Medical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy

MEDCOM - 22685
DOD-036261
NSN 7540-00-634-4159

MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print) Products are requested.)
R ED BLOOD CELLS TYPE AND SCREEN
. SH FROZEN PLASMA . DI OPERATIVEPROC URE
units) 9CROSSMATCH

.
PLATELETS (Pool of

.
CRYOPRECIPITATE (Pool of units) WillaftiP

DATE `QUESTED
I have collected a blood specimen on the below

. Rh IMMUNE GLOBULIN V) LJ C) -"Z named patient, verified the name and ID No. of the
patient and verified the specimen tube label to be

DATE AND HOUR REQUIRED
correct.

. OTHER (Specii)
SZ 4--/---
VOLUME REtUEFED (If appicable) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGN TU 0 VERIFIER REACTION (Specify)
ikY- I. -ML -V— rn
? (QA.17'

IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERI 4r-/ )09
REMARKS:
RhIG TREATMENT? DATE GIVEN:
TIME VERI HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO. TEST INTER PRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH RECORD . NO RECORD PATIENT NO. FOR MING T
NA CD flip
DONOR RECIPIENT
. CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ DATE /A/OV05 ABO ABO REMARKS:
Rh r, 31140, D'3
Rh poi
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
INSPECTED AND ISSUED BY (Signature) ML REACTION TEMPERATURE PULSE BLOOD PRESSURE NONE . SUSPECTED
our) .. e ON (Date) 14/0.10.3 IDENTIFICATION If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag.

4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. 1st VERIFIER Si DESCRIPTION OF REACTION
. URTICARIA . CHILL . FEVER . PAIN
. OTHER (Specify) 2nd
JL_t OTHER DIFFICULTIES (Equipment, clots, etc.)
. NO . YES (Specify) SE BP
SIGNATURE OF PERSON NOTING ABOVE DATE OF TR SION TIME STARTED
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; SEX WAR rate; hospital or medical facility) _
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMA 141 CFR) 201-9.202-1

MEDCOM - 22686
Medical Record Copy

DOD-036262

NSN 7540-00-634-4159

BLOOD OR BLOOD COMPONENT TRANSFUSION
(Pool of named patient, verified the name and ID No of the

MEDICAL RECORD SECTION I - REQUISITION (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)
COMPONENT REQUESTED (Check one) TYPE OF REQUEST Products are requested.) DIAGN ERATIVE PROCEDURE LL..)
Ir RED BLOOD CELLS TYPE AND SCREEN
FRESH FROZEN PLASMA CROSSMATCH e below
units) I have collected a blood specimen on

. PLATELETS n 0 3
DATE REQ9ESTED patient and verified the specimen tube label to be
units)
(Pool of

CRYOPRECIPITATE
IV 0 LI
correct.

.
DATE AND HOUR REr54._ --Rh IMMUNE GLOBULIN 1 SIGNATURE OF VERIFIER
.
KNOWN ANTIBODY FORMATION/TRANSFUSION OTHER (Specify)
REACTION (Specify) r 5 applicable)
VOLUME REQUESTED (If ML D •TE
11 --

IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN: REMARKS: HEMOLYTIC DISEASE OF NEWBORN?
TRANSFUSION TESTING
PREVIOUS RECORD CHECK: SECTION 11 NO RECORD
– PRE­

TEST INTERPRETATION RECORD
CROSSMATCH
FORMIN TRANSFUSION NO,
ANTIBODY SCREEN UNIT NO.
CPT
ATIENT NO.
o5
DATE

FOR THE COMPONENT RE RECIPIENTp\ ROSSMATCH NOT REQUIRE
CROSSMATCH DONOR
REMARKS:

ABO ABO
0.

16 Rh Rh RECORD OF TRANSFUSION POST-TRANSFUSION DATA SECTION III

TIME/DATE COMPLETED/INTERRUPTED

PRE-TRANSFUSION DATA BLOOD PRESSUR
ignature)

INSP
IMMEDIATELY: If reaction is suspected—

Discontinue transfusion, treat shock if present, keep intravenous line open. r
AT (Hou 1. Notify Physician and Transfusion Service.
form and I find all --) Follow Transfusion Reaction Procedures.
2.

IDENTIFICATION matches item by item. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Ba
I have examined the Blood Component container label and this3.
entL intended recipionent Transfusion Form and

with the
tainer this Blood Comp

information identifying the cornon named on REACTION PAIN
LS DESCRIPTION OF
The recipient is the same pes LL 0 FEVER/Th on the patient identification tag. . URTICARIA
.

k_i
OTHER (Specify)

1st V -
C---)
.
(Equipment, clots, etc.) OTHER DIFFICULTIES 0 YES (Specify) NO
.
SIGNATURE OF PERSON NOTING ABOVE

BP PULSE WARD TEMP.
TIME STARTED
T tit
DATE OF TRANSFUSION

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank:
rate; hospital or medical facility)

BLOOD OR BLOOD COMPONENT TRANSF
Medical Record
STANDARD FORM 518 (REV. 9-924

prescribed by GSA/ICMR, FIRMR (1 CFR) 2(
Medical Record Copy

MEDCOM - 22687
.4711111ae

DOD-036263
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 TIM

PATIENT IDENTIFICATION LI DATE OF ORDER.TIME OF ORDER
ORDER
NOTED AND'231.Opt . 2.-/ -5' 0.HOURS

SIGN

l,r.,,/ 71.Ter) /C I-/
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NURSING UNIT ROOM NO. BED

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TLuu 0.. Ar Lei/ 3_ /k/jC)
PATIENT IDENTIFICATION ATE OF ORDER.TIME OF ORDER

Il9
. HOURS
ii.

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all kittd-0 "-.•.:. 1,,.V 08
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PATIENT IDENTIFICATION 'i ATE OF ORDER.TIME OF ORDER
. HOURS
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IIII

DATE OF ORDER.TIME OF ORDERPATIENT IDENTIFICATION
. HOURS

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NURSING UNIT ROOM NO. BED NO'Ilk

1=1111110:111=11.1111111111111111M /6..,
REPLACES EDITION OF 1

DA 1FAOPRPM79 4256
Mc)

MEDCOM - 22688
DOD-036264
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DR SHALL REORD DATE, TIME AND IGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD C
OCTO PROBLEM NUMBER NCO UMN INDICATED BY ARROW BELOW. SYSTEM
IS USED, WRITE LI0TI
TIME OF ORDER ORDER

DATE OF ORDER0
NOTED ANDPATIENT IDENTIFICATION

HOURS SIGN

URSING UNIT BED NO.
PATIENT IDENTIFICATION
3--rs ROOM NO. PATIENT IDENTIFICATION et NURSING UNIT BED NO.
NURSING UNIT ROOM NO. PATIENT IDENTIFICATION OF ORDER e_70 HOURS

NO. BED NO.
UNIT ROOM
NURSING
MAY SE :USED.

REPLACES EDITION OF 1 JUL 77, WHICH
DA, .4256
, A., 79

MEDCOM - 22689
DOD-036265
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 TIME
TIME OF ORDER

DATE OF ORDER ORDERPATIENT IDENTIFICATION
NOTED AND
SIGN
(.304`

01 1.103 0 3 RS
ROOM NO.

NURSING UNIT
PATIENT IDENTIFICATION
ROOM NO. D NO.
NURSING UNIT
PATIENT IDENTIFICATION

DATE1 OF R(DNEIR
BED NO.
NURSING UNIT ROOM NO.
PATIENT IDENTIFICATION
ROOM NO. BED NO.
NURSING UNIT
MAY BE. USED.

REPLACES EDITION OF 1 Jul. 77. WHICH
DA 4256
, FAOPR
M 79

MEDCOM - 22690
DOD-036266
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.
IST TIMETIME OF ORDER

DATIOF DER nianF R
PATIENT IDENTIFICATION NOTED A
10C-5

ezv OURS
cA)
SIGN

NURSING UNI ROOM NO. PATIENT IDENTIFICATION BED NO. V' DATE OF ORDER1 ft TIME OF ORDER
NURSING UNI ROOM NO. PATIENT IDEM IFICATION BED NO. DATE OF ORDER TIME OF ORDER 1 HOURS A/W 76,6---

NURSING UNIT1ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER1db CS. TIME OF ORDER P`9t) HOURS
5­60 7'ltz1 6.4z 71-p
(
NURSING UNIT ROOM NO. BED NO. 0-ear.,mss

REPLACES EDITION OF 1 JU
DA 4256
IFA7:79

MEDCOM - 22691
DOD-036267

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 M SYSTEM IS USED, WRITE PROBLEM NUMB R IN COLUMN INDICATED BY ARROW BELOW.
LIST TIME

DATE OF ORDER
ORDER
NOTED ANO
SIGN

PATIENT IDENTIFICATION
BED NO.

NURSING UNIT ROOM NO.
TIME OF ORDERDATE OF ORDERPATIENT IDENTIFICATION

I 1HOURS °If"
ftry-P-1.-
%,.•

11S
UNIT ROOM NO.1BED NO.
NURSING
DATE
PATIENT IDENTIF CATION
BED NO.
NURSING UNIT ROOM NO.

TIME OF ORDER
PATIENT IDENTIFICATION

DATE OF ORDER
,q 520

0,110)0.
k-ko fneC1\.TY\ \°C)
ROOM NO. BED NO.
NURSING UNIT 77. WHICH MAY BE USED.

REPLACES EDITION OF 1 JUL
M
DAFOR4256
1 APR 79

MEDCOM - 22692
DOD-036268
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM 0TENTED MEDICAL RECORDTHE DOCTOR SHALL ITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
SYSTEM IS USED. WR LIST TIME
TIME OF ORDER PATIENT IDENTIFICA TION DATE OF ORDER1ORDER
NOS AND HOURS

ot t¦loti 03
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC AT ION
ROOM NO.1BED NO
NURSING UNIT
1'\ NkAci
AT ION
PATIENT IDENTIFIC
ROOM NO. BED NO.
NURSING UNIT
PATIENT IDENTIFICATION
ROOM NO. BED NO.
NURSING UNIT
rI

TIME OF ORDER

DATE OF ORDER1
1 HOURS
1
C-ic2,,

? VeIACtLtk--.
6/U
DATE OF ORDER
1

foi•1Lrc
( 1•.4161
HOURS
\pr
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411.111
TIME OF ORDER

DATE OF ORDER
1 HOURS
BE ED.

REPLACES EDITION OF 1 JUL 77. WHICH MAY
4256
DA 1 APR79

MEDCOM - 22693

DOD-036269

AUTHORIZED FOR LOCAL REPRODUCTION

PROGRESS NOTES
MEDICAL RECORD
NOTESDATE

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MI 0 ---T
?ELATIONSHIP TO SPONSOR SPONSORS NAME SPONSOR'S ID NUMBER
LAST F IRST MI (SSN or Other)

DEPART.iSERVICE HOSPITAL OR MEDICAL 6ACILITY RECORDS MAINTAINED AT
ATIENT'S IDENTIFICATION: 1For typed or written enrries, give: .Name - last, first, rnicdle; REGISTER NO. WARD NO. ID No or SSN; Sex; Dare of Birth; Rank/Grade,
PROGRESS NOTES Medical Record

STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR I41CFR) 101-11.2030)/00/
USAPA V1.00

110

MEDCOM -22694
DOD-036270
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
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.
THE DOCTOR
LIST TIME PATIENT IDENTIFICATION
DATE OF ORDER. TIME OF ORDER
ORDER NOTED AND

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PATIENT IDENTIFICA ION DATE OF ORDER. TIME OF ORDER
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NURSING UNIT RO•M NO. BED NO. 016u f.g.,-.11I Atr6Q.e.0-4.rui-W..G`V.

DATE OF ORDER. TIME OF ORDER
PATIENT IDENTIFICATION
HOURS
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DATE OF ORDER. TIME OF ORDER
PATIENT IDENTIFICATIO /tea.HOURS
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-

NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
DA 1FXRP79 4256
MEDCOM - 22695
DOD-036271
THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )
For use of this form, see AR 40407;
CLINICAL RECORD Mo, Yr. 2003
the proponent agency Is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY INITIALING ;:0.ANCAStegnighat
HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTION, DATE . FREQUENCY,1TIME 31 .-1-
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PAGE NO•
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PATIENT IDENTIFICATION:D
\t/"-'-1/1(D
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

D 8 91
10111112113 14115 lib (01\ r-11
E116117 18119120121122123 N124 01 02 03 04 05 06107
D

EDITION OF 1 DEC 77 MAYS USED.
DA FORM 4677, 1 OCT 78
MEDCOM - 22696
DOD-036272
Verity by Initialing Order Date Clerk Nurse THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION ) SINGLE ACTI?NS Date to be Done Mo Time to be Done Yr Time Done 2003 Initials
--- ajiliVA11 CA-)1/CA:1)
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Expir
Date Nurse ACTION, FREQUENCY
TIME/DATE COMPLETED

— — — — — — — —
MEDCOM - 22697 USAPA V1.00
DOD-036273
(MEDICATIONS)

CARE PLAN
DAR 4G-407 ; NISTRATION

THERAPEUTIC DOCUMENTATIONtee ADMI
For use of thls form
the pro nent a ency Is the Of4ice of The Surgeon General. WING EACH :::: INIIIAL PROPER COLUMN FOLLO
to
.........................
..........................................
..............

CLINICAL RECORD1 •DATE DISPENSED
a
.......................................

aD

VERIFY BY INITIALJNG
RECURRING MEDICATIONS, D

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CLERK/D
DOSE. FREQUEN CYDlbD
ORDER
DATE NURSE

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ADDITIONAL PAGES IN USE: OY ES O NO
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DISPENSING TIMES PATIENT IDENTIFICATION:
P N IL CIRCLE MED TIM S
D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
111111 (*)
USED UNTIL EXHAUSTED.

OF I DEC 77 WILL BE
MEDCOM - 22698
h _Fgr49 4678

DOD-036274
THERAPEUTIC DOCUMENTATION CARE PLAN
Order1 Clerk/ Date1 Nurse (MEDICATIONS) SINGLE ORDER, PRE-OPERATIVES1 Data to Time to
be Given be Given Time Given Initials

cm
1I 100 • Oq o 0

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Nurse INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Date

TIME/DATE DISPENSED
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MEDCOM - 22699
'U.S. GPO: 1998454-110/95216

DOD-036275
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use o this form, see AR 40-407:
Mo. Y r.

the Proponent agency. is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
VERIFY BY INMALING
HR DATE DISPENSED
'31 ) "2-

^i

ORDER CLERK/ RECURRING MEDICATIONS, DATE NURSE DOSE, FREQUENCY
tO rI ­iiii t\I
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ADDITIONAL PAGES IN USE:ALLERGIES: YES M NO PRIMARY DIAGNOSIS:

-YES.El NO

PAGE NO .
PATIENT IDENTIFICATION:.

DISPENSING TIMES
USE PENCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 . E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
DA FORM 4678, 1 FEB 79 1 .
MEDCOM - 22700
DOD-036276

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo. Yr.

Order Clerk/ Date to Tme to
SINGLE ORDER, PRE-OPERATIVES Time Given.Ini '
Date Nurse be Given be Given
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C41) .-.—
USAPA V1.00

MEDCOM - 22701
DOD-036277

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-86: the proponent agency is the Office of The Surgeon General.
OTSG APPROVED (Dare)

REPORT TITLE TRAUMA FLOWSHEET QI Appr 11 Jun 97
The proponent is Dept of Surgery
ARRIVALSTATUS
1/min . C-Spine Immob
. 02 .
U IV x.

TIME.
UNIT: .
ETA:.

TIME:.
0 Yes:.

Meds:.9eUKN.. None.
MED COM:
. Yes:.
. None.

a
Allergies: 9(LIKN1.
. Current Last Meal/Fluid Intake .hrs
UKN.

Tetanus:.
LMP:
. Warn . Cool . Hot
. Absent SKIN:

PULSE: 04Present
. Labored 'UnlaboredD. Absent

. NaturalDPatient
. Pink . Pale . Cyanotic ..
BLEEDING:

a a a
TRACHEA: ft Midline . Deviated

. ETTD.
. Dry . Moist . Diaphoretic
. Muffled

= HEART TONES: . Clear
CHEST SYMMETRY:

. Secretions ( 13 a
SECONDARY SURVEY.
ABDOMEN
HEART

a
. Soft . Rigid . Non-Tender
..

RHYTHM: . Regular
. Dilated.PUPILS: . Equal . Fixed . React

GCS: E
. Tender:. Peripheral

PULSES:.. CentralD
• TIN1. Clear . Blood a VD
PELVIS
LUNGS -

`NECK ,
. Stable . Unstable
. Equal . Clear

BREATH SOUNDS: . Bilat
M a .
C-Spine Tenderness:
SPHINCTER TONE: , Blood at meatus/vagina: U

Absent

Decreased
a a a
Pain @. WNL

Hems+ / -Prostate: . WNL . Abnl
Crackles

Wheezes Ugii
. None JVD:
VASCULAR ASSESSMENT
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN

(AB)rasion
(ANIPlutation

kr
(AV)ulsion
Battle's Signs
(BL)eeding
(B)urn
(Dieformity
(Elcchymosis
(Floreign Body

(Hiematoma
(LAC)eration
(P)uncture (W)ound

(Pain)
(S)eatbelt (S)ign
(S)tab (W)ound
(GSW) Gun Shot Wound

+ Strong + Palpable Dopler

PHYSICIAN
RN
/
ue on reverse)
1.-- l
DATE .(21

DEPARTMENT/SERVIPREPARED BY (Signatur
,54

(For typed or written entries give: Name--last, first, HISTORYIPHYSICAL()rBTLOW CHART
PATIENTS IDENTIFICATID .
middle; grade; date; hospital or medical facility)
El OTHER EXAMINATION . OTHER (Specify) OR EVALUATION
. DIAGNOSTIC STUDIES
Cs-(01
1:1 TREATMENT
111 0

-...¦-

TIME PROCEDURE .SIZE , SITE BY RESULTS TIME1PROCEDURE1 ACCOMPANED BY RETURN
Oral 110"/ _ 0 ETCO2 Change

ET CT Scan:D0 Contrast
/ &;::9
5.6 0 Nasal CI BBS Post Int
Intubation Teeth 0 Post CXR

0 Head10 AbdD0 Pelvis ,p--) ,,jcz Air.0 Contents . C-SpineD. T/L Spine . Chest
Gastric 0 Oral 70 /
Verified

4,(Z1
,D. Nasal it" 0
Tube Suction: Y.N
0 Return.cc

A-Gram Site:
vq.5 Urinary
Home Dip:.+ •

1 /4, . Meatus PA'
'f.„--. Supra-Publi IV ACCESS &FLUIDS.
0 Secured . TIME .1 , IW TYPE AMT UP : AMT IN
0 Grossly:.+.- ,

DPL CI Opened
Cell count

e t.-..
0 Closed ib ric
(9()1L

Sent@

0 Air 0 Blood / i 1 I A Chest
. Pleuravac cm A 1,72;' (-''­
/S /. /r
L R —
Tube #1
. Autotransfuser

0Air CI Blood
0 Pleuravac.cm MEDICATIONS
Tube #2 L R ._ ___ „,... ,..•

Chest

0 Autotransfuser ' MEDICATION TIME TIME TIME1
N: DOSE RTE DOSE RTE DOSE . FITE
12 Lead

Rhythm:. Comments

• , ..,a,,.1. h fr• r A?/ ABG SITE' TIME pH pCO 02
1,4,-1 /co 01
1) j ,, . c ....0 ( ,f.20 /(4./2
2) . / tc..„ ,..1 • - ,---1./C i? i 87

LABS ' )(RAYS i

,1.1..., bo - , Lit c:,96 /
nrA
Ve t=
/d /0;25
O 0-stick .0 SHctD 0 Chest Initial

4 ,-,--,. L ?C`-''' F1/
. 0-stickD0 SHctD. . Chest Post ET A---/j/ CVO AV
'CBC ai Chem )0 PT/PTT . Chest Post CT

BLOOD PRODUCTS
0 ETCH Crt&S.O&C x. 0 C-Spine ;-START,.... 1......:, .': (irate1MT ill

0 Tox Screen Pelvis
CI UA.0 HCG CI

0 OTHER

,¦.
0 OTHER

LAB RESULTS INTAKE & OUTPUT

CBC: Chem: ,NI,MC AMOUNT'. T %INT
IVF Urine NGT NGT Blood EBL Other Other
TOTAL TOTAL
TRAUMA TEAM ARRIVAL
VALUABLES & CLOTHING
,-.

-: ,..grrtvi: 0..,. NAM.i.,.irl S1N s1A'.,-..-%.:•f D Phys
None Found

urgeon
Given to Patient

, nesth Given to Family Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696 Other: See Nursing Notes . • X-Ray
DISPOSITION

RT
0 Home 0
Ortho
Admitted to Neuro Report Called to Chaplain Time Transferred
Accompanied BY MEDCOM -22703D0 Wheelchair I
DOD-036279
7 7 1
GLASGOW COMA
SCALE
Recta/ Temp:

GCS: EYE OPENING ; REBLE RESPONSE
1-MOTOR RESPONSE
TIME BP HR RHY RR SAO2 F102 MODE

E V M
4 -Spontaneous 5 - Oriented
6 - Obeys Commands
/ VC ,
ie/ii///9"/S S--
—..Ki__
3 - To Voice 4 -Contused
5 - Localizes Pain
/ I( /c99La, /,--
2 - To Pain 3 - !nape Words
4 - Withdraws to Pain
/e3= c ocv6f /3i=
1 - None 2 - Incomp Speech 3 - Flexion to Pain
/ y
/Wicri /3e/
1 - None
2 - Extension to Pain
i '.i'12
-/.57 id
1 - None
/
TIME1
PROCEDURE:
PERFORMED By
/
0 Backboard Removed
BY:
/
. Downgraded BY:
/
NOTES
/
/
/ .
/
/
/
/
/

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`..¦Kank•Ml aWr

MEDCOM - 22704
DOD-036280
PAGE 1 OF 4 EDICAL RECORD
-SUPPLEMENTAL MEDICAL DATA For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General
REPORT TITLE
OTSG APPROVED (Date)

INTENSIVE CARE NURSING FLOW SHEET
TIME N
PUPLIS
E
SENSORIUM
U

R
O
R
RESPIRATION PATTERN
E
S BREATH SOUNDS

P
SECRETIONS
R
A

O.

R
COLOR
S

INTEGRITY
N
LOCATION
CONDITION
E
ABDOMEN
A
S

BOWEL SOUNDS
T
R

URINE COLOR/CLARITY
U
C
CARDIACRHYTHM
A .

A S
INITIAL SHIFT ASSESSMENT
)(0 -2
INTILAS

I .S9, I INTI
An-vrn
vyNx-N&SLIA s_Aa\-(= c)(2.— FlAksEaks. (ZIL AG roo PAD LAI "To Rc0.. Pimp -xe-ViTet-?;.F-).7 12. • 16NE • nAcItte07kca
r

Mal. a -c"
-CID-C eVNA1\A-312' I tlpDItt)C1(.,
`‘. OCT
Q•cetc14

PAS -1`..\,-kcc..; c_xo
)
A 2-e0 &D
90—b

QA Appr 8Mar 89
INTILAS
C-krf
Cr - Creatinine
CP - Intracranial Pressure .
i
U o -Fraction of inspired 02

LEGEND FPCO2 -S/A - Fractional
PRESSURE OF ARTRIAL CO2L Ft 02 - Bicarbonate SAI -Saturation
PEEP - Positive end Expiratory Pressure

A
. TRACH Tracheostomy
R

PREPARED BY (Signature & die) (Continue on reverse)
DEPARTMENT/SERVICE/CINC

10,{ j DATE& (),....

r03
PATIENTS INDICATIONS
(For typed or written entries give: Name ­middle; grade; date; hospital or medical facility) Last, First,
El HISTORY/PHYSICAL ID FLOW CHART
. OTHER EXAMINATION El
OTHER (Specify)
OR EVALUATION
.
DIGNOSTIC STUDIES

.
TRETMENT

DA FORM 4700
1 MAY78
WAMC OP 375 (Redesignated)

Proponent Dept of Nurs
MEDCOM - 22705 1 APR 90 (HSXC - NU)
DOD-036281

PAGE 2 OF 4
DATE DX
HOSPITAL DAY

I 02- 03 0 6
TIME

ormatmegmram.
BP Arterial line
.

smeatiomae 15/4mummulDNI
BP Cuff

EIIMILI PANIIIIIIIIIIIEDIII
Temperature

EMICSIMMEMS 'TT cl 1 ..Mini
Pulse.

KIM= fg. EIRE=MI=

Respiratory Rate

IMPIIEWIIIIII le Emu.ailm
immlimmtimon96 com.maw
ENIM

ILIMOIRMIEILICIIDII
man toomptraranDii

min.I
.0- mairmirs SEEM1Mk
IIII •

L=JVNIMMMFA17:1a MI1MEM
114 15 8 ° T
DRAINS
SOO
N\CAS:2Q.,
st)C
TOTALS
PAGE 3 OF 4
POST-OP bAY

ACUITY LEVEL CLASSIFICATION .0
1 19 20 21 22 23 TIME
MODE
F1 0 2
D. TV RATE
PEEP
A A T A P H PCO 2 PO 2
G HCO 3 SAT
BASE
TIME
17 18 19 20 21 22 23 8 °
,ZZ

TIME T TIME
U
R
SKIN CARE N
FOLEY CARE TRACH CARE S U C
ROM EXERCISES 0 N
WT Yesterday. wt Today rriALs.
IV INTAKE OUTPUT Urine: (9(()\

Po TOTAL.TOTAL
BAP ANr.F

MEDCOM - 22707
DOD-036283

PAGE 1 OF 4
DICAL RECORD­SUPPLEMENTAL MEDICAL DATA

For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General
NREPORT TITLE
OTSG APPROVED (Date)

INTENSIVE CARE NURSING FLOW SHEET— (q1C\ r-Z-8Mar 89
INITIAL1ipSSMENT
TIME INTIL

INTILWA
IFDoo

PUPLIS pg1k4frivi-\ 6', 40 'F•ccerN u9Rte
E SENSORIUM 1.
U -• ICYN•c-c---A 6, 1 v-_ t. cc:AT6,0V;

R

— 0
)
R
RESPIRATION PATTERN
E t-R-tA Etc,
E:TV4 S-1
SS BREATH SOUNDS
sur,
slraNt--­
SECRETIONS

Tv-'s30 0 ; A 0 ce.,AA,;0,1 5 sue,
46,603fr" neft\rfflis
0 01.¦ vro-A2-68-1-)

V R. %-so,o2
`Ar-14 5

s COLOR
INTEGRITY Itzegirff—Az71 --kirp

ler it-4_0k relvOsA-brecu

N -s,==oszA•-) • (T)
PIrvviN -c; e.f"L-N4 +" 5' r:-11.4A
LOCATION
.S4

§
DT-
V CONDITION ,.....L i
) • 1-•--v
61E) t`$ c_ct,1-A -Vv-r., cocc% • %,...dc,cs4::‘.
E
G ABDOMEN
Piet(M;A-t. 0,5 X10; sum COI
As

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R. f¦-3Lvi — v­
d6w,X4-,y?-

O;
--ck(A-ZQJ`kkti
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URINE

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U COLOR/CLARITY cAr-414 11?-1/k")

S'etrz
ov4--

A CARDIACRHYTHM
Qt k9 ) 1 neo ii4-rxx.. is,

,R
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ccuo.,,,.(t), (I..) tvc- tA-
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crig-r7

A 'Vc-Yt(v5 e-114-`"
z le-2_ s e
Cr -Creatinine
Intracranial Pressure

F, 0 - Fraction of inspired 02 S/A - Fractional
LEGEND PCO 2 - PRESSURE OF ARTRIAL CO, 2 - Bicarbonate F, 0
SAI - Saturation
PEEP - Positive end Expiratory Pressure
TRACH - Tracheostomy

A 1
(Continue on reverse)

PREPARED BY (Signature & Title) DEPARTMENT/SERVICE/CINC IQ)( I DATE/ too 1. 03
PATIENTS INDICATIONS
(For typed or written entries give: Name --- Last, First,middle; grade; date; hospital or medical facility)
.
H 1STORY/PHYSICAL . FLOW CHART
. OTHER EXAMINATION .
OTHER (specify)
OR EVALUATION
. DIGNOSTIC STUDIES
11111111P
. TRETMENT

DA FORM
1 MAY78 41700_ ,", WAMC OP 375 (Redesignated)
Proponent Dept of Nurs
MEDCOM - 22708 1 APR 90 (HSXC - NU)
DOD-036284

4
d

PAGE 2 OF 4
MEM •• ra 6'6 a
BP Arterial line

MUM iItanammoinal¦¦i ¦¦emurimul
BP Cuff
Temperature

1.4 11111111111MEN
imanorms 9cis mu
Pulse

Mum Ivy W? iL1-0 13(-Ewan
Respiratory Rate
MOW

t+ I1+ V4 11111EIMIMMIrsin
IMISIMMIMENIIMINIMIONME811111
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Emma= , 2atirtm
TIME

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tw PAM= , •
ll 2
4:0 4o Co q_u a) 4Z

tis 11)).-
STOOL
-0
DRAINS
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)

MEDCOM - 22709
DOD-036285

Doc_nid: 
3961
Doc_type_num: 
77