Medical Report: 28-Year-Old Iraqi Male, Detainee, Abu Ghraib prison, Baghdad, Iraq re: Gunshot Wound to Chest

NSN 7540-01-075-3786
LABO RDER S
_
• LOG NUMBER TR
EMERGENCY CARE
MEDICAL RECORD AND TREATMENT

RECORDS MAINT
(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DATE ay/, i: .th, nTIME) .a00
'O I
PAC
CITY STATE ZIP CODE TRANSPORTA 0 FACILITY

UV P\C_.
SEX DUTY/LOCAL PHONE MILITARY STATUS . THIRD PARTY INSURANCE AREA CODE NUMBER ITEM YES N/A ITEM YES NO PRP ADDITIONAL INSU AGE HOM NE' FLYING STATUS DD 2568 I ART AREA CODE BER MEDICAL RY OBTAINED FROM N OF INSURANCE COMPANY
CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT
WHEN (Date) DATE LAST VISIT 24 HOUR RETURNITEM YES NO
7 y.f.S n NO
..--"--.-... IS THIS AN INJURY? WHERE US ALLERGIES ... INJURY/SAFETY F S DATE LA OT COMPLETED INTITIAL SERIES HOW . YES . NO
f• ....-...._ CHIEF COMPL
)CiNkfnt -
CATEGORY OF TREATMEN T -VITAL SIGNS
TIME TIME I Va.) S

EMERGENT
BP 1:7* iL^^ 13
PULSE

3_
RGENT
RESP . ay

TEMP
NON URGENT

w KC& ?CO970
(CBC/DIFF ABG .1N PT/PTT BHCG/URINE/BLOOD/QUANT CXR PA & LAT/PORTABLE C-SPINE •
URINE C&S UA MSCC/C ATH CHEM:M.: "— ACUTE ABDOMEN LS SPINE

• CC
BLOOD C&S X CC 0 SINUS HEAD CT
X 0¢ ANKLE R/L

ORDERS
PULSE OX MONITOR
ECG
. .
TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS n HOME n FULL DUTY ri 24 HRS. n 48 HRS. n 78 HRS. MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE TO WHEN

100,
REFERRED
. IMPROVED • UNCHANGED
TIME OF RELEASE I have received and understand these instructions.
PATIENT'S SIGNATURE
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; 10 no. ISSN or other); hospital or edical facility)
. DETERIORATED
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)110) USAPA V1.00
MEDCOM - 18041
DOD-031615

NSN 7540-01-075-3786 TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
Check it read by . ABG/PULSE OX RADIOLOGY radiologist
U
H/H et SUP 02 PH P02 RESULTS
PLT PCO2 SAT OTHER

PT DIP
EKG INTERPRETATION
APTT BHCG ETOH GLU MICRO
PROVIDER HISTORY/PHYSICAL

sr a'Pc-t; c-P C CSW c c,in Q PC , v% e-ckl C l'axtf-rt e e\ - cv Nto-v-00-3
1/4
0 f .
CA tAk 41,3s-,l,„„L RAIZ

u,--L4Ji
-41.01t
Atz
(c) ?-tivte-n)
tt--v a_ cliK)
CONSULT WITH TIME ACTION RESI DENT/MED AL STUDENT SIGNATURE AND STAMP
P .
DIAGNO SIS
rt-M, ur tu
O O
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. ISSN or other); hospital or medical facility)
b C-L) -R-
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.203IbI(10) USAPA V1.00
MEDCOM - 18042
DOD-031616

...---_,,—.,.. •.._,,,,,...
-F eA i ILi' I
1-kl.,I1V11ItS F'._UVVSHEET For use of this form, see MEDCOM Circt. /
5
SECTION I - PATIENT ASSESSME;
DATE: ...._ CV
4
PATIENT ACUITY LEVEL :
POST-OP DAY:
HOSPITAL DAY:
IS
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN
-TELEPHONE REPORT:
Time C')C/2- ( To I C.i.0 D- From
I C. Ut) 1 II AMBULATORY
0 CRUTCHES 111
WHEELCHAIR X STRETCHER
T Total ER/RR/PACU time Physician Anesthesia (Specify):Procedure/Diagnosis aA.C4,0--e(-­
ji-Q-. / 5.0.(iGt-e- L4C-e--4 B/P P
A Cea-73 (CQ
T Neurovascular checks S Dressing/cast •
N LOC
Tubes (YicS 4-c4vul F Intake (IV, po)
Output (EEL, other) -...
Voided
gni No III
Yes Amount:
E Medication R
Other
Report From I--

Received By
b ­
rZ.. TIME: 0(0
BP ARTERIAL LINE .-----------
—0Z
eL c1C—Z
BP CUFF
TEMPERATURE PULSE RESPIRATORY RATE
OXYGEN (L/%)
PULSE OXIMETER
02 METHOD
tnqi 1/6/
/0
70.3
r75

ay
ICI ifo ,-------
ICU % Ur
94-
(1 / •
fq (
.3'
f:7b
0
S
L
T
1
V
Oxygen Method Key: NC = Nasal cannula NR = Non rebreather FM = Face mask VM = Ventu i mask
MT = Mist tent
PR = Partial rebreather
A = Aerosol TC = Trach collar
TIME: 400
TIME:
10 ••
. . 'Skin breakdown
PAIN . . , pr entililvtj, 0 s

INTENSITY • • p "Fal s evention protocol
. . •• CE -Res craint protocol
o • • MED ADMINISTERED (Yr II
_..._ .. __ .._ ' Seizure precautions RELIEF ACCEPTABLE (YIN)
A
-
Isolation precautions
A
TIME:
0 E
T FINGER STICK GLUCOSE
.___. . . . .
H INSULIN (YIN)
D
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT:
E S
_
WEIGHT CHANGE:
R -----
• Per hospit -II pohey.
24 HOUR PO IV #1 IV #2
TOTAL IN Urine Stool TOTAL OUT
TOTALS
1
PATIENT IDENTIFICATION
DIAGNOSIS:
DRG:
ADMISSION DATE:
CIE LOS:
EXPECTED RELEASE:
(0 - II
CASE MANAGER: PRIMARY CARE MANAGER:
/
ISOLATION REQUIRED (Specify):
-
( CHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC V1.00

ni 0 M

SECTIOI \TIENT ASSESSMENT - REVIEW OF SYSTEr
in the small box indic.. . patient assessment criteria have been MET. II ,.. .ne stated criteria are not met, a brief explanation of abnormal findings will be noted in the appropriate column.
DIRECTIONS: A check .
1. NEUROLOGICAL: Alert and oriented to
time place and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.
2. CARDIOVASCULAR: Pulse regular & rate within range for age. No dependent edema.
• Nailbeds and mucous membranes pink. No calf tenderness. (See page 3 for extremity perfusion)
3.
PULMONARY: Respirations within normal rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sounds.

4.
G.I.: Abdomen soft and non-distended.
Bowel sounds active. Reports no N/V.ipain
with eating and no problems chewing)
swallowing. Denies constipation, diarrhea or
rectal bleeding.

5.
G.U.: Reports no dysuria, retention.
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.

6.
MUSCULOSKELETAL: Normal muscle

development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling/tenderness, weakness or paresthesia.
7.
SKIN: Warm, dry, intact. Good turgor. No rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.

8.
PAIN: No complaints of pain/ discomfort.

(See page 1 for documenting pain intensity.)
9. PSYCHOSOCIAL: Behavior is appropriate
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
appropriately with others.

10. IV SITE ASSESSMENT:
IV patency I q_ hr: . IV site care provided:
IV tubing changed:
LOCATION
IV Site #1: IV Site #2:
Comments:
TIME: t 30 INITIALS:
IP"
.
I
I 1 Ciatiz, Stiavv-qL„, (N iC3 .
7-1-eicli2i;-i-c,
7
I
I
k 44-0.9-. Cof...Q.....
I I-CfrA-Q_CLLJO
55
Far
TIME: . I TIALS TIME: INITIALS
,0
CI
t 0 IN
gd
JI
I I Csat-05 I I C.-(9.12.1D _..Q.-.4-AL•V .1.-72-
.
C .A-e.".

..43-Cra-e. -)—•
I I
(Q
1...-4.--,S14-.-4___

C__40.--1-c__
k.r...4-4,24.,..1,)
'. V
/-A--oo L
uysLt-e-

fo dc
a-4A-
.
Ullr\---Ley\_&
I I C)
V-r-1.--/sa. la-
Ages..0-(2-cill_e/.4_jr"'
I.
(LEGEND: P - Puffy I - Infiltrated R - Reddened OK - No swelling!redness - Central line)
TIME:
1 2j3 (....) /...(0 INITIALS: IME: 9 pril
INITIALS: IME:
INITIALS:
IV patency ,/ q hr: IV patency J q hr: IV site care provided:
IV site care provided:
IV tubing changed: IV tubing changed:
CONDITION OCATION CONDITION LOCATION CONDITION
14."1-(----iv Site #1: t......)A___IV Site 111:
TE0.----0"- 0 le---
IV Site #2:
IV Sitc 112:
Comments:

Comments:
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 2 of 4 pages
/—
OTION III - PATIENT INTERVENTIONS & TEA' .1

SITE: r-----......„.TIME:
• TIME:
._
COLOR CAPILLARY REFILL -- S A .ID band visible/legible –• Orient to environment prn
TEMPERATURE EDEMA SENSATION FE T y Side rails (2/4) up Bed position low Call light within reach MI=11 Aal
MOTION

Z w =CcO cn 0 D --I cc
I
PASSIVE FLEXION
Review & post lab results
PERIPHERAL PULSE
Notify MD abnormal labs
•
LEGEND
Color: P-pink (normal); C-cyanotic; W-pale, white
I 0 F--iwcc
Incontinent urine/stool
Capillary Refill: 1-(0-2 secs); 2-(3-5 secs); 3-( 5 secs)
Temperature: C-cool; W-warm; H-hot
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
Motion:
U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Linen change prn
Turn/reposition q2h
ROM q2h if immobile
Antiembolic hose
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;
Ni ¦
D-doppler, P-palpable
BREAKFAST

0 PM
..--------- LUNCH
DINNER
D
TYPE:
TYPE: TYPE:
/.....PERCENT CO UMED: ;c::)7(..1 PERCENT CONSUM : cic
HOW TOLERATED: t.„,11_,OLIZ___ cidic
HOW TOLERATED:
[SELF 01 ASSIST MA MPLETE
. SELF .
ASSIST IN ;ad PLETE
PERCENT CONSUMED:
E
HOW TOLERATED:
T
.
SELF G ASSIST

.
COMPLETE

BATH/ORAL CARE
A D L
TYPE OF ACTIVITY
S (Circle all that apply)
• TIME:
CONTENT:
T
E
A
C
H
I
N
G

0700-1500
.0 SELF 6COMPLETE
. ASSIST TOTAL BEDRE1S . SELF
LATE . ASSIST
BSC # TIMES/SHIFT
BRP CHAIR
INITIALS:
El Patient/Family Verbalizes Understanding PATIENT IDENTIFICATION
MEDCOM FORM 689-R ITFATI /11Ar•i-inl n• .1„ ",
TIME: CONTENT:
1500-2300
. SELF MPLETE
.0 ASS.1,5T .0 TOTAL
DBEDREST E 0 SELF s T
BULATE ASSIST
BSC
BRP # TIMES/SHIFT
CHAIR

INITIALS: TIME:
CONTENT:
2300-0 00
. SELF CI COMPLETE
. ASSIST . TOTAL
BEDREST 00 S ELF
AMBULATE ASSIST
BSC
BRP # TIMES/SHIFT
CHAIR

INITIALS:
. Patient/Family Verbalizes Understanding INITIALS . Patient/Family Verbalizes Understanding SIGNATURE 7-71A--).1 SHIFT 1---) rj" ceime;...-_. Lx(r)Y`-'
Page 3 of 4 pages

MEDCOM - 18045
DOD-031619

SEC --'I III - INTERVENTIONS & TEACHING (Cont)
T
TREATMENTS
W I
LOCATION OF WOUND APPEARANCE AND
M
0 E DRESSING CHANGE

SO.Ca5-01-6____CUU----.g d-%-•-•..--1-fatir-A -e.24

U L) t_1-- ----
N 6 q ALci. , 'kr'
D
C
A

R .
.

E •
SECTION IV - NOTES
1.
340 f ''
2 l_iiia.11.-IL.-.1 dA.9.-,-, o___,tA„,
—
4, ... IL...a
C--1-e_p t,,) ( S'._: • A. a 0
Th,..--e_.,
d-f-41,-,4-)cf--8.--0"¦ -1Q 44 A_ _ A Am....' 4r,‘ -\:„ , ..._,Q 6--(— li
0+ -ic--/le__d t A.-JIL. Vii
b (;)
---2-
• _ _ _ __._.... __.________

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
Page 4 of 4 pages
MEDCOM - 18046
DOD-031620

r" c DICAL RECORD - PATIENT ACTIVITIES
r. I _ 0 W S H E E T
For use of this form, see MEDCOfv1 Circ
1-5
SECTION I - PATIENT ASSESSME
.
DATECRvio..\jr p3
PATIENT ACUITY LEVEL : ikl: POST-OP DAY: HOSPITAL DAY:
COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN -TELEPHONE REPORT:
T Time To Total ER/RRiPACU time From Physician I 111AMBULATORY CRUTCHES I WHEELCHAIR Anesthesia (Specify): I STRETCHER
A N Procedure/Diagnosis LOC B; P • • scular checks T
S Dressing/cast -- Tubes
F Intake (IV. pol a tput (EBL, other) -- ... Voided 111 No II ' Yes Amo unt:

E Medication
R
Other Report From Received By
TIME: idia
BP ARTERIAL LINE ....../..-
- -(.7z
-0 I-
BP CUFF Ir. TEMPERATURE q , \i' PULSE 90 RESPIRATORY RATE 1 co OXYGEN ILM)) ..---------PULSE OXIMETER c(k 02 METHOD .,"------
Oxygen Method Key: NC = Nasal cannula MT = Mist tent NR = Non rebreather PR = Partial rebreather FM = Face mask A = Aerosol VM = Ventu i mask TC = Trach collar

I U) 0- L1-1 -
Ell ILI C4
TIME Cfnp. ..
„...9p.--
TIME: CV-1:j
-e1•015' • •
to k breakdown
-• ••
•
• .
•
prevention
.
.
.
PAIN
s
I
• e?
•Falls prevention protocol
*Restraint protocol
•
Seizure precautions

•
Isolation precautions

YESTERDAY'S WEIGHT:
6:
5
INTEN SITY
. .
.
•
-
o
•
•• . .
:

MED ADMINISTERED IY;NI
_.._ . ..
... RELIEF ACCEPTABLE IY/N1 r, n tf
__....__
TIME: FINGER STICK GLUCOSE
INSULIN IY/N1
TODAY'S WEIGHT:'
WEIGHT CHANGE:
24 HOUR TOTALS PO IV 4'1 IV ,,t2 1 TOTAL IN • Ppr hospit II policy. Urine Stool TOTAL OUT
PATIENT IDENTIFICATION Li DIAGNOSIS: DRG: LOS: SI r —_te d c_ J-5. ' ,.._ 051 ADMISSION DATE: EXPECTED RELEASE: c_reDQ_,,,,rm....., s.)..L.Sp__I
• CASE MANAGER:
PRIMARY CARE MANAGER: ISOLATION REQUIRED (Spe y Ma

MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC V1.00
MEDCOM - 18047
DOD-031621

SECTION I' ''\TIENT ASSESSMENT - REVIEW OF SYSTEM'
tient assessment criteria have been MET. I, stated criteria are not met, a brief explanation of abnormal findings will be noted in tr,.. .
DIRECTIONS: A check ,./ in the small box Indic propriate column.
TIME:03Z) INITIALS: IME: INITIALS: TIME: INITIALS:
Alert and oriented to time plac.,
1. NEUROLOGICAL:
and name. Responds appropriately. Communication is adequate to express needs. Pupils equal and reactive to light.
CARDIOVASCULAR: Pulse regular & rate
within range for age. No dependent edema.
Nailbeds and mucous membranes pink. No calf 'tenderness.
2.
(See page 3 for extremity perfusion)
3.
PULMONARY: Respirations within normal

rate for age group; quiet and regular. Depth is regular. No cough. No abnormal breath sourds.

4.
G.I.: Abdomen soft and non-distended. Bowel sounds active. Reports no N/V/pain with eating and no problems chewing/ swallowing. Denies constipation, diarrhea or rectal bleeding.

5.
G.U.: Reports no dysuria, retention, urgency. frequency, nocturia. Urine clear, yellow m No unusual discharge.

iaber.

6.
MUSCULOSKELETAL: Normal muscle development and mass for age. No deformities. No assistive devices needed. Normal active ROM without pain. No joint swelling:tenderness, weakness or paresthesia.

7.
SKIN: Warm, dry, intact. Good turgor. No

rashes, inflammation, ulcers, breaks in skin. No redness, blanching, irritation over bony prominences. Mucous membranes moist.
8. PAIN: No complaints of pain/ discomfort.
(See page 7 for documenting pain intensity.)
9.
PSYCHOSOCIAL: Behavior is appropriate to the situation.
Anxiety is controlled or mild and appropriate to situation. Interacts appropriately with others.
10. IV SITE ASSESSMENT:
(LEGEND:
TIME: 07"41
INITIALS:
IV patency I q

lo:
IV site care provided:
IV tubing changed:
LOCATION
CONDITION
IV Site ;1:.
Oar rrL C51( IV Site ;2:
Comments:
R-
I
Li eolo7A-6-Yv.;\ c, tererS_IZ. Last,
5 k-c-01
-t-oknz i
pal( -kA
_
I I i-I
i-/.ca. eQ.. , I
1-0W 4.66-
'69"nizve--

I j %,c.tC,CL, e012.CAAA_IC)
I
aitelzt +0 fiVii-a, LAY`Q—:_-1DI-

, I
I
.3Je.q - ct
Fir."----
LI
I LI
I
.
I I
—
ri
P - Puffy I - Infiltrated R - Reddened OK - No swelling/redness * - Central line)
TIME: INITIALS: TIME: INITIALS:
IV patency ,,/ q hr:

IV patency I q hr:
IV site care provided: IV site care provided:
IV tubing changed:

IV tubing changed:
LOCATION CONDITION LOCATION CONDITION
IV Site #1:
IV Site #1:
IV Site #2:

IV Site //2:
Comments: Comments:
—
MEDCOM FORM 659-R (TEST) (MCHO) MAR 99
Page 2 of 4 pages
MEDCOM - 18048
DOD-031622

SECTION III - PATIENT INTERVENTIONS & TEACHING
SITE: TIM' TIME: CM)
COLOR band visible/legible -
CAPILLARY REFILL TEMPERATURE EDEMA SENSATION A F E T Y orient to environment prn Side rails (214) up Bed position low Call light within reach
MOTION
PASSIVE FLEXION PERIPHERAL PULSE Review & post lab results Notify MD abnormal labs ir
LEGEND -

Z w D CC O N C.) D CC —wI--I F— J — Z(.7
VI

NM

Color: P-pink (normal); C-cyanotic; W-pale, white Incontinent urine/stool
0 Lucc
Capillary Refill: 1-10-2 secs); 2-13-5 secs); 3-15 secs) Linen change prn
Temperature: C-cool; W-warm; H-hot
Turn/reposition q2h I"
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
Sensation: A-absent; N-numb; T-tingling; S-sensation (present) ROM q2h if immobile
Antiembolic hose
Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM
Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain
Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding;

D-doppler, P-palpable
BREAKFAST LUNCH
DINNER
TYPE: ) ._e__ TYPE: R,,_,.TYPE:
PERCENT CONp MED: , r,) a PERCENT Cl/FUMED: PERCENT CONSUMED:
...-
HOW TOLERATED: ... 4111, HOW TOLERATED: L ....9._, J
HOW TOLERATED: /.....p-F . ASSIST . COMPLETE , ?LF . ASSIST . COMPLETE . SELF . ASSIST . COMPLETE 0700 500 1500-2300 2300-0700
. SELF OMPLETE . SELF . COMPLETE . SELF (CI COMPLETE
BATH/ORAL CARE
. ASSIST TOTAL . ASSIST . TOTAL . ASSIST . TOTAL
'EDRF SELF BEDREST . SELF BEDREST . SELF AMBULATE l ASSIST AMBULATE . ASSIST AMBULATE . ASSIST TYPE OF ACTIVITY
BSC BSC BSC
(Circle all that apply)
TIMES/SHIFT # TIMES/SHIFT II TIMES/SHIFT
BRP BRP BRP
CHAIR CHAIR CHAIR
TIME: / 3etr INITIALS: rt-r TIME: INITIALS: TIME: INITIALS:
CONTENT: I CONTENT: CONTENT:
.6.-7.4---Le cri,„._ rc,... Of
--/-C6-iel-iC more

6,
LA:t CO

._.—) •
.: .tient/
ily Verbalizes Understanding . Paiient!Farnily Verbalizes Understanding . Patient/Family Verbalizes Understanding
PAT -• '
IFICATION
INITIALS SIGNATURE SHIFT

mrd /
—.
(al (0 () - 4 .19 0-10 co - -
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 3 of 4 pages
MEDCOM - 18049
DOD-031623

SECT . "'" III - INTERVENTIONS & TEACHING (Cont)
W 0 U D N T 1 M E LOCATION OF WOUND 3 ct.c_ rcA_C) deak___-1,--) . APPEARANCE -­,etiety-t,1:at -tle TREATMENTS AND DRESSING CHANGE L.,." ­-7 ctr77­10 ...._
C A R .
1 —ol) c 1 rocA c c..e,..i +0 .----/_..„ (g I \ 1 C/I/ . O fe_ p...%•"--._Q__ SECTION IV - NOTES .0__Igo,,,t,,,, I Vi aVI 7/, Ph e._..63,'s re -lc:4 er, vss-...____ _ 6
6 (6) ­-1

MEDCOM FORM 669-R (TEST) (MCHO) MAR 99
Page 4 of 4 pages
MEDCOM - 18050
DOD-031624

624TH FORWARD SURGICAL T • PATIENT RECORD
DTG IN: 2-46o3
AIRWAY: PATENT ORAL TO OR: TIME OF INJURY: Ell' NASAL NA TAILS OF INJURY EVENT:
Pin
SSN: • /1,1-viknA a A. co .
CHEST:
WT LBS:

LiJkaeitm
ALLERGIES:
RIGHT BS= LEFT BS=
IV SZ SHE
GCS PRIOR TO ARRIVIAI_,=

')0W-N
"NW
ighxo-r\
1611s--7K P

Hz-0 4 I 1(
LITER OF FLUID 1 :

, (lute.A.
CV-1 c-rs.
itis-1(42_14 .p., 1 114304, 3
I)

UNITS OF BLOOD IN:
TIME MED & DOSE INIT.

10
2V
CL.ecu
INTERVENTION
LOWER OXYGEN ON 8c RATE: 5 L, ETT SIZE: SURG. AIRWAY 197-Y CT #2 & SITE: 12C FOLEY11/4? te)GASTRIC
MEDICATIONS FLUID TOT
MIDAZOAM ANTIBIOTIC: RYSTAL:
INCISION PENTO • /IA
OMEDA riedIP

PROC END
EBV
..?6601.4 crEVE$AL
TO AcW:
EBL.

MAC:
DRAINS
REGIONAL: b 16)

TIME IN: 02 VIA & RATE:
V SITE RE-EVALU
SURGEON(S):

IV SZ SITE
PROCEURE:
DRESSINGS:
POST-OP MEDICA TIME MED & DOSE
RR: TEMP:
CUMULATIVE I & 0TUBES:
INTAKE OUTPUT SOURCE AMT SOURCE AMT
DRAINS:
MEDCOM - 18051
TOTAL=
DOD-031625
PLAN OF CARE FOR SKIN BREAKDOWN AND WOUND MANAGEMENT
MEDICAL RECORD. PROGRESS NOTES ;Adniission Date: I Cf (--4-83 Diagnosis Ato • 4 . HD: ,, POD: 4-(
. L pri.....T466barst Date: )q/.90t-oY Time: 1 0 ' Signatur CIL(' r--1—(MI-6
.,,
Skin breakdown as evidenced by mmobility, a lotion, •• wourd,lain tear.
° t6) '''
Wound type: Surgical wound (s) Location:aU_ 35644..ThsiAe4". -,.., Drainage:f,2'5 Diabetic ulcer Tubes: Pins: Appearance: Venous stasis ulcer Dressing change:
Other ! ...," Describ -
Burn wound (s): % BSA Location: Appearance: Dressing change:
Pressure Ulcer s :
,,. _ A. -i/ _ . _ • / Partial Full 0 / . -Size
ptitiStage I, II, I 110 mole the one that appliqsand describe below) , --ii
Location: fi.82.0_,_.L.A._,K .41) r)-v--Size: lb I 114 IAA le0-14/4 N. -L-Z,1-ty A-Lie(/i Woun hara6ter: Pink 0 Moist L./Dry Granulation tissue Yellow slough I 6144 `--1-Tunneling Undermining I/ Odor Purulent discharge Eschar Exudates
I ut1aek.-4 it "1 -
00,ic ),:xdr_Le
Refer to SOP for Dressing Change Instrucitons.
Please check the appropriate dressing Change:
OrWet to Dry pressing
ac (a 1
.
Carrasyn-V GelDressing

.
Alginate Dressing
10/7Comfeel Dresising

eCC-c. pc f
.
Pin Site Care

.
J-Tube Care

.
Colostomy Care

.
Chest Tube Care

.
Bum Care

7?( i.pt Q._ A . e 61.44 a 4.-41Ata
Select the appropriate products used:
.
Sterile 4x4 gauze dressing

.
Sterile 2x2 gauze dressing

.
,Sterile gloves Kerlix (super sponge) rI;11._.,auze bandage

erile Normal Saline Sterile Water

.
8 x 4 Sponge gauze

.
p-site Tegaderm clear dressing /

.
Alkare skin prep cl-C1-41-1

.
Comfeel clear 02"—Comfeel pressure ulcer din

.
Carrasyn-V Gel e;•cc`Pm

.
Alginate

.
Bacitracin

.
Silvadene Cream

kat, 1 A-c421 t-NOTE: Document daily wound and 20-&..4.12.44 ei."-c-V, 1,4c11-(-dressing change on Progress Note or .11( .4(1410/4,4_, i_. Nursing Note. 0
Patient's Identification (For typed or written entries give: Name-last, first, middle: Grade; rank; hospital or medical facility)
e.....
' -e

(le ed
:g.):.1, cP ot) /4 11 ° C
.
Petrolatum gauze

.
Hibicleanse

.
Non-adhesive dressing

.
Telpha Pad

.
Carra-smart film

.
Sterile Q-tip applicator

.
Xeroform 5 x 9.

.
Moisture barrier cream

.
0.125% Dakins sol

.
Betadine Swab sticks

.
1/2 Hydrogen Peroxide & 1/2 Sterile Normal Saline

Select the frequency of dressing change:
El-.
b.i.d.
Cl t.i.d

br
MD Signature and Date:
.
"CI °'
19 (L, 1
Medical Record, SF 509
SKIN AND W __.

MEDICAL RECORD.
PROGRESS NOTES .. •.. :,
AdinisMon Date: !
Diagnosis: HD.
' :.
Skin asscssment must be done initially and every 7 days.
Braden Scale Evaluation (See Braden Evaluation Table for Details)
Sensory No impairment
4 Mobility No limitations
Perception Slightly limited
0 Slightly limited 3
Very limited 2
Very limited 2
Completed I
Completely immobile
CP
Moisture Rarely moist 4-
Occasionally moist • 3

Nutrition Excellent
Moist
2
Adequate (Eats 50%) 3
Constantly moist
Adequate (Rarely eats) 2 Very poor cr,Activity Walks frequently Walks occasionally 3
Friction and No apparent problem .:'
Chairfast
Shear Potential problems 2
Bedfast
Problems
Add the total score
Total Score: 1 S
Above 20 Low Risk
Between 16 and 20 Me ' *sk
Between 11 and 15 High Risk
Belo_w 10 Very-High Risk

'Note: ABraden Scale Score of less.than 15 indicates, HIGH RISKrreqUires,iinmechate OicerPreventiOniirogea
-
Surgical wound (s): Yes VI(o-1_ Location: 61-6,1? .

Size: 3 S e6ei. &IA 6,13faidalge:-.14
,
Tubes: Pins: Appearance:, _ _ / .„„ .-„,, /
...._
Dressinechange: ,e__L-x.v, ,
A C
n •
Burn wound (s): Yes_ No__ % BSA

Partial Full Location:
Size
Appearance:
Dressing change:
Pressure Ulcer (s : Yes No
Stage I, II, III

Circle the one that ap lies and describe below)
Location: ete_t_eft

) A.../e.,,i Y-y--Size: .':, (ciA etia bfArd_tk_ -
Wound character: inl?..---"Moist
ry GrUnulation tissue. Yel,low slough
Tunneling L-------
Undermining j.„..-----Odor Purulent discharge.geZst6Aschar
Exudates
Type of dressing change: Wet-to-dry ss.,....".--COTnfeel dressing
Carrasn-V Gel Alginate 5/10 1.Arat.t4,4c\ cetiLtiLe_e_tire-----Physician notified/consulted for wound debridement: Yes_
Wo Date/time MD notif D Z.L4/7:0J—
CNS notified/consulted for Stage II and greater: Yes t/- No Nutrition Referral: Yes
Not,' P1 JD L6) - 2Physical Therapy Referral: Yes No L.--
.
Action taken..
Date & Time
ow ot - a
-6'744 cell/Gal-1r— ((9) -7-REGISTER NO. NO. PatiAnt,c Iri..•:n...•,..— (For A_ _ _ A -WAR/DCa
Lanwil krur ty ped or written entries give: Name-last, first, middle:
Grade; rank; hospital or medical facility)

PROGRESS NOTES Medical Record STANDARD FORM 509
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of this form. see AR 40-66; the proponei
is The Office of the Surgeon General.
2.
1. AGE: KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
ULWL91,0v3r\
HEIGHT:
3. PREVIOUS SURGERY [ NO [X] YES (type):
WEIGHT:

L-ai
4.
PROPOSED SURGICAL PROCEDURE: -9/f)

5.
ADDITIONAL INFORMATION: Last PO: pPa Implants: 6

Medical FIs:
Medications: Veiled Jewelry removed: /no Family waiting: yettr3
-Fc c....taruy fro ttbc.,1
ram_
Ver.4.1..vb11.4%
6. PATIENT PROBLEMS AND NEEDS 7.
PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
A. PSYCHOSOCIAL / Allow pt. to verbalize
Pt. verbalizes any specific anxiety. freely. Potential for anxiety Explain OR environment Pt. exhibits relaxed body posture. and answer questions
related to traumatic injury;
re arding surgery.
language barrier; family
Offer comfort measures,
separation; surgical environment (e.g., warm blanket, touch) Explain all nursing procedures before they are done. Remain with pt. whenever possible.
51 Maintain family interface.
B. AERATION 9/ PT. will be able to breathe without Offer to elevate head of Potential for /difficulty during immediate intra-litter or offer pillow.
operative phase.
respiratory dysfunction due to Observe pt. while awaiting
sedation; positioning; injury surgeryfor signs of distress
Assist anesthesia during
'intubation and extubation

,.PT. will not exhibit signs of impair-
C. IN EGUMENT
71 Utilize pressure preventing
ment of skin integrity (e.g., reddened
devices on OR table and Potential impairment areas. accessories.
of skin integuity due to bovie / Check for proper
/positioning and support to

pad, position; fluid shill
/
maintain good body alignment.I Pad pressure points. Place ESU ground pad on
non compromised skin surfaceE.,lea. p Keep prep fluids from
/pooling.
. PATIENT'S IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility)
DA FORM 5179, JUN 91 Previoius editions are obsolete.
USAPA V1,01
6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION
Potential for inade-quate tissue perfusion due to anesthesia; traumatic injury; position; shock; previous surgery
E. NEUROMUSCULAR
CONTR)31L

E.1. \/ Potential impairment
of mobility due to sedation; pain;injury
`
2 \ZPotential discomfort due to injury; pain
F. NEUROMUSCULAR
CONTRpf_

F.1. V Disminished visual
perception due to being injury; sedation;
F.2. \z"Potential for decreased communictaion due to language barrier; sedation
F.3. Potential injury due to
dentures.

G. OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse).
Pt. will be transferred to OR table vithout difficulty. ; Pt. will not experience unnecessary physical discomfort.
/ Pt. will be made aware of surroundings prior to anesthesia induction.
yal Pt. will be transferred safely to OR table.
Pt. will be able to understand
to tructions.

Minimize danger of injury during
intraop period.

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS
/Check for support stockings or ace wraps. If none, check with doctors. /Check that safety straps are correctly applied.
/ Offer pillow for under knees.
0 Place and take down legs from
stirrups with slow bilateral motion.
9/Check that rings have been
/removed.

9/ Have sufficient people
ailable for transfer.
Insure proper body

/7
alignment.
Allow patient to lie in

/position of comfort while
waiting for surgery.
Offer support (i.e., pillows,bathtowels, etc.) for positioning.
31 Introduce self. Keep pt. 'informed as to where he/she is and what is happening. Inform pt. in which direction to move and assist if necessary. / Speak clearly and slowly. y/ Address t. from side.
y Validate pt.'s understanding of verbal communications.
,9/ Verify removal of dentures.
OTHER NURSING
INTERVENTIONS.
Or continuation of above
interventions.
10 tr
cc)
\ IQ SOMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.
0:3
DATE
11 POSTOPERATIVE VALUATION:
\\\,) 51 D. cti3v1551. aucl
(6)
12. PREOPERTIVE
(Signature and Titl

DATE:
t3
TIME: It
REVERSE OF DA F M5/79, JUN 91
17(0-2
13. PREOPERTIVE E BY (Signature and Till
DATE: cpviu iati5
MEDCOM - 8055
USAPA V1 01
PREOPERATIVE/POSTOPERA--,IE NURSING DOCUMENT
MEDICAL RECORD
FOR Use this form. See AR 40-407: the Propone. ,,ency Is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication)
1. AGE 3 5 NKDA 0 PCN
. LATEX . IODINE . TAPE 0 FOOD
REACTION:
HEIGHT: 3. PREVIOUS SURGERY [ ] NO 1)(1 YES (type):WEIGHT:
Sx
I `s )
4. PROPOSED SURGICAL PROCEDURE: •
5. ADDITIONAL INFORMATION: (Previous surgical and medical hist FY) Skin Condition-c------N-1*-%-...5
Tobacco ppd X_vrs Body Pierciy Diabetes (Y)

ROM
SA/Motrin W 72hrs (Y).04)"ETOH Implants Respirato isease (Asthma C PD) ) (N) Anticoagulant
Glasses/Contact (\OJAI Dentures Hype sion (Y) (N) Herbal Medicines (Y) 4 MEDS:
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
A. PSYQUOSOCIAL
Allow pt. to verbalize freely.
potential for anxiety related
. Explain Or environment and answer
to:
estions regarding surgery.
Surgical Procedure&
. Offer comfort measures. (e.g. warm
Operating Room Environment
anket. touch).
2) Separation Anxiety
. Explain all nursing procedures before
sC29,
I y are done.
3) Surgical Outcomes . Remain with pt. Whenever possible.
0. Maintain family interface. Parents to
stay with pt.
B. AERATION t. will be able to breath without
Offer to elevate head of litter or offer ----Potential for respiratory
difficulty during immediate intraoperative llow.
dysfunction due to:

1i
. Observe•pt. While awaiting surgery forphase.
1) Positioning
gns of distress.
Effects of Anesthesia
. Assist anesthesia during intubatior
3) Medical/Smoking History
and extubation.
C. INTEGUMENT
Pt. will exhibit signs of impairment of
I. Utilize pressure preventing devices ----Potential Impairment of Skin skin integrity (e.g., reddened areas).
OR table and accessories.
Integrity due to:
Check for proper positioning and
1) Intraoperative Immobiljty
pport to maintain good body alignment.
2) ESU Pad Placement
Pad pressure points.
---3) Positional Aids
. Place ESU ground pad on non4) Prokigais
mpromised skin surface area.5) Pooling of Prep Solutions
. Keep prep fluids form pooling.
9. PATIENT'S IDENTIFICATION: ( For typed or written entries
VERIFICATIONS AT HOLDING AREA:
give: Name-last, first, middle; grade, data; hospital or medical facility)
! ID/Allergy Band`/Dentures Remo
d 41111 (6) I H & Ps' 1 Contacts Re ved NPO Since ORO ! Jewelry oved
Otk !--141-feettlotr^ ! Body erce Removed ! Consent/Blood Transfusion
ut
Signedtnessed/Dated .-
OEM
! Surgical Site/Consent verified by Ijkosc Pt./Anesthesia/Surgeon
! Contact precaution ! Family/Friend:
DA FORM 5179, JUN 91
Previous editions are obsolete.
USAPA VI.0
6. PATIENT PROBLEMS AND NEEDS
D. CIRCULATION
C" Potential for inadequate tissue perfusion due to:
1) Intraoperative Mobility
2) Positioning
3) Existing Disease 4) Safety Devices Hypothermia
E. NEUROMUSCULAR
CONTROL

E.I. ----Potential Impairment of
Mobility due to:

1) Pain
2) Intra operative Hazzards
3) prosthesis
—4) Positioning

/ 5) Transfer pt. To/form OR table
E.2. Potential Discomfort Due to:
1) Length of Surgery
2) Positioning
3) Arthritis
F. Sp.erdal Senses
F.I. Diminished visual perception due to being:
1) pre-medicated
2) VV 0 GLASSES
F.2. e—Pbtential for Decreased
Communication due to: •
• 1) 'Diminished Hearing
2) Language Barrier
F.3. Potential Injury due to Dentures:
1) Upper 4) Caps
2) Lower 5) Crowns 3) Bridges
G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.
7. PATIENT GOALS AND EXPECTED OUTCOMES
will exhibit signs of adequate tissue perfusion (e.g. color, warmth. pedal pulse.
1
1 pt. will be transferred to OR table without ifficultly. pt . will be not experience unnecessary
hysical discomfort.
nor to anesthesia induction.
pt. will be transferred safely to OR table. pt. will be able to understand instructions.
Minimize danger of injury during intraop
period.

OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above goals and outcomes.
8. OR NURSING INTERVENTIONS O Check foe support stocking or ace warps. if none, check with doctors. O C heck that safety straps are
correctly applied.
O Offer pillow for under knees.
O Place and take down legs from

stirrups with slow bilateral motion. .43--Crleck that rings and all body piercing has been removed.
Have sufficient people available for t nsfer. Insure proper body alignment. Allow patient to lie in position of mfort while waiting for surgery. Offer support (i,e..pillows. Bath t wel. etc) for positioning.
Introduce self. keep pt informed as to here he. she is and what is happening. Inform pt. in which direction to move Ind assist if necessary.
Speak clearly and slowly. Address pt. from .."e---k side. Validate pt.'s understanding of verbal
mmunication. 0 Verify removal of dentures.
OTHER NURSING INTERVENTIONS OR continuation of above interventions.
10. OR NURSING INTERVENTION COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
DATE
11. POSTOP N SKIN INTEGRITY: Bovie Pad Site:
Clean and Dry . Red
. N/A D ESSING DRY & INTACT:
LEVEL OF CONSCIOUSNESS: . A&O Er Drowsy . Sleepy . Intubated N)
LEVEL OF ACTIVITY: . MOVES ALL EXTREMITIES $Moves Upper Extremities ATHING EASY:

. Transferred to Litter With roller due to spinal N)
12. PREOPERAT REPARED ¢Y 13. PREOPERATIVE TION P
(Signature and Title)
BY (Signature and Title DATE: zrto.A..._O-
1. MEDCOM - 18057 , TIME:
z
INTRAOPERA--,OCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the propt, gency is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING ROOM 2. PATIENT IDENTIFI -' ND PROCEDURE
VIA LatEr BY •-i\VnttA-Wa VERIFIED BY I L 1

3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
3 b --Ku-CAO.9 ---:"--TIME 1 (p 37 NUMBER .=:. -

5. PREOPERATIVE EMOTIONAL STATUS
. CALM /ANXIOUS MI EXCITED U CRYING . ANGRY U WITHDRAWN OTHER (Specify)
COMMENTS: 514) ,....„., g ,;....„,, .4_ Liour
14 • tyclu,,toatid 0,, uem-t_ , CT )(2, isk - L.,:vv_ Tc Lo-L1 . -t—,1--#kA_ , .
6.. NURSING PERSONNEL
ASSIGNED Cl. if RELIEF
SCRUB SCRUB

ASSIGNED 1 LT RELIEF
CIRCULATOR CIRCULATOR

11"1--
7. POSITION AND POSITIONAL AIDS "Specify)
[SUPINE • LITHOTOMY • PRONE U KRASKE LATERAL: IN LEFT SIDE UP U RIGHT SIDE UP
1
¦
,tcy.i\tDvv iic.._ roloeig-\\Atuy\--t v\i\ wt.t..6,.t,vszfik .
COMMENTS: Vbmg. bOcixi
8. KIN P-Fl ATION
HAIR REMOVAL . YES \NO PREP SOLUTION (Specify) 13e....-U_ciALV--2-1/ ZizZ3401....y4../2 DONE BY: . OR . NURSING UNIT SITE: -A-toct0V),Atv\ .. m t j:..3._ BY WHOM: i cr METHOD: • DEPILATORY • RAZOR SITE: 'l+pt,Liais -BY WHOM:
. CLIP COMMENTS: 163 j IN COMMENTS: IN) tAjAC) or QaARvc,z feCICS-61"
9. LOCATION OF EXTERNAL DEVICES
r
.. _
I.I Ak-
_
I.•.
,.. _____ ............4immmillm—

ray .
...---
LEGEND X oun d = = = Tourniquet
ltki#N41 : rLft = Cor ect I = Incorrect
y A-14.1.4 First Closing Final losing
10. COUNTS ther • ' Count Count SCRUB
CIRCUL' • :
Sponge a Yes . No C.. C-MP, Needle Sharp 0 Yes . No (...
Instrument N Yes III No
e_ =EtAlli1111101 LT
Other NI Yes • No C____ WANAMINIIM Iffirni
0.e
NI ' •
Name - Last, first, middle; 11. PATIENT IDENTIFICATION Grade; Date; (For typed or Hospital written entries give: 12. ELEL -. - -¦ Y IC E(S) ESU) r
or Medical Facility;)
c.V*: 30
KicE io 53 0
A ESU NO: coa5:.30/50,(00,. 15-0
--F-VO
GROUND PAD: BRAND VL vork q)IN,Iteswt.at.
0)_11
LOT NO: (PrI3to -E-Pc-f .0C.).C -03
.
ESU NO:

GROUND PAD: BRAND LOT NO:

.
BIPOLAR NO:

-I , REPLACES DA MEDCOM - 18058 H IS OBSOLETE. USAPA VI.00
13. PROSTHESIS, IMPLANTS
[i] YES NO
IF YES NAME: ID NUMBER; MANUFACTURER
ED CATI
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM

(NOT BY ANESTHESIA)
YES NO .
:;MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY
,
s1.kralco c14-5,31--irot, Ivrt-Q -op
Lelock Awe:
WOUND IRRIGATION
YES . NO, TYPE(S):
0.9 0/0 .1/4)C.,t
OTHER ORDERS •
TIME
CARRIED OUT BY
16. SPECIMEN (5) YES . 15 NO NO NAME ROOM LABORATORY SPECIMENS NAME IF Y , SITE
FROZEN SECTION (F YES . NO NAME
CULTURE (C) YES . NO NAME NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
TYPE/SIZE TUBES, DRAINS/PACKING YES

19. ADDITIONAL INFORMATION 6 6 -
Sikfaain
-Iserves:theis;t1 c_rr 6(q-L

— rey oC cich,te_-no c-iiii^ 4-e-v1 41 0,.%
re-91c-‘440133 "415 `b°4-eciallip
20. OPERATION(S) PERFORMED bia
Ce049r )Cla-r+ a-1 1 vec 1-'65-ed.; c" . \
21. PATIENT TRANSFERRED TO
METHOD
22. tur3 (€,) -z_ Utter c n?_
REGISTERED NURSE SIGNATURE
AN)
REVERSE OF DA FORM 5179-1, OCT
USAPA V1.00
MEDICAL RECORD I INTRAOPERATIVE DOCUMENT
For use of this form, see AR 40-6e, the proponent agency Is the office
of The Surgeon General.
1. PAINT TRIN T OP RAT' )OM
2. PATIENT IDENTIF = WED D PROCEDURE
vIAWA0,1pd BY i
j449-S) VERIFIED BY CACr,
\O 6 ) -1.,
3.
DATE

TIME PATIENT ARRIVED-1N SUITE
4.
PATIENT IN ROOM
1i 5 _i.',0 3 /01 5

TIME /0/5-7
NUMBER ,Vi
5. PREOPERATIVE EMOTIONAL STATUS
• CALM I. ANXIOUS U EXCITED L CRYING
U ANGRY U WITHDRAWN
THER (Specify) COMMENTS: A Ilergies:TV .V._ Prik 86,04d,
.n. •,. ‘,..;..
6. NURSING PERSONNEL
ASSIGNED .1::'(. 9/ 0 .5 PC._ 9/0
• RELIEF
SCRUB
SCRUB / 2-0-Ci —
"C-\:) (6)
6(0 -I . -0 -2
0_,P1--
ASSIGNED 66 e: RELIEF
CIRCULATOR CIRCULATOR
POSITION AND POSITIONAL
• # , AIDS (Specify)z-cy,d,rila_ 0 L, 4etL4end 9-,A4c3c3 1-.-. ctOz 1-44_2., /37--...‹,.., -,--0;tbedkra/avz
L.-MO y ea Cdt,19-2.c.AA/.e.a_ 1-,
4 .r),-. bag r .
.101r P`' c_., --ke.. aly--,45., -Vep IcLuL fo“.4.15 uel Ap,,--4,e,i 5
SUPINF yug-cHop-omi MI PRONE
M KRA§KE . 1 LATERAL: ,.. II LVT SIDE UP • RIGHT SIDE UP
fir lb fitoiled .40 k--44
od- -5/ cl-e_E 0_, rot tPci skwi--/ , --' ka 't 6E
i; -to
COMMENTS: C rmej_ --5'tCOC71 1,1-¦ aia 4(d 4'1., 13-14 1
fiiiy.--,-,
8. SKIN PREPARATION
HAIR REMOVAL U YES I10

PREP SOLUTION (Specify) 73e.„ 71---c,
DONE BY: OR
II NURSING UNIT SITE: c-k.401,-,,
i0.ct. t. Y WHOM: 0—PT
METHOD: DEPILATORY III RAZOR
SITE: . 5 tZ-e.tob..) BY WHOM:
. II CLIP

'-' Ca I
it-I2C.k...
COMMENTS:

COMMENTS: /-70 leo-oh
c3T-5•41-141 01 S /-NOIC
9. LOCATION OF EXTERNAL DEICES
..-.'". I
. .10°'--- .... 41

;#4111.1- -11 '4350
. . kt.
gillealllik
ID.=,,,e• .40A 0:*,* IIIIICiat.— .
-.
Ats=i, tiri a:paw-
."441%.,N.4ip ,- ..

19 (4-7 -----
ilig ailic/ ..

LEGEND Illiground Pad
ty Strap "Tourniquet C = Correct I = Incorrect i /I Ilya/ First Closing Final Closing
10. COUNTS
Count Count SCRU:
.CIRCULA • r
Sponge L0 Yes No b 6 -
5c)C._
Needle Sharp
C ' No
I.¦
Instrument Yes
I/ No ..-----
Other r 1

MI Yes f9-No
SP
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. EL
ICE(S) (ESU) c ES 11 NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility,)
ilL
rdif SU NO: tbze IO 5 r
GROUND PAD:.
BRANDMIDIVIMBEFEM
LOT NO: (2); 41 11 ESU NO:
0 (0, -c,/,:oos----0---
GROUND PAD: BRAND
LOT NO: U BIPOLAR NO:
DA FORM 5179-1_ nr-r R7 nFO, erFC DA FO
RM 5179-1 tic
DEC BA WI-111,11 IS OBSOLETE. USAPA V1.01
MEDCOM -18060
NO IF YES NAME: ID NUMBER; MANUFACTURER
13. PROSTHESIS, IMPLANTS Li YES
::::i::ii.:::iiii::::::: :::i ::::0iii:Mi:i:ii:i::::MEDICATIONS/ORDERSORM::;:iii::;iMe;!.!:;:i;: ] :',:i;];!i!!,;Miiii!:;:ai.r.::::::::::::: :i.;:i;iiigNeM:Mli,:i IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO IV DOSAGE TIME METHOD PREPARED BY IVEN BY
:::::::::::::ii:]:1:Pi::i0:?:iiii:ii:!ii.:•:ii:*: ,::::::::!::Iii:ii: •:.:.
lvIEDICATIONS/SOLUTION
WOUND IRRIGATION YES II NO, TYPE(S):
0.9670 /O A - a
TIME CARRIED OUT BY`OTHER ORDERS
;PHYSICIAN'S SIGNATURE ................,..........,...............,....... ... ............................
,... ---...-...---------------...--...............----...,...... -............... .....-..:.-...............-.........-...-. . -....... --.......-..... ....

IF YES, SITE
15. X-RAY IN OPERATING ROOM
YES • NO
LABORATORY SPECIMENS
16.
SPECIMEN (S) NAME NAME
YES i NO,
FROZEN SECTION (FS) NAME NAME

NO xi) CULTURE (C) NAME
YES •
NAME
YES ¦ NO yfi
NAME NAME

NAME
18.10SING/IMMOBILIZATION (Specify)
NAME NAME
*)-9..c_.34.-'19
— 47/xg -e t
17. TUBES, DRAINS/PACKING YES NO .
.ii. ----
TYPE/SIZE 1/6r
14; t-7 r-r-
ceillur2A-Q./ -4-fac -1-n 1 4. c.i.
SITE ,...1.6----''--rAi akastp2. ei 6Cf oWi fkc't

er I 3.-v-tt tINCY21/4
t -,-;47-erri arA \ \ vN e A ci o L bdelUiet

19. ADDITIONAL INFORMATION
VIC-17--
Surgeons: D Anesthesia: 1l Anesthesia Type: G_e4.-2 i614
Bovie Pad site intact pre -op C.A21 ; post-oprpf Bovie Settings: Coag/Cut 30/36 51-a-•1l /
Tourniquet Site intact -pr?-4T ler post-op .

Tourniquet Time: Upk) Do n A , 1 -10 ---j-r, 6/4. , iciza ,vrjej.t.:-­
r oas).nor\-€0,/ 'rid r 1: .
d-
el-red,le-ol -4- preff-ed ng` Ito&
S 17 7 er-eviO4,.y. Co. ,-1 14, 9 1-e)
20. OPERATION(S) PER ED
-/ --r--1 C ,--2,-, C_01--/-Lie,
"Pic..(2,--1.J2-,--
h
._...r-.
,_.././
-I 1 a r 51-c-P-71 Pict CO---,--.-0--.--,--/
21. PATIENT TRANSFERRED T 1_ TIME P-. METH.Or
1 CAA .
/ , S----1-)3k IOLA-61(
22. REGI
MEDCOM - 18061 s_."7-7,7-k-'-
I
INTRAOPERATIVE DOCUMENT
MEDICAL RECORD
.For use of this form, see AR 40-66, the proponent agency is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERAT )OM 2. PATIENT IDENTIF =_ AND PROCEDURE
VIA 0`/oult.z4 BY VERIFIED BY
-1--a=e241.---2.. -(..4 P-7/4--.0
3. DAtE TIME PATIENT ARRIVED IN SUITE 4. PATIENT INR
„------._
TIME 0 536 .`l'1 NUMBER A--/ ca.)
° ';
5. PREOPERATIVE EMOTIONAL STATUS
Eq.cALM • ANXIOUS . EXCITED • CRYING IN ANGRY • WITHDRAWN • OTHER (Specify)
COMMENTS: Allergies: if
t ..P r 0i/d1-0.17j61-4-6-4.
6. NURSING PERSONNEL
ASSIGNED SSCP RELIEF
SCRUB SCRUB

..-,
ASSIGNED 69-r @ C RELIEF
CIRCULATOR CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify)
EK_SUPINE • LITHOTOMY II PRONE II KRASKE LATERAL: . LEFT SIDE UP • RIGHT SIDE UP
COMMENTS:
8. SKIN PREPARATION
hod) ":1/ HAIR REMOVAL • YES W NO PREP SOLUTION (Specify)
• SIT t._ . -_AIII
DONE BY: II OR NURSING UNIT BY 1-01 : et
METHOD: • DEPILATORY ¦ RAZOR SITE: B WHOM:

• CLIP (-----
COMMENTS: COMMENTS: Vlb pAv2p /„4/ .
C.
9. LOCATION OF EXTERNAL DEVICES
• 11rAP•"-
-44
VG) -7- b(o-i ,-.-
LEGEND d .p === Tourniquet YJ CO --1
= Correct I = Incorrect
it/) '17-a--t First C losing nal C losing

10. COUNTS Other" Count Count SCRU :
• Uft ' -
Sponge II Yes ¦ No C___.. moinummmi mit
Needle Sharp E Yes • No 0 , IIIIIPPAIIIIIIIMIIIM N.W _

I nstrument • Yes In No
IIIEIIIIIIIIIMIIIII
Other Ill Yes ¦1 No
11. PATIENT IDENTIFICATIO (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) YES II NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
—0 A-G -----­
‘3°
1:14,ESU NO: CUP A-A-1--Al"
BRAND" / ./
C.)
(6 ) "? GROUND PAD: / i • Ila.AL .. "
... — _
LOT NO: bi5r9 r4 z7o_C--.03
• ESU NO:
GROUND PAD: BRAND )( 2 1.--LOT NO:
• BIPOLAR NO:
IPIIIMIIII-,
.
USAPA V1.01
DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE.
13. PROSTHESIS, IMPLANTS [ j YES NO IF YES NAME: ID NUMBER; MANUFACTURER
4
IRRIGATION/MEDICATIONS GIVEN IN OPERATING R OOM (NOT BY ANESTHESIA) YES . NO
;MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY GIVEN BY

::WOUND IRRIGATION 1St YES . NO, TYPE(S):
:OTHER ORDERS
ORDERS TIME CARRIED OUT BY
PHYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING ROOM IF YES, SITE YES . NO'

16.
LABORATORY SPECIMENS SPECIMEN (S) NAME

NAME YES . NO FROZEN SECTION (F ) NAME
NAME YES . NO CULTURE (C) NAME NAME YES . NO NAME NAME
NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify)
17. TUBES, DRAINS/PACKING YES . NO TYPE/SIZE 2.
SITE
19. ADDITIONAL INFORMATION
WC
MAS-
Surgeon Anesthesia: Anesthesia Type:
Bovie Pad site intact pre-op Aid ; post-o Bovie Settings: Cong/CutTourniquet Site intact : post-o
•
Tourniquet Time: Up_ Down
20.
OPERATION(S) PERFORMED

21.
PATIENT TRANSFERRED TO

TIME METHOr
I 0 Ac
22. REGISTERE
MEDCOM - 18063
INTRAOPERA 1 t VF DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, the prop& s•ncy is the office of The Surgeon General.
1. PATIENT TMNSPOIRTED TO OPERA: 2. PATIENT IDENTIF IEWE AND PROCEDURE
VIA 0 ' Lej I I-we,- (---BY iR VERIFIED BY ....2_,
3. DATE TIME PATIENT ARRIVED IN SUITE 4: PATIENT IN ROO
, C.)&/
nqua-03 ,
TIME -623')S NUMBER / - 7
5. PREOPERATIVE EMOTIONAL STATUS CALM • ANXIOUS . EXCITED. CRYING • ANGRY El WITHDRAWN In OTHER (Specify)
COMMENTS:
AKA-
. NURSING PERSONNEL -
p f c, _i`. I D
ASSIGNED ---RELIEF
SCRUB . . / . SCRUB

ASSIGNED -A1111111111111Wi RELIEF
CIRCULATOR __. ... . _

..___ ...... .. . NT:-
¦
7. POSITION ANp POZZIAL AIDS ISppcify)1"-ii on-,00,5
OK: at.4162...., k,lio1,o,--fcv;)rr:otg--Arz-fr(d."/ I -0_2.. 2z a ,
41 yy't A -e,t •• a ) A i9-p...e.i.. re 7,v• 12 g /VI 00(=jreris C _S At ni-UPINE U LITHOTOMY
II PRONEet. K,RAW . LATERAL: , ¦ LET slog , D,I RIGHT S DE UP
., i/u70 J...
•ps, LLE pro peed I n 10 -5 -feri'Le. . 'Y d___. -1-och...„ rui..-y--... cAncti.-
CO MENTS: C-Or re C. --/-._..d)/ ill i'"1-) fryt..a4i -i--mai h-4.44,2o'
8. SKIN PREPARATION HAIR REMOVAL
rib YES El NO " ' PREP SOLUTION (SpeiifY) Be1/47erzi --. 1
DONE BY: • OR • NURSING UNIT SITE: LL 6 4-- fib doi.-0-.,, BY WHOM: C

CP
DEPILATORY jRA OR )
METHOD: • )j-SITE: ,ct S. L-e--- ePt4.1 BY WHOM:
• CLIP Or _______...
.._. ..,. 2(6)-Z-
COMMENTS: fievi
ickc o r 0,i4-1:, rl COMMENTS: /74 ra„h9, of: .5,/,,A,,,s 11.04­
e.
9. LOCATION 0 EXTERNAL DEVICES • ...' ‘)-'4
.
....."'"..
_._.....___....;
,_......e".
_ ..-

tta Z,* NA Alltwirsw-
40....,¦,...../, /Iv
-. p 1111o
t(6)-1 .....,:„, r
0¦WeA r
LEGEND round Pad - - ety Strap = -44/ It rn i q u et. - --- -- -- ...„0. ¦¦¦¦ 47 1191"`,7-
C = Correct I = I orrect

13 G) -2
f First ClosinA Final Closing
10. COUNTS Count ..:*-® COunt SCRU:
Sponge r, , A . mirAnir e.il cie - -
Needle Sharp ‘11,ry es o
-..
Instrument E Yes RA o
IP'Alliinfil
Other Yes Ye ' o
1 1 . PATIENT IDENTIFICATION'(For yped or w tten entries give: 12. ELECTROSURGERY DEVICEIS) ESU) ES U NO
Name - Last, first, middle; Grade; Date; Hospita or Medical Facility;)
ZeESU NO: K. r /0-s-3 5 GROUND PAD:
t BRAND IG Eq4.jalitgalK e-,...
._,
b:_ .
LOT NO: ., •11MMP.:_11.410 -----10 _
-,. ` :.ESU NO:
,•• --GROUND PAD: BRAND LOT NO: III BIPOLAR NO:
r% A Ert/-111/1 ew,n w r - s oN-1- v....-. 179-1 (TEST), DEC.82, WHICH IS OBSOLETE. USAPA V1.00
MEDCOM -18064
DOD-031638
13. PROSTHESIS, IMPLANTS II YEE :VNO IF YES NAME: ID NUMBEF ,. TURER
., ' ...-_ 'I MEDICATIONS/ORDERS , -
,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES MO ^ NO MEDICATIONS/SOLUTION DOSAGE TIME METHOD • : • 11: II =Y
G Y
Pi ; n_tr a I 01 I 0-1-1C-l'olre4,-4p -1-eipag I
.r..
WOUND IRRIGATION '12YES • NO, TYPE(S):
01
q a/0 it)a 01 -05 -
OTHER ORDERS
TIME CARRIED OUT BY
_......._ -

4
PHYSICIAN'S S1GNATU
15.
X-RAY IN OPERAT IF YES, SITE
YES • NO :-

16.
' --: LABORATORY SPECIMENS

_
SPECIMEN (S) NAME __ ___.......___ ,.. NAME
YES ¦ NO
FROZEN SECTION (S) NAME

• NAME
YES NO

CULTURE (C) NAME
NAME
YES ¦ NO _ ___ _ ._ _,_. _ __
NAME NAME

NAME
NAME NAME -
1. DRESSING/IMMOBILIZATIOV /Specify)),
-.2.--e_A\Gr fr.._ C)-aryc_e
-,-4..,-­
17. TUBES, DRAINS/PACKING YES is NO )r i-e-opt (c0,62,e /e_Qa
TYPE/SIZE 1. 2. T . . /

1:._
n) Ili .yi---a_ -°sile . , SITE 1. 2 . N606,--,,,,,. -chcS-- piaiv, Si27A-,e5 ) SI 1k
.
-1-0)(f2...e_ _
19. ADDITIONAL INFORMATION
W C.
Dr-
av, e &I.. ,. 30/30
3oui e id Si re -0.05-1 -op Ca-
....
bil C.,-,-\ .S--/ 9 cr rz vii 0 I '
e 01 S. O W
20. OPERATION(S) Pn,i7IED `A-:
5-T:3(7, --0 /. /awes- Ie -c-ov,.— a._.)--i-ki A__

ctos,,,Y e Q-C /91-adorlivi.0 Gootit n c4---. .• 62...efrvi aveA 0-P G--i c-A ---/e-
21.
PATIENT TRANSFERRED TO TIME mErmieci

22.

MEDCOM - 18065 USAPA V1 .00
INTRAOPER, .VF DOCUMENT
MEDICAL RECORD
For use of this form, see AR 40-407, the prop(' mcy is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERAThvk • A 2. PATIENT IDENTIF. D AND PROCEDURE
7ce_A
VIA 1.-t\-c.",-BY +/ALA }1.0 ".VERIFIED BY b (6)-2,
3. DATE TIME PATIENT ARRIVE IN SUITE 4. PATIENT_IN ROO .2-0 0 Lk.-Lr-TIME: NUMBER
• 1s 9
5. PREOPERATIVE EMOTIONAL STATUS N CALM ANXIOUS • EXCITED. • CRYING II ANGRY . WITHDRAWN . OTHER (Specify)
COMMENTS:
6. NURSING PERSONNEL
_. .
ASSIGNED ......,-., -----BELIEF
41
SCRUB . SCRUB
P
(5' '

ASSIGNED RELIEF
CIRCULATOR ....... __CIRCULATOR

• Ii ; _...,
7. POSITION AND POSITIONAL AIDS (Specify)
• SUPINE LITHOTOMY N PRONE • KRASKE,..; . LATERAL: . LEFT SIDE UP RIGHT SIDE UP ccr,...p_c .-17, 0 Qi.,_ ,,..,,___Iii..A.------.c...;...,.._, -1....
czil'I COMMENTS: ?‘"-.."-•25k-A--',. % (11.-i 0,--wv¦--c. kr" rc"k. 61-'-' -5 cr--)c' °`re--- **-11,5kedk 1 G-1--, 0-6ry le (›e-cA b-46--4- o.--....-,zs,en;NstriA0L
8. SKIN PREPARATION
HAIR REMOVAL . YES g NO ' PREP SOLUTION (Specify) 3.-14(N.Sc-Nr..x_kr I . -,-k-DONE BY: • OR • NURSING UNIT SITE: l,01+-ex Da-c-k. -ko cc:cc...AK BY WHOM METHOD: MI DEPILATORY II RAZOR SITE: U BY WHOM:
. CLIP
.---- \2(b) "Z
. .,.. COMMENTS: .. .COMMENTS: .-Y-1/0 ) 0-y-V......._", 1. --t_Adr,
9. LOCATION OF EXTERNAL DEVICES
•
1.
..
— /1 .111: --
.
I • ea¦ A
...... --.."111M1111"1/11411.111111111
¦ . NIO
•
11:1111"—
¦--7
LEGEND X Ground Pad -- Safety Strap = = = Tourniquet.--r—ey cu-csi,_,
C = Correct I = Incorrect
First Closing Final Closing

10. COUNTS Other"• Count ' COunt SCRU -2-CIRCULATOR-.0 (4 :2. Sponge [X1 Yes Vo Needle Sharp RI Yes No Instrument p Yes No _...„...----. _ ._ -.. • ;,....._ r.,W_:7••
.. . Other I/ Yes Vo -------
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) T„A YES . NO
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

('0'140
E. ESU NO: VCAll-e-y lo-Cts- .-cri-clz., 4-0 RAS 1!)2341-5
PAD: BRAND VI--9-0.,-,---. fiaAp(AV-€3r LOT NO 68 2 4-5 . S--Oa
, _ .... _.,....
to(c) -1-1 . ..: Er,ESU NO:
-.GROUND PAD: BRAND
LOT NO: 10(7)'Z • BIPOLAR NO:
.
-11rZtD 0 Li- 63 179-1, OCT 87 REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE. USAPA V1.00
..
MEDCOM - 18066
DOD-031640
13. PROSTHESIS, IMPLANTS 111 YES 'NO IF YES NAME: ID NUMBE9'
URER
•;14. ­
.-"IiOMEDICATIONS/ORDERSan,c, IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES . NO g MEDICATIONS/SOLUTION DOSAGE TIME
METHOD PREPARED BY GIVEN BY
WOUND IRRIGATION YES . NO TYPE(S):
O. °/0 Vick-C-1Z_
`,OTHER ORDERS
TIME CARRIED OUT BY
-Q
:PHYSICIAN'S SIGNATURE
15.
X-RAY IN OPERATING ROOM IF YES, SITE YES . NO [FI

16.

:"::!LABORATORY SPECIMENS SPECIMEN (S) NAME
NAME YES . NO FROZEN SECTION (FS) NAME
NAME YES . NO CULTURE (C) NAME
NAME YES . NO Dig NAME NAME
NAME
NAME NAME
18. DRESSING/IMMOBILIZATION (Specify) ,r1. X
17. TUBES, DRAINS/PACKING YES LSI NO TYPE/SIZE 1. ilT• (osuway 2.
SITE 1. 2.
3.
took
19.
ADDITIONAL INFORMATION

20.
OPERATION(S) PERFORMED

21.
PATIENT T N TO

TIME METHOD
oFV1/1-t..)
USAPA V1.00
MEDCOM - 18067
biq - _
DOD-031641
INTRAOPERATIVE C ',UMENTMEDICAL RECORD
For use of this form, see AR 40-407, the propr ' • is the office of The Surgeon General.
1. PATIENT TRANSPORTED TO OPERATING M 2. PATIENT IDENTIF
IEWED AND PROCEDURE VIA 1_,\,r `{A/ BY itiAJLV\I\•WQt VERIFIED BY LR 1T
-7
3. DATE I T ME PATIE7IRIVED IN SUITE 4; PATIENT IN ROO
26100-G3 TIME i& k5
NUMBER 13
5. PREOPERATIVE EMOTIONAL STATUS
[Xi CALM ¦ ANXIOUS ¦ EXCITED . ¦ CRYING ¦ ANGRY 0 WITHDRAWN . OTHER (Specify)
COMMENTS:0 C--a-Y\aAA& VIS
.S. ltekd
6. NURSING PERSONNEL
ASSIGNED
-- - 'RELIEF
(S-EQC_.) SCRUB
SCRUB
ASSIGNED CV\ C 1
RELIEF
t - CO C,
CIRCULATOR
- ........ __CIRCULATOR i(q .-1 . :
7. POSITION AND POSITIONAL AIDS (Specify)
--.. .
0 SUPINE . LITHOTOMY III PRONE ¦ KRASKE__ LATERAL: . LEFT SIDE UP ¦ RIGHT SIDE UP CCTTN-e-OS-b t(6.-4, --,-.(2t.; *Q"-,.-ki-cia... 1 °-/N' \/---\- GrY\ I? '''-ok Q.\-k-0---
cl,i,i wlvs.NscAX,4c-.COMMENTS: CvN kAAbOci-Pid.S°0, 3/4-kegs' tkAGam. ci 0 s' ‘ q_c=, *1$.)sl-y 0-(%)1 kl‘t-kol 125\-2j sA,vv-seef-k. ,.-./¦,\Q_Lk-IAIDA, ,--
8. SKIN PREPARATION
HAIR REMOVAL 6YES 111 NO PREP SOLUTION (Specify) VrzA-0.,
C.i¦A-A.93 \-
DONE BY: OR ¦
NURSING UNIT SITE: kboLcrifw-LA-BY WHO
METHOD: 1111 DEPILATORY zi RAZOR SITE:

BY WHO
. CLIP
,)b -2_
COMMENTS: "443:5 (
AA:¦ 06S Vi( CA- -14 S COMMENTS: ,L.A,C) y i3D-ktVw 0\r-c.,‘„\A 5 A.A.04.0A,
ektik:7 ---
9. LOCATION OF EXTERNAL DEVICES
...,.... ...
\

, .- P• I . lik" --. ..
¦
----.
1¦1011P-
LEGEND X Ground Pad - Safety Strap = = = Tourniquet., --., -
b (c) --7-
C = Correct I = Incorrect J-w1Va....9...: First Closing Final Closing
10. COUNTS -
Other • • Count .. i.:.. Count
SCRU
CI LATO Sponge 0 Yes Vo
IO 6 -2 Needle Sharp E Yes ] No
. -.. ... Instrument Yes No CA __ C-. :,..,, iY!%,-i'
... Other Yes No „.....----:' -------------
"----
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) j YES ¦ NOName - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
5.0130 4, 1111116 '44 . ESU NO: Vet L ¦e-y(a...tr-1-0--r C....k. Ra 102 3c1 S GROUND PAD: BR ND V L._ 2.4.-k......, fluutiv4... sa-LOT NO: 1-001 i -Z.qD
illinia bLi-\yZ__ --04' --0740 NO:
2ck 6 u(-077 --GROUND PAD: BRAND
...: LOT NO:
. BIPOLAR NO:
I-1 A C non,' ca -7n a es n-r r.-,.---- - --- - - -- -
-1 ITESTL DEC 82, WHICH IS OBSOLETE. USAPA V1.00
13. PROSTHESIS, IMPLANTS • -I NO IF YES NAME: ID NUME
JFACTURER
-. MEDICATIONS/ORDERS -IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES •
NO ill
'MEDICATIONS/SOLUTION DOSAGE TIME
METHOD PREPARED BY GIVEN BY
,
• -
,,. -
,-.
MOUND IRRIGATION X] YES NO, TYPE(S):
' C;1 910 ILiA_UL
OTHER ORDERS
TIME CARRIED OUT BY
PHYSICIAN'S SIGNATURE
15. X-RAY IN OPERATING ROOM
IF YES, SITE
YES • NO 0
16.
".':LABORATORY" SPECIMENS
SPECIMEN (S) NAME

- - -- .- -. -
YES / NO
FROZEN SECTION (FS) NAME
• a NAME
YES NO
CULTURE (C) NAME NAME
YES I/ NO 0 _ __._ ... ._ __.. .__ . _
NAME NAME NAME
NAME
NAME ' 18. DRESSING/IMMOBILIZATION (Specify) ItKg
17. TUBES, DRAINS/PACKING YES al NO U
TYPE/SIZE 1. .. . i-eve e

16 •P-1 c 2318 \\A fe-1AVOSe
(nos-VC-11 1,
SITE 1.
2. 3.
0)..04,9Ce.1,. kiocA-0-vv..SI-vt

19. ADDITIONAL INFOR
A. 4_..Q....--p_a_ -;',st.7...C_(z_
SV¦Arat0A.
rICP‘r

ta.---
/bAQ.W(\i/, C\ 1 _.... .... ..
_—DA5-11.0) 0-v\ cAi1/4-0-4 I 53-5 A&03R-cA/
_ __•

20.
OPERATION(S) PERFORMED

21.
PATIENT TRANSFERRED TO

-1,)k ‘rt-AJ\-. C CA3IC:=1\--t.TY14..8
. ._.

TIME;-es..._ METHOD
-1- (-1-1 a 191f.) -2_ DA-3,g e\ Lt.qt_A/
22 -­
aka
ik
R
USAPA V 1 .00
DATE ox
HOSPITAL DAY
TIME c9 /192 0+2, (t3
MIt] 16? 1113 la MEM1=M11111ffillEIBMIIIIIERRIMMONIMIM
BP Cuff
Temperature
gift
Pulse
Respiratory Rate

5­
4.132_
FU
QrAi. ct
TOTALS
TOTAL
FIBIEHREIMPORIMMITAIN
URINE
SP gr

GUIAC
EMESIS
I.I I.
10111 I
STOOL
DRAINS
111111111111111111
TOTALS

A

0
MEM
t MEM
ROMEMEME
EIMMEIMMEMENEMENER

9)
MEM MI
SEEMEINE laripsd
EINEMINEME.8 SIMON:

NM
.0
Oy 00 0
MEHMENENSI
ro 3
ENIEMMENIMMIN ear)r)
cC
IBEHMEIRE (S
,F,`3 i c
0 ,f)
SOMINZISMENEM
INEMENEMENE
Ci)(-) 0
2M51MEIHMEMIMMMILIEMI 0 rs' 0
1111111111111111t
EIMEMENEMERINIEW 6 tEnii

O
111111115NENEFEENEEMOM
1110 1011011110 ()1 m t) -&"
C
0
IEM3

-0
011111111111111

9
sAU‘
r4 rJor-Jo
L./
cJ
"M6

6-r
-Zriv•I W-Lc
cbc- -\c'
GQ
(.11 rc
ti
I 33HS Al 071 YOIVILLA 1

L

icr

-"..n 0
11111 I 101111111111
n,
11101111111111111511111 m X811133 113313111
LA 0
PINEMEMIN A
1 EMI 11111311M
ummigimiciummen:
enamossnommonomma m
Gain
hamar. 4 aNIESINCERIN'
gro UOIELMIMEEEMERESSIE5
REM BMW 1

0 N
-
0°
to
m x
rs1 C)
E
1111111111111111111111111 E.;
0 _c 0 m
0 m
ktk aG m 0 c m
1111M11311111111113111111111,1112M1 ro m ro
0
„co

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
DAY
POST-. c r 3 ocko
IT _ e 4 Da Lv
MONTH-Y • R DAY ar
_ r A ilarliMil HOUR • • MEM `111 •• WA • • Ing • • • • Ma-CI7 -A3-0 • •
--I LJ4) CA)G..)4)C..) C) 4) U.)Ch.)A A m CTIai 0) a) ...1-...1 -.I 0) 00 (000E
O0) i-b ....1bi..) ix L.) Zo :II. b0) :17
0 0 0 0 o o 0 0 0 00 0 ,
(Centigrade Equivalents, for Reference only)

PULSE
. . & ef, •. . . . . :::::: . .
i Fa
(*) -. y . . . . . ...... . . 105° ,., I Niko ,., ;IA Al . . . . . . ...... . .
, . .
:..•• ...• :. W • .• . .• ...... . . -
, •. . . . . . . . . . . . . . .
180. 104°
... ...... ..
... ... •• •-
..... •
... •
... • ... ... ... ...
1. .•
'.•
...
......
. ......
.
• " • ••
170. 103° •
... ... ... ... ... ...
.
....
. ... ... ... ...
. .
•• •• • • •• •-••
160. 102 ° ...
... ...
...
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RESPIRATION RECORD
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PATIENT'S IDENTIFICATION (For typed or written entries give• Name—last, frst, middle; ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
MEDCOM - 18077 VITAL SIGNS RECORDS Medical Record STANDARD FORM 511 (REV. 7-95)Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202--1
DOD-031651

MEDICAL RECORD VITAL SIGNS RECORD

HOSPITAL DAY
a..
POST-DAY I. I
MONTH-YEAR DAY
19 HOUI) • • I • ' • ,A9 r • •' • A ' •• • "
• . . . . . . . .
PULSE TEMP. F : : . 1 • . : : . •. : . . . . . • . . TEMP_ C
(0)
(.) •
. . . .
105° , , , ; . ; .
40.6 ° . • .
. . . . . . . .
. . . . . .• •. •. .• 6 •. .••.
....... . . .
180 104°

• • • ...... • • ......
....... ...... . . ...... °40.0
.............. .
: • : : : : ............

: •: ........

.. . . . . . . .
170 103° -,
39.4° 5. .......
. . . . . . . . . . . . . . ' ......
o
........ . . . .

. . . . . . . . . . . . . . . ..
: : ....... a) 160 102°
...
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........ .. .
.

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140 100°
37.8 °
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. . To

‘1..•• ..... •• • • . . . ._
130 99° •' m
37.2 °
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98.6°
. . . . : : . : 37.0° i.0 120 • ••
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. . . . . . . . 35.6 °
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. . .
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. . . 35.0° .
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.
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60
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RESPIRATION RECORD
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(Record specialdata only when so ordered
l'qiNgAMIIII741111E01 :4
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-
PATIENT'S IDENTIFICATION (For typed or wri ten entries give' Name—last, first, middle; ID No. REGISTER NO.
WARD NO.
(SSN or other); hospital or medical facility)
STANDARD FORM 511 (REV. 7-95) BACK
MEDCOM - 18078
DOD-031652
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MEDCOM - 18079
' Ii I ! -1 1 i ilL I -I --r Ii ! 1 I il !1....' ' I 1 0 1 I 1 1 1 1 I1 I I 4 1 1 -1--'-1 , .LU ! 1 IL11 I I \III 0 I i I I I
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MEDCOM - 18085
pli. H /i t
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5
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i Li 1 1 t ; ;
:
MEDCOM - 18086
NSN 7540-00-634-4124
VITAL SIGNS RECORD
MEDICAL RECORD
HOSPITAL DAY
DAY
POST-
--,..-
31 09--
j
MONTH-YEAR (A...) DAY
•
•
•
-i• • ••
40-\ HOUR
I: •. . •.
TEMP. F
PLSE
—I COCOCO GOCOCOCO4)COCOAAm
Ul toCO0)-4-4V COCOCD0PK
Ooi-, ...4 ON bo 4) CO 4:. bO) 70
0 0 0 0 0 0 0 0 0 0
o
(Centigrade Equivalents, for Reference only)
(0) (*) 0 ; ; ;
105° . . . . . •. . . •

. • •• •• . • • • • •• •• •• -• ••
"
180 104° •• •• •
•
•
170 103°
•• •' " • • " " •• " " ••
, 4 i : : •
102° ••
•,4
160
• ,. . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 101° • • • •• •• • • .•.• .•.• .• •. •. •. •. .• •. •. •. •. •. •.
. . . . . . . . . . . . . . • •• •• •• •• •• •• •• " ' • •• • • •• ••
140 100° . . . . . . . . . . . . . . . . . . . . . . . .
. .
. . . . .. . . . . .. .
.
..
99. at .. .. .. .. .. .. . .
...
. .
130
98.6° Ai; •
. . . . . . . . . . . . . .
. -. . . . . . . .
120 98°
•• •• •• •• •• •• • • • " • •• •• " ••
.
. . . . . . . . . .
. . . . . . . . . . .
. . . . . 110 97° • . . ..
. . . . . . . . . .
. . . . . .
. . . .
. . .
. . . . . . . . . . . . . . . . .
•
•• •• •• •• •• •• •. . .
.
. . . .
. . . .
! • • • •
....
" ••
100 9E° . • •• . • •• •• •• •• •• . •
• • ' • " "
•• •• •-•• "
. . . . . . . . . . . . . .
Cl._ • • •
90 95° . . . . . . . . . . . . •. . • • • . . . . . . . . . . . . .
• ' " "
. .
•• •• • •• •• •• •-•• •• • " •• •• •• • •' •' " ••
70 . • •. . . . . . . . . . . . . . . . . . .
. .
. . . . . . . . .
. . . . . . •• •• •• •• •• •• . .
' "
50
' • • • •
• • " . . . . . . . . . . . . . • . • . • . • . • . • . . . .
40 • • • • • • • • • • • " • " •
RESPIRATION RECORD it 0

BLOOD PRESSURE sk i2/g1 lievii
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HEIGHT: I WEIGHT +
in
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IKID

r r
PATIENTS IDENTIFICATION (For typed or written entries give• Name—fast, first, middle; ID No. REGISTER NO WARD NO.
Record specialdata only when so ordered
(SSN or other); hospital or medical facility)
CM)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 18087
DOD-031661
[Cla'\1\rue_k_.-R ECORD PROGRESS NOTES
• TE
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Continue on r- erse side
PATIENT'S IDENTIFICATION (Fo.typed or written end, s give: Name • las.first, middle; REGISTER NO. WARD NO. gra e; rank; rate; hospital or medical facility)
PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV. 7911
Prescribed by GSA/ICMR. FIRMR 141
CFR) USAPPC V1.00
,07e1111111
.1111po "eife/
MEDCOM - 18088
DOD-031662
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
FROM HOURS TOTAL HOURS DATE ........,TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET COVERED
TO HOURS
S1
INTAKE
ORAL INTRAVENOUS
TIME TYPE AMOUNT ACCUM TIME AMOUNT TYPE AMOUNT TIME ACCUMTOTAL STARTED (Include Medications) RECD COMPL TOTAL
i rM .u3c6cQx_
(
k_Ob 27,t • 16( C-'a-piu-( (XL-t (S6t-
,suA.,Q._. sAco Szkc 1(921) 1,/.alf2) OD ASN) Malik 160 ODOD bUetheil ioto
IV1) ' 0133 vocy -A. 3,131) Sao
, ...
zy-r) d:--)
IRRIGATIONS (N/G, Bladder, etc.)
in-ic d0r) -110
Pce:
TIME TYPE ACCUMULATIVE
AMOUNT
Igur +V) I a)
TOTAL
_A 0 G . ‘g,Q I b 0 91D 11-4(---Hg) l0/2 I opb 09-ec 14-10 VS HOD
BLOOD/BLOOD DERIVATIVES
TIME PRODUCT (i.e. B1, TIME ACCUM
AMOUNT OTHER INTAKE
STARTED Alb, P. cells etc.) COMPL TOTAL
TIME TYPE ACCUMULATIVE
AMOUNT TOTAL
GRAND TOTAL INTAKE
nn rnmn -nan JAM 7A ICI-.1
DITION OF 1 SEP 54 IS OBSOLETE.
Designed using Perform Pro, WHS/DIOR, Jun 94
1111111 -
)
—....—
OUTPUT
URINE NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
l'W Igt)() -41().--0
---,,
9 6.15 •t .QDC)
11 i 0 Med0 100 _. _
fOrS. ,ic-951-)C
b(000 CD 2,60D
...
CHEST EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
. .
GRAND TOTAL OUTPUT
REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date: hospital or medical facility) INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS (1 az) . 30 HALF PINT MILK
6 240 120 LARGE SOUP BOWL
240 SMALL FRUIT CUP 160
II. b )( _c t
LARGE WATER GLASS 240 COFFEE MUG 180
PLASTIC OR PAPER
• JUICE CONTAINER
180
DD FORM 7R2_ mini 7d
Page 2
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
FROM HOURS TOTAL HOURS DATE
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET To COVERED
HOURS
I-UZ2
INTAKE
ORAL INTRAVENOUS
ACCUM TIME TYPE AMOUNT TIME ACCUM
TIME TYPE AMOUNT AMOUNT
TOTAL STARTED (Include Medications) RECD COMPL TOTAL
.
DIGD Di (0° CCICg\01IC C 1 C°
C000
r&C,3 A ja I CIDECBC1 nCO LI r '2rirc 51c
0
taQ3-1-1i CO LcCa
161) o n,or s e
_ .
Or) R20 100 Cq572c
IRRIGATIONS (N/G, Bladder, etc.)
ACCUMULATIVE
TIME TYPE AMOUNT
TOTAL
TIME STARTED BLOOD/BLOOD DERIVATIVES PRODUCT (i.e. B1, Alb, P. cells etc.) TIME COMPL AMOUNT ACCUM TOTAL TIME OTHER INTAKE TYPE AMOUNT ACCUMULATIVE TOTAL
GRAND TOTAL INTAKE EDITION OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94
MEDCOM - 18091
DOD-031665

OUTPUT
URINE NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
(NV_ 1 (&) I (i3C)
L-*) aLID‘ Cia 0
5 10 LF{ 0 CI 1 0 .

.
VD CP114;
loi-V /
(.22k0
(...___
CHEST -. _.
EMESIS
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT

TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL

OTHER OUTPUT TIME AMOUNT TYPE
ACCUM TOTAL .. _ .. .
..... . . .
GRAND TOTAL OUTPUT
REMARKS

PATIENT'S IDENTIFICATION (For typed or written entries give: Name -last,
first, middle; grade; date; hospital or medical facility,)
. INTAKE EQUIVALENTS (Serving levels cc)

3
(1_0 C-101)
MEDICINE GLASS 11 oz) .
30 HALF PINT MILK 240
• 120 LARGE SOUP BOWL
240 SMALL FRUIT CUP 160
LARGE WATER GLASS . . . 240 COFFEE MUG
180 PLASTIC OR PAPER
71111111 Y(0 - ,
JUICE CONTAINER 180
nn Fnpnn 7q7 IAKI 7A
Page 2
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
FROM CCnflOURS TOTAL DEE
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET -
TO )URS g °
.,o ct-0'-.
ORAL ACCUM
TIME TYPE AMOUNT TOTAL
1500 b---occ*) 5D66 t_i63
0 goo t-6_.° ) g-06 3d,:4-P (;.0 103 i0 -(490 --1,606_,L.
BLOOD/BLOOD DERIVATIVES TIME PRODUCT (i.e. BI, TIME ACCUM
AMOUNT
STARTED Alb, P. cells etc.) COMPL TOTAL
INTAKE
INTRAVENOUS
TIME TYPE AMOUNT TIME ACCUM

AMOUNT
STARTED (Include Medications) RECD COMPL TOTAL
.-
IRRIGATIONS (N/G, Bladder, etc.)
ACCUMULATIVETIME TYPE AMOUNT TOTAL
OTHER INTAKE
ACCUMULATIVETIME TYPE AMOUNT TOTAL
GRAND TOTAL INTAKE
.
DD FORM 792, JAN 74 (EG) EDITION 9FI SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94
OUTPUT
URINE NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
Ng 2a)(01/41U)grft( if-GIC 1000 1 2-490t4d OD 3c0 noo . .

.
CHEST -EMESIS TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT TIME AMOUNT TYPE ACCUM TOTAL
--..
...
GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; date; hospital or medical facility) .
INTAKE EQUIVALENTS (Serving levels cc)
MEDICINE GLASS II oz} . 30 HALF PINT MILK
240 120 LARGE SOUP BOWL
240 . t 111111D (0 "-Li SMALL FRUIT CUP 160 LARGE WATER GLASS 240 COFFEE MUG 180 PLASTIC OR PAPER JUICE CONTAINER
180
DD FORM 792, JAN 74 Page 2
MEDCOM - 18094
E PRIVACY ACT OF 1974
FRO HOURS TCO
TVAELREHDOURS DATE o....
I
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET HOURS
INTAKE
INTRAVENOUS
ORAL
ACCUM TIME

TYPE AMOUNT TIME ACCUM
AMOUNT
TIME TYPE AMOUNT TOTAL STARTED (Include Medications) RECD COMPL TOTAL
DECO 20 7SiECC-1 ' -
R26
IRRIGATIONS (N/G, Bladder, etc.)
ACCUMULATIVE
TIME TYPE AMOUNT
TOTAL
..._
BLOOD/BLOOD DERIVATIVES
ACCUM
TIME PRODUCT (i.e. B/, TIME OTHER INTAKE
AMOUNT
STARTED Alb, P. cells etc.) COMPL TOTAL
ACCUMULATIVE
TIME TYPE AMOUNT
TOTAL
GRAND TOTAL INTAKE
.
EDITION OF 1 SEP 54 IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Jun 94
DD FORM 792, JAN 74 (EG)
URINE TIME AMOUNT ACCUM TOTAL TIME ,65 ezapara. AMOUNT OUTPUT ACCUM TOTAL TIME AMOUNT NASOGASTRIC TYPE ACCUM TOTAL
65 vCl. .
I &30 (9 DO 6 0 d

CHEST -' EMESIS TIME AMOUNT ACCUM TOTAL TIME AMOUNT
ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL OTHER OUTPUT
TIME AMOUNT TYPE ACCUM TOTAL
DOCC bn,..). anii _ ii vox), w,
\LH-5 It)M 1 Sant — 1 i ) ZOCCC
Ye, 110 litke
-Risb i .()/Th ( ,t-V Akeil ‘199` 1-/.°)e c
GRAND TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last,
first, middle; grade; date; hospital or medical facility)

INTAKE EQUIVALENTS (Serving levels cc) 00-7 46
MEDICINE GLASS (1 oz) . 30 HALF PINT MILK 240 120 LARGE SOUP BOWL
SMALL FRUIT CUP 160 LARGE WATER GLASS 240
4) -1-f 240
AM 19
COFFEEMUG 180 PLASTIC OR PAPER JUICE CONTAINER 180
DD FORM 792, JAN 74 Page 2
MEDCOM - 18096
DOD-031670
1-SIHI 6;11-

am 19 )L
24 -

TA2

1C;
42.1 mmHg
88 mmHg
23 mmol/L

• -3 mmol/L
%
Kcalculated

pie Type_:
1RUG03 04:17

-r:d111111
;sician:
.4111111

JAM3046R

CLEW R93

Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM
(Subject to the Privacy Act of 1974)
LAST, FIRST, MI. ,
DATE TIME . -
SSN/PSEUDO SSN:
. r .
TES ....(Hematology) C _ - Tirmalms F. RANGE TES '-- -`-F. RANGE TEST Serology,. RESULT REF. RANGE
limn Color Negative
Wiii L\ App Glu - Nn N/A Negative 'Mono Negative °V-.-,
ilffIll;T: Bili Negative Source
Ket 04'1 Negative Gram Stain
., i se 62-5- Negative • .... ;
Bid Negative H pylon Negative
450. lall C 5 N/A Micro
1' Parasites
Prot
4 Urob
1 Nit - .. i

_
Atyp I 1mm - aik
Microscopic rill" sia '
....
Negative
)P0 INT WAti ANAL Y/ ER V4.54
.
T. 1100b485 08/29/03 04:53 PM
rit 111:111111 (0 -1-1
5 t Name . — CSF..... . .Blood.Ba
. . .

t.Resull -19.6 s .. -. .. ._.: • -. IRESUI T NO 1 n • .KED*" 11 MUST.• i.8 WITH
tint
LLD = 1 . 5 EVERY UNIT REQUESTED lculated INR ,-: 2.19 .ectigen Negative
ABO/Rh
nple lywcardted wh. blood ,

, .

)1 I id i e :08/29/03 . • -
-- .:. .Blood ;Baiirdiiit Crosson c
-
:.1 Hie :04:51 PM : .. (111
T5UBMIT. Sf.518.4/TH EVERY .UNLIT 0.LOOD: ' • :
. ._ . , . ..... . . . • . . .

rd Lot :080201

---';:--. • ;•.• .•,-, .::.:.REQUESTED)..:, ..•.- -..---•.'-:: -.
....: • :, •
-
:.1 a tor• UNIT
:111111111 12 (‘)--7.—.

CROSSM4TCH
-
VOINI LUAU ANALYZER V4 .b4 \I. 1100!-,405 16/211103 04:56 PH
'. -
±„I 101111/ )0(0-q
1111IR

'01

1 1'i 4b .ti WBUL1 NOI R ' ' *41 nple lypt::cil!Aled wh. blood it Dale Aid!:...i, 11:i
E: LAB D. NO.:.. .
A .1 lie :04 :Si PM
, ,. ._,.
I , , .1)1 iy:•,(11
b
MEDCOM - 18098
DOD-031672
(6 )-z
Ward/Section:
CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)LAST F T, MI oil i SSN/PSEUDO SSN:
)
le
A LA ...
f:
. . 4400 , ,4011I ' ' 4P4A41040*ftlii t:
'''.•.• 5:.. .:)9,:-..,,r.
TEST RESULT REF. RANGE TEST RESULT REF
TEST RESULT REF. RANGE RANGE
Na 138-146 mmon ALB
' 3.5'15 e/41 . GLU 71-118 mg/t11
K 3.5-49 mmol/L

: ALP 26-84 u/1 BUN 7-22 mg/dl 98-109 mmol/L ALT 10-47 u/1
---,, CA1, 1 . 8.0-10.3 mg/dl
pH 7.31-7.45 AMY 14-97 u/1

CRE 0.6-1:2 Ing/d1
PCO2 3515 mmHg (art) AST 11.38 u11 NA* 128.145 mmoUl
41-51 mmHg(veal).r
80-105 mmHg (art) ,

P02 3.3-4.7 mmelrl
N/A (veal
TCO2 23-27 mmol/L (art)

PICCOLO L" 98-108 mmol/1
24-29 mmol/L (ven)
HCO3 22-26 romol/L (art) 29/08/03 16 : 52 :x:),2 .

18-33 mmoUl ,:-
23-28 mmol/L (yen).
REFERENCE RANGE : MALE
s02 95-98%
PAT I ENT # : ' :.:(1PiCCOWOieiTan,400.§.-
BEecf (-2) — (+3) METLYTE 8

TEST RESULT REF. RANGE
r-inmul/L
DISC LOT # : 3141AA4
AnGap 10-20 mmol/L i 3.3-5.5 g/dI
OPER it : DR # : 000 1B
Ca i .12-1.32 mmol/L
SERIAL # : 26-84 u/1
BUN 8-26 mg/di ,,LT 10-47 u/I
GLU 142* 73-118 MG/DL
GLU 70105 mg/di BUN 9 7-22 MG/DL LMY 14-97 u/I
CRE 0.6 0.6-1.2 MG/DL

Creat 0.7-1.5 mg/d1 11-38 u/I
CK 534* 39-380 U/L PST
Hct 38-51% PCV

NA+ 129 128-145 MMOVL .1311, 0.271.6 mg/d1
Hgb 12-17 g/d1 K+ 4.1 3.3-4.7 MMOVL i GT 5-65 u/I
.,-CL 107 98-108 MMOVL

:P 6.4-8.1 g/dl
t CO2 20 18-33 MMOVL
TEST RESULT REF RANGE colo)+:ElecfPvlyl
I NST OC : OK CHEM QC : nK -,
Troponin-1

HEM 0 , LIP 0 , ICT 0 TEST RESULT REF. RANGE
Drug of ,,FAt -128-145 mmol/1 -

Abuse
C.' 3.3-4.7 mmol/1

:.T..; 98-108 mmo1/1
CO2 18-33 mmol/1 ¦
REMARKS:
REPORTED BY:
Ward/Section: xr.QUESTING PB SICIAN: LAST, FIRST,ML
ematol
TEST RES LT J F. RANGE TEST RESULT
WBC 4.8-10.8 x 101 Color
RBC App
Hgb Glu

Het Bili
MCI Ket
Pit SG
Lym Bid
pH
Segs Prot
Bath Urob
Lym Nit
Atyp
RBC [DPOIN1 WAG ANALYZER V4.54 Morph [Al 4005485 08/29/03 In:22 PM
• !cut ID: est Name
Spun ­
it Res
Hematocrit
RESULT 801 ED444.
Sed Rate
to = 1.6 alculated INR 1.11
-
ample Type:cit rated oh. blood
Other
est Date :08/29/03
ast Time :10:21 PM
a
and Lot :110201 perator
:11111111(6)_2_

101 301N1 CUAG ANALYZER V4.54 TAL 11005485 08/29/03 10:25 PM
lent ID: b((0) -L\ est Name est Resu
41, RESULI
FDP h A
ample Type:citrated
est Date :08/29/03
REMARKS:
est Time :10:22 PM and Lot :ran
REPORTED II
Aerator
LABORATORY RESULT FORM (SuFect to the Privac Act of 1974 SSN/PSEUDO SSN:
D
Misr. Serology
. . • "

REF. RANGE TEST RESULT REF. RANGE
N/A RPR Negative
"N/A Mono Negative
Negative
Negative
PICCOLO

Negative
28/08/03 22:20

REFERENCE RANGE',

'N/A PATIENT #: as MALE Negative GENERAL CHEMISTRY 12 DISC LOT /1: 3204AA4
N/A
OPER #: 1111 _ca #: 000 SERIAL #:
Negative
0.2-1.0.ALB 3.0* 3.3-5.5 G/DL 'ALP 43 26-84 U/L
Negative
.ALT 508* 10-47 U/L
AMY 40 14-97 U/L
AST 405* 11-38 U/L
TBIL 1.5 0.2-1.6 MG/DL

give.BUN
11 7-22 MG/DL
.CA++ 8.6 8.0-10.3 MG/DL

•CHOL 35* 100-200 MG/DL
CRE 1.1 0.6-1.2 MG/DL
GLU 131* 73-118 MG/DL
TP 4.6* 6.4-8.1 G/DL

ii
INST DC: OK CHEM DC: OK Negative HEM 0 , LIP 0 , ICT 0
041:Bisi
.Sr: 518.
B ID NO.:. .

i-STAT 03+
Ft \\.f'0
Pt Name:
\j/ 142-- rif
23 mmol/L iDE 24 mmol/L
Name:
pH 7.200 P.4 7.420
7..02 23 PCO2 54.2 mmHg 35.5 mmHg
P02 30 mmHg .502 64 mmHg
37C HCO3 21 mmol/L 23 mmol/L
7.415 BEecf -7 mmol/L .;-.,cf -1 mmol/L
34.6 mmHg s02* 92: ,ra* 93 %
isc. mmHg *calculated .calculated
03 22 mmol/L
-:ecf -2 mmol/L At Patient Temp • Dati4nt Temp
2* 99 % p-: 7.219 L 7.405
calculated
50.9 mmHg ::c , 37.1 mmHg
73 mmHg 1:' 69 mmHg
Patient Temp
7•436 Patient Temp: 96.0F 'tient Temp: 100.4F
32 32.6 mmHg FIO2 : 50 02 : 40
"2 149 mmi-; Sample Type_: ampleType_: ART
•tient Temp: 96.1F 30AUG03 1227 30AUG03 06:12
02 : 50
amplerype_: ART Uper ,-r:
29AUG03 22:09 lysician:
?r: JAM5046A
CLEW R93
r'hy5ician:
Irt IMP
.r: JAM3046A
CLEW A93
-J
Cr, :L cn 0 0 1:0
S. ".
Ck1 • - 0 0 W W I T. 'Tl • • a en
• -1- .13 1 -t
Li I- UJ
.1 —I
U
C1/41 C.) ¦"7.' 0 U 0 W 0 0 4.1 0 77 0 'et cri 3t e

DOD-031675

SPECIMEN/LAB. RPT. NO.
Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE REPORTED BY. MD CHEh, URGENCY TODAYTODAY 0 . PRE-OP STAT . PATIENT STATUS 11 KBED . AMB 8 OUTPATIENT . I'd u. . NP . DOM UI* r F.= a SPECIMEN SOURCE . BLOOD . OTHER (Specify) LAB. ID. NO.

,40.11N1 WA.C, ANALYak V4.54 1 41 #0115465 08/30/03 07:42 PH
,11 111: hCG

9

Name —

ResqLnj sec.
1w4J1 I NUI RANUE CHEMIII*4
11111 ripe:citrdted wh. Hood

I Oide :08/30/03
, !imt: :01:39 PM

I :G 0301 0(

W. Section: RE IAN:
LABORATORY RESULT FORM
(Sub' ect to the Privac Act of 1974 D TE TIME SSN/PSEUDO SSN:
',Ac_s-c:C1
(Hero* Urinalysis Misr. Serology
TEST I RESUL REF.: GE TEST RESULT
REF. RANGE TEST RESULT REF. RANGE
A 9_1A.in3
7-1

Color N/A RPR Negative
RB( App N/A Mono Negative
Hgb Glu Negative
Microbiology
Hot Bili Negative
Source
MCI Ket Negative
Pit SG 'N/A
PICCOLO alive
Lymj Bid Negative 30/08/03 02:30

;ative
REFERENCE RANGEi MALE

pH N/A
PATIENT #:

b((0)--t-t
METLYTE 8

Segs Prot Negative
DISC LO #: - 3151AM
Band Urob 0.2-1.0 OPER #: DR #: 000
SERIAL #:

Lymr Nit Negative
GLU 109 73-118 MG/DL
Atyp Negative BUN 12 7-22 MG/DL

'!DPOIN1 COAG ANALYZER V4.54

CRE 1.6* 0.6-1.2 MG/DL

At 000546 08/30/03 02:9'2 /III

RBC Negative CK 986* 39-380 U/LMorp
NA+ 131 128-145 MMOVL

Itut
In:
K+ 4.3 3.3-4.7 MMOVL

I: Peso It 14.5 sec. CL-105 98-108 MMOVL

Spun
44SULT NOI ,KED44,* CR*: tCO2 22 18-33 MMOVL
Huila
ii io 1.2
SedR • tiuuldteil [NP 1.32
INST 0C: OK CHEM GC: OK 11Th

Bp; I elye:i;itratecl jh. blood

HEM 0 , LIP 0 , ICT 0.
'ED
I;ate :08/30/03

Other Neg
ime :02:30 AM
lot :080201

i0U; at Ul •Blood:
OMR17(0 -1/

SUBMIT Sr:. )1)
TES . •1141.01. LUAU ANALYZER V4.54 rcjq
'4005485 08/30/03 02:35 AM

PT
ieot ID'
APTI
-:2st Ndme
est R€sul

ID dim
'-'RESULT NU 044*
dmple Type:Gardted wh. blood

FDP
est Date :08/30/03
est Time :02:32 AM

REM.
ard Lot :010301

•perator

REPC
LAB ID NO.: .
Ward/Section-
YSICIAN:
lcu, LABORATORY RESULT FORM
#S'b'LEIRS
A.
em

logy) CBC ::
TEST RESUL RANGE
VT:
RE

He
M(

Pk
Lyi
Seg
Bar
Lymph I.I Baso I
IDPOINI [0(4, ANALYZER V4.54 IAL 400!)4iv, 06/30/03 06:10 All
ID:111111 4c.) -11

lent
est Name :PT
est Result:. 16,2 sec.
.**RESULT NOT RANGE CHECKED***

atio . 1.3
-alculated INR . 1.58
Ample Type:curated wh. blood

est Date :08/30/03
est Time :06:16 AM
and Lot :080201

1)(0

perator
1DPOINT WAG ANALYZER V4.54 IAL #005485 08/30/03 06;21 ,1:1
AXE (c)--14

ient
est Name :APT1
est Result:= 41.2 sec.

*RESULT NOT RANGE CHECKED*** ample Type:citrated wh. blood est Date :08/30/03 est Time :06:18 AM and Lot :010301
(,(2)

perator
(Suliect to the Privac Act of 1974
DATE TIME
0 C5,2Cs, C)
Urinalys
TEST RESULT REF. RANGE TE
Color N/A RPF
App • N/A Mor
Glu Negative
Bili Negative --­¦¦=211.Soul
Ket Negative Grar
Stair
SG 'N/A Occ
Bld Negative H. p:
pH N/A Micr
Para
Prot Negative Mala
Urob A 1_1
CL.103
58-108 MMOVL

Nit
CO2 . mmol/L 370
7.423 t 36.6 mmHg T Pi-12 34 mmHg
,.003 a4 mmol/L RF.ecf -1 mmol/L Sn2* 5, 7 *calculated
Type_: 3ORUGO3 02:25 '..Per:
MIN
.2pme4,,n
MEDCOM - 18104
SSN/PSEUDO SSN:
PICCOLO -------
30/08/03. 06:14
REFERENCE RANGE: MALE
PATIENT C11111111
METLYTE 8
DISC LOT #: 3151AA4
OPER #: DR #:
SERIAL #:

GLU 92 73-118 MG/DL
BUN 14 7-22 MG/DL
CRE 1.4* 0.6-1.2 MG/DL
CK 1195* 39-380 U/L
NA+ 130 128-145 MMOVL
K+ 4.4 3.3-4.7 MMOL'L

-:

tCO2 21 18-33 MMOVL

INST DC: OK CHEM DC: OK
HEM 0 , LIP 0 ICT 0

t.--iMISTRY RESULT FORM
(Suliect to the Privacy Act of 1974)
.
Tai_....
T RESULT REF. RANGE
138-146 mmol/L 3.5-4.9 turnon 98-109 mrno1/I. 2 C_C C 30/08/03 REFERENCE RANGE: PATIENT #: 14:18 MALE
7.31-7.45 GENERAL CHEMJSTRV 12
(-2) — (+3) mmol/L 10-20 mmolfL 1.12-132 mmo1/1 35-45 mmHg (art) 41-51 rnmEl Yen) 80­105 mmHg (ari) N/A yen) 23-27 mmol/L (art) 24-29 mmol/L (yen) 22-26 mmol/L (art) 23-28 mmoUL (yen) 95-98% DISC LOT #: 3204AA4 OPER #: DR #: 000 SERIAL #: ALB 2.7* 3.3-5.5 G/DL ALP 48 26-84 U/LALT 529* 10-47 U/L AMY 43 14-97 U/LAST 476* 11-38 U/L TBIL 1.8* 0.2-1.6 MG/DL BUN 14 7-22 MG/DL CA++ 8.0 8.0-10.3 MG/DL CHOL 65* 100-200 MG/DL CRE 1.4* 0.6-1.2 MG/DL GLU 100 73-118 MG/DL TP 4.7* 6.4-8.1 G/DL
INST OC: OK CHEM OC: OK
N HEM 0 , LIP 0 , ICT 0

REPORTED BYla
Ward/Section: -
LABORATORY RESULT FORM
1(L
(Suliect to the Privac Act of 1974
LAST, FIRST,
DATE TIME co
SN:
(H. Urine Is
roiogy :
TEST RESULT REF. RANGE TEST
RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10'
Color N/A
RPR Negative App N/A
-
Mono Negative Glu Negative
Nficrobiollogy
,
Hct
Negative
Source
MC

Ret Negative
Gram StainPit
SG N/A
Occ Bid Negative
Lyn

Bid Negative
H. pylori Negative N/A
PH Micro Parasites
Seg
Prot Negative
Malaria
Ban

Lyn
•• IbPOINI COAG ANALYZER V4.54 IAL 0005485 08/30/03 02:22 P14
Atyp 1mm I
mopic Urina
ient ID:
RBC lest Name TPT1
Morph res t Result:= 18.6 sec.

roRESULT NOT RANGE CHECKED***
atio = 1.6
ilculated INR - 1.62

Spun 42;52% (M)
imple Type:citrated wh. blood Ilood Bank
Hematocrit 3747% (F)
".•.•
!st Date :08/30/03
Sed Rate
st Time :02:21 PM
MIT SF 518 WITH
• .rd Lot :110201

()-1 TT REQUESTED
rat or
Other
°nulition StUdies:.
. J1DPOINI CIAG •ANALYZER V4.54
IAL 0005485 08/30/03 02:28 PM NIT or BLOOD .
TEST RESULT REF. RANGE
lent I V0-41 CROSSIVL4TCII
PT 9.8-13.6 secs est Name st Result:= 58.1 sec. AM 21-34 secs RESULT NOT RANGE CHECKED*** imple Typexitrated wh. tdooUD dimer 20 ug/m1 st Date :08/30/03
st lime :02:25 PM

FDP 10 ug/ml rd Lot 10301 erator
REMARKS:
REPORTED BY: JJ-2.DATE:.LAB ID NO.:
MEDCOM -18106
DOD-031680
. - --
WardiSe ion:
T ABORATORY RESULT FORM (Sub'ect to the Privacy Act of 1974) LAST, r s.• , 'Tim—... SSN/PSEUDO SSN:
tc) -2_
12 i — Li e-4 ss---0 egy:) CI3C :. Urinalysis MisCiSeroloi&f ----. -- •
TEST RESULT REF. RANGE TEST RESULT REF. R, NGE TEST RESULT REF. RANGE
WBC 4.810.8 10' Color RPR Negative
RBC 4.7-6.1 x 9 App Mono Negative
14-18 Gat (M)
Hgb Giu Negative 11,UCrobioto-gy
Het 42-52%(ht) Bili . Negative
\./ Source
37-47% (F) Negative
Gram
81 -99 fl (17
Stain Plt 130-500 x10 SG N/A Occ Bld Nes.-ative verified Lymph °(,) 20.5-51.1% Bld Negahve H. pylori Negative
(HematOlogy).Manualpifferentiil . pH N/A Micro
Parasites
Segs Mono Prot -Negative Malaria

Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative .Mici'oscti.pie U.rinalysii'
RBC HCG Negative
Morph

Spun 42-52% (1v1)
CSF • Blood. Bank •-•
Hematocrit 37247% (F)
Sed Rate
Ce11 MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh
Coagulation Studies. • . • •- .Blood Bank Uuit Crossatatcli, . . (MUST SUBMIT SF 518.WITFE EVERY UNIT OF BLOOD ..
•:. REQUESTED) • . ' '.: -
TEST RESULT REF. RANGE LTN1T TYPE CROSSA ,L4TCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/ml
FDP 10 ug/Ent
REMARKS:
REPORTED BY: DATE: LAB LD NO.:
Ward/Section: REQUESTING PHYSICIAN:
LAST, FIRST, MI. DATE TIME
_.._ __ _ :i4614Cliiitii5
i-5TAT E67+ PEST RESULT REF. RANGE N a P ilk ID' ) - t( .B 3.5-5.5 Wdl
K Pt Name: _.1) -• 26-84 lilt
CI ,T 10-47 ufl pH Na 141 mmo 1 / 1_
v1Y 14-97 u/1
4.5 mmolli__
1.-11-38 u/1 TCO2 23 mmol `L PO i1L 0.2-1.6 Ind& iCa 1.ail mmol'! TC IN 7-22 mg/d1
PC "
Act 30 %Pcv 8.0-10.3medl
HC [-lb* 10 gidL
*v i a Hct (OL 100-200 roWd1
80:
_E 0.6-1.2 mg/di
BE' Rrt :37C
An( ;5H 7.402 , 73-118 mg/d1
' 'CO 35. 4 mmHg 6.4-8.1 srldl
Ca
217 mmHg
BU PlY4 tcco1o);Metlyte 8 . 1CO3 22 mmo 1/L GL1 EST RESULT REF.
-Eecf —3 m rao 1 /L
.3
RANGE
100 %
Cre. 3°2* 73-118 me di
*ca 1 cu at ed

Het 1 N 7-22 mg/di
Hgt E 0.6-1.2 mg/d1
:z..temple Type_•

39-380 u/1 (M)
-. . ..-.:.., :. ..• 30-190 u/1 (F) TEST RESULT REF RANGE NA+ 128-145 ramolil
,.4.
Troponin-1 3.347 EarnoUl
Drug of CL-98-108 mmol/1 Abuse tCO2
18-33 mmol/1
REMARKS:
'REPORTED BY: DATE: I LAB ID NO.:
e--2,-0›,
ClziErylASTRY RESULT FORM Sub' ect to the Privacy Act of 1974) SSN/PSEUDO SSN:
-(,ic1=:41. ..o).44le.t.io1iC;.P.aliel
TEST RESULT REF. RANGE
GLU. 73 -118 toWdl BUN 7.22 n-ddl CA4* 8.0-10.3 rag/d1 CRE 0.6-1.2 mg/di NA+ 128-145 mr.r.o1/1
K 3.34.7 mrnolil
CI: 98-108 mrnolil
tCO2 18-33 mmolif
(Piccolo} is,..0 P011 -ej PIpS:.:.-.:'
TEST RESULT REF. RANGE
ALB 3.3-5.5 g/d1 ALP 26-84 u/1
13-47 1.2./1
ALT
AMY 14-97 u/1 .
AST I 1 -381,11 TBIL 0.2-1.6 mg/dl
5-65 Lill TP 6.4-8:1 Vd1
GGT
. c..color)..Eleiti•Obie;
•-
TEST RESULT REF. RA.AIGE
128-145 mmol/11\1A÷ 3.3-4.7 orio1/1
98-108 mm0111
CU
tCO2 18.33 mmol/1
MISC URGENCY 1.A.ZTINE TODAY El EPRE-OP STAT
Enter hi above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE RE RE BY
REPORTED BY
6 (6)
RE
*'UI NI COAL ANALYZER '14
\I 0005485 08,1;110:1

ID (.‘')
I I: 40.9 !sec..."
41SULT N0 LCKF04.t
twit: Type:citrated [duo
I 001e 08/31/03
1 I 11110 :02:24 AM

ird Lot 030201
)erator

OPUINI LUAk ANALYZER 14 h4
AL itliu548h 08/31/03 02:28

Ndihe :PT
I t 11.9 sec.
RLWLT NOT RANhE r

10 — J
culated INR 1.66
pie r;t1A-A III Wood
t Date :08/3013
11 1ii :02:21 Al')

I ot. :080201
.
citor (6)\ -1,
SPECIMEN/LAB RPT. NO.
PAJIENT STATUS BED :IAMB "IJTPATIENT El DNP DOOM SPECIMEN SOURCE
(Specify)
LAB ID NO.
PATIENTS MED. RECORD
pa.12_ • ._
poz_
-3TAT ECA+
L NBMP:

M9sdL
---722

MaMe: 1.2
Type_: 88 mq/dL 30RUGO3 19:3s
138 mmol/L
er :1111111/

5.0 mmol/L
P'Asician:

111 mmol/L T02: 22 mmol/L 12 mmol/L
VI?r: jRw.7.434:7.1

34 .1-;PCV OLE'' n9:=;
12 gsdL
*via Hct

7.297 -, CO2 42.2 mmHg G3+
21 mmol/L
mmol/L

t Name:

Type_:
26

30RUGO3 19:36
,t 37C

„Am
PH 7.349 , lysician . _ PCO2 45.1 mmHg 'TAT CREA P02 5, mmHg
..?r#

25 mmol/L
e,-: !AM50ill,r
E-ecf
CLEW- R93 -1 mmol/L
LC:,*
*calculated

1.2 mg/dL
Type_: ,ample Type_:
02:14 ARUM
1111111r
.111111,

JRM5046R

JAHSO4,SR CLEW
093
CLEW R93
SPECIMEN/LAB RPT. NO
Laic_ 1 6tte-co --1 PT--
'SC
.,4CY
. ROUTINE
TODAY .
E P111111111
( (9) . PRE•OP
IcLkiL
STA
Enter in above space
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE REQUESTING PHYSICIAN'S SIGNATU
REPORTED BY
/ADI DATE
31 /211.,G
TECH
b(&) sZ
3TAT EC_ ;+
•

(1
III 6(4)­
Name:
ae mg/dL
15 mg 'dL
140 mmol/L
4.5 mmol/L
103 moll_
25 mmol =`L
ap 11 mmol/L

ict 33 7-:PCV
11 g/dL
*via Hct
=, 1 7.347
43.8 mmHg
05 24 mmol/L
.ecf -2 mmol/L

Type_:
i1RUGO3 02:14
-

..-er:111111

,sician:
IMO
•JAN5046A

CLEM A93
PATTEN, ATUS
0
0 BED AMB U OUTPATIENT .
. NP.El DOM w
X
SPECIMEN SOURCE (Specify) in
11 1116-K, t
LAB ID NO.
i.
MEDCOM - 18111
Wiard/Secfion-REQUESTING PHYSICIAN:
___4-C.A LABORATORY RESULT FORM I LAST. FIR .(Subject to the Privacy Act of 1974)
DATE
TIME SSN/PSEUDO SSN: (.Se Q\-1- (¦1 0
can.) .CBC
_Urinalysis
Misc. Serology
TEST RESULT GE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8x 10'
Color N/A
RPR Negative App -N/A
Mono Negative
17, (0 -11
Glu Negative
ilIN Werobiology
Bili Negative
Source
Ket Negative
Gram Stain
Ph ?. 7 L qsdi-
SG 'N/A
2 L Occ Bid Negative
Ly FL

Bid Neoativf. r.
Negative ri.C.PL .32.2 L 13.0 37.0
pF
51.1
Se
Pr
Ba Ut

Ly Ni
Atyp J 1mm I Lc VuiNI LuAh ANALYZER V4.54
ic Urina
L 00054115 09/01/03 04:4.5 AM

RBC
Hi
Morph nt ID:11111 M-11
t Name :PT 1
t Result= 18.1 sec.

•RESULT NOT RANGE CHECKED:**

Spun 42-52% (M)
to = 1.6

Hematocrit 37=47% (F) ed:Banic .
coldted INR = 1.57

Sed Rate
Ci pie type:citrated wh blood
IT SF 518 WITH
t Date :09/01/03

7 REQUESTED
t Time :04:44 AM

Other Di
d Lot :110201
,_nrator

imp
TOP' BLOOD
POltif COAG ANALiLER 04.54

RESULT
1 0005485 09/01/03 04:49 AM

CROSSM4TCH
(.k),)—
t Name :AP1F
t Result:= 31.8 sec.
RESULT NOT RANGE CHECKED***
rle type:citrated wh, blood

t Date :09/0

•t Time :04:48 AM
Lot

REMARKS:
REPORTED BY:. DA1
.QUESTING PHYSICIAN:
1­
5TRT G3t I /-02--

TEST RESULT
e75

LB
Name:

'.LP
LT
TCO2

28 mr'ol/

MY
fiST
qt :37C

fBIL
7.371 PCO2 BUN
45.5 mmHg PC)2 CA++
1% mmHg

. 03 .CHOL
mmol,
BEecf

1 mol/ CRE iL02*
.39

GLU
*calculated

rample Type_ Ar

015EP03

04:36

GLU
:per: 8835

BUN CRE
Physician:

CK
•er# 42011

NA+
• JR145046A
CLEW A33

Kt
.CL
rm..ruac
1C92
REMARKS:
REPORTED BY: DAT]
...-i:MISTRY RESULT FORM (Sub. ect to the Privacy Act of 1974) SSN/PSEUDO SSN:
3.5-5.5e/d1 26-84 u/I REF. RANGE BUN GLU TEST RESULT 7-22 Ing/d1 73-118 mg/dl REF. RANGE
-
10-47 u/1

CA++ 8.0-10.3 mg/dl 14-97 u/1
CRE 0.6-1.2 mg/dt / 1-38 WI
NA+ 128-145 nuno1/1 0.2-1.6 mg/d1
Kt mmula 98-108 ramoUl 18-33 mmo1/1
_ ----= PICCOLO
01/09/02

04:42

RV REF. RANGE
-El-I:NU. RANGE:

MALE

3.3-5.5 g/d1
.(6.)
Li
MbLYTE 8 26-84 u/I DISC LOT #:
10-47 u/I
3152M4

OPER #111,

DR #: 000

SERIAL #:

Mon

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

GLU

BUN CRE CK
NA+
K+

tCO2

8

3-ii8 MG/DL
14 7-22

MG/DL

1.0

0.6-1.2 MG/DL
1194* 33-380

U/L
14;EFT128-45 MMOt/L

4.2 4v
1 3.3-4.7 MMOtL
.1.08

98-108

MMOI/L

25 18-33

MMOW-

INST OC: OK

CHEM OC: OK

HEM 0 , LIP 0 , ICI 0

14-97 u/I
11-38 u/1 0.2-1.6 mg/d1 5-65 u./1 6.4-8.1 g/dl
'444

REF. RANGE
128-145 mmo1/1
33-4.7 mmolii
98-108 mmoL'l
18-33 rrmao1/1
Ward/IS6c101:44.
4• ,.
TEST ULT F. RANGE
Na 138-146 mmol/L
K 3.5-4.9 inmoUL:
CI 98-109 mmol/L
pH 7.31-7.45
PCO2 35-45 mmHg (tut)41 -51 rnmElg (yen)
P02 80­105 mmHg (art)
N/A (veal
'PCO2 23-27 mmol/L WO 24-29 mmol/L (yen)
HCO3 22-26 mmol/L (art) 23-28 mmol/L (Yen)
s02 95-98%
BEecf (-2) — (+3)
mmol/L
AnGap 10-20 mmol/L
Ca 1.12-1.32 mmoUL
BUN 8-26 mg/d1
GLU 70-105 mg/d1
Creat 0.7-1.5 mg/di
Hct 38-51% PCV
Hgb 12-17 g/dl

:::iJA.fi;',: Yi.iO40: .. -ft 'Y'r)771. Pl.;::
TEST RESULT REF. RANGE
Tr
Drug of Abuse
REMARKS:
REPORTED BY:
..
\ TEST
J
ALB
ALP

ALT
AMY
AST
TBIL
BUN
CA-H-
CHOL
CRE
GLU TP
TEST
GLU BUN CRE CK
NA+
_CU
tCO2
DATE:
...5°1015. ,,,„
RESULT REF.
RANGE
3.5-5.5 Mil
26-84 u/1
_ 10-47 u/1
14-97 u/I
11-38 u/i
0.2-1.6 ing/d1
7-22 mg/di
8.0403mg/d1
100-200 ing/d1

0.6-1.2 mg/d1
73-118 mg/d1 6.4-8.1 g/dl .... leCiAii! ... '''''
..1=3.0: si • -.t1,4 .„.
RESULT REF.
RANGE

73-11 8 mg/dl 7-22 mg/d1 0.6-1.2 mg/dl 39-380 u/I (M)
128-145 mmol/1
33-4.7 mmolli
98-108 mmol/1
18-33 mmol/1
LAB ID NO •
C.70
..
AVILSTRY RESULT FORM (Subject to the Privacy Act of 1974)
lergiiot,.,1-....
TEST RESULT REF. RANGE
GLU 73-118 mg/d1
BUN 7-22 mg/d1
CA++ -8.0-10.3 mg/dl
CRE 0.6-1.2 mg/d1 NAS 128-145 mrnol/1 IC 3.3-4.7 raino1A
a: 98-108 mmol/1
tCO2 18-33 mmol/I ":.'' ...— "-
),....4!"...„ - 'T:Af-P,Orkt , NA.
, .r,,F,
".2. !:C...
TEST RESULT REF RANGE
ALB 3.3-5.5 g/dl
ALP 26-84 u/1 ALT 10-47 u/1
AMY 14-97 IA
AST 11-38 u/I TBIL 0.2.:1.6 mg/d1 GGT 5-65 u/1 Tp 6A-8.1 g/dl
'
1.... :

TEST RESULT REF. RANGE
NA' 128-145 mmoUl
33-4.7 mino1/1
CU 98-108 mmolll
tCO2 18-33 mmoUl
•
33 19 62 (9-1
MEDCOM - 18114
LAST,
TEST
RB(
Hgb
Hct
MC
Pit
Lyr
Seg
Bai
Atyp
RBC
Mo.-Ph
Spun
Hematoc
Sed Rate
Other , .
EST
PT AM
Dmer
F DP
REMARI
REPORT
R ue,ST
RESULT REF. RANGE TEST RESULT
Color
Imm Leuk
01)01111 COAG ANALYZ ER V4.54 Al. 0005485 09/02/03 04:37 AM
eiJt ID: N.11!!.• :AP IT ist kesu se. *RESULT NO1 NANGL CHECKED*** Type:citrate.d wh. blood ;est Date W9/02/03 est Time :04:34 AM
•rd Lot :030201 ioerator 1111111111 10(.,q
-
PwIDPOINT COAG ANALYZER V4.54 [Al. 0005485 09/02/03 04:40 AM
Hñent Map U0-11 ist Name :
est Result := :**RESULT NOT RANGE CHECKED*** = 1.3 :alculated INR = 1.28
ample Type:citrated wh. blood
lest Date :09/02/03
lest Time :04:38 AM

CSF

REF. RANGE
N/A
Negative Negative Negative
Negative
Negative 0.2-1.0
Negative
Negative
Negative
Negative
LABORATORY RESULT FORM
(Suliect to the Privac Act of 1974) SSN/PSEUDO SSN:
Negative
Source
Gram
Stain
H. pylori
Micro Parasites Malaria
Other
.
.11ficioscoPic
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED

.BIoód.BaflkUnitCrowatch" : .
romrr sr:lis.WriTi.yERy UNIT QV St.
.001) .lig LISTED "
CROSSMATCH
LAB ID NO.:. .

-0

CRER

TEST RESULT REF. TES
RANGE
3.5-5.5 g/dl 26-84 u/1
10-47 u/1
14-97 u/1
11-38 u/1
0.24.6med

7-22 mg/d1
1-STAT G3+

:OM

zr Name:

7 002 • 27 mmol/L
37C
z.1-1 7.377
C"-02 Pea 113 a;:-ucf =62* 43.6 65 mmHg mmHg 26 mmol/L 0 mmol/L 92

*calculated

a Patient Temp
PH 7.361

45.6 mmHg
u2 70 mmHg

-a-tient Temp: 100.5F
=102 • 50
;ample Type_: ART

25E1:03 04:09

per

P, 2sician:

5er41.1
Yer: JAM5046A

CLEW A93

MEDCOM - 18116
GLU BUN
Dt Name:

CA++
CRE Crea 1 .1 mg/dL
NA+
Type_:

CI: 025EP03 04:17

OPer: 11111

Aysician:
11111
Ver: JAM5046A

CLEW R93

11-38 u/1
0.271.6 mg,/d1 5-65 ull 6.4-8.1 sku
T RESULT REF. RANGE
128-145 mmol/1
3.3-t7 mmo1/1
98-108 uunoL'I
18-33 mmolll
:-TRT EC8+

Pt Name:
BUN
Na

Cl
TCO2
AnCap

Hct

Hb*

(.-41.
59 mg/dL
11 mg/dL
140 mmol/L

3.8 mmol/L
107 mmol/L
26 mmol/L
12 mmol/L
27 %PCV

9 g/dL

*via Hct

7.360
T:u3a______44.2 mmHg
HCO3 25 mmol/L
Bi7Prf 0 mmol/L

Sample Type_:
025EPO3

°Per: 1111111
Physician:
Ser# 1111111
.er: JAM5046A

CLEW A93

REPORTED BY:
druyvA
04:16

ALB
41,P
00,T
klsorY
NSF

MIL
BUN

E5
G]

ET1
CI

C]

K
C.

-

I
c e),T /DD
%Val . ( c .„QUES ;i:...v1ISTRY RESULT FORM (Subject to the Privacy Act of 1974)
LAST 'MST, M TIME TSSN
(a)
V.0-4
(i-S
TEST RESULT REF RANGE
13S-14( mmoVL
Na
3.5-4.9 rnmol/L
K
98-109 minon
,
• pH 7.31-7.45
35-45 mmHg (art)
PCO2
41-51 maillg (veal 80-105 unit In (art)
P02
SPA (veil ) 23 -27 mm0111. (art)
Tc02
'4-29 tilm0W1 . (ven)
"-26 mmaIL . (art)
1-1CO3
23-28 annul:Liven) 95 -981¦¦
s02 •
13Fecr (-2) -1+3)
10-10 mmolil.
AnGap
L 12-1.32 mmoUL
Ca
S -26 mg/d1
BUN
70-10:Sing/di
GU 1
0.7-1.5 nig;d1
('real
38-51`!.-1, PCV
Hct
Hgb l'-17

Misc. Chemistry
RESULT REF. RANGE
Fronon in-I Negative
Negative
Drug of
Abuse
Negative

Negative
Negative
REMI-U2KS:
• (Piccolo emistry 12 (Picco o) Metabolic Panel
• REF. TEST RESULT REF. RANGE RANGE
12.411 73-1 ) N mg.'d I
GUI
7-22 me/d1
8(1-1)3 ing!d1
==z::::= PICCOLO =7- zzzzz

0.6-1.2 ingatil
03/09/03

03:59

REFERENCE RANGE: 1'8-145 inniol
MALE

PATIENT #:

3.3-4.7 11111101A
b(4)-4

GENERAL P
MIS

12 98-108
DISC LOT

3204AA4

18-33 minold
OPER #:

#:

SERIAL #:

(Piccolo) -Liver Panel Plus
...........................

EST RESULT REF. RANGE
ALB

1.5* 3.3-5.5 G/DL

U/L /d1ALP •sf 26-84 ,B
ALT 154* 10-47 ,P 76-84 u/I
U/L
AMY 17 14-97 U/L 10-47 ti I

AST

83* 11-38

U/L

TBIL 1.4 r V1Y 14-97 u/I
0.2-1.6 MG/DL.

BUN '44.1-6 7-22
MG/DL ST
11-38 ti;1
CA++ 7.8* 8.0­
10.3 MG/DL

.6 wil.,¦ 411
BIL
CHOL 31i,1 100-200 MG/DL
CRE mmr 1 Gr 5-65 u/I
.40.6-1.2 MG/DLGLU 135* 73-118 MG/DL 6.4-8. I gidl TP 4.5* 6.4-8.1 G/DL
(Piccolo) Electrolyte
INST DC: OK

CHEM QC: OK

TEST RESULT REF RANGE
HEM 1+, LIP 0 , ICT 0

128-145 mmol/1
3.3-4.7 nanolil
98-108 nunold
C I;
18-33 minoV1
tC0?
DATE: LAB ID NO.:
9). .4 cp (D
a w aQ.
0
-t,
9.)
O
1
o- o-
O
O
O co
CD
.0
Cl)
o.
3 TI O1
3

I CU -3 cvest-ed Ictj (6) -
,04111111 DI-s. 3 Sef
Lime og s
40-- Li
Lymph % Bands Lymph WBC TEST 14-18 g/dl (M) 12-16 g/dl (F) 42-52% (M) 37-47% (F) 80-94 tl (M) 81-99 11 (F) 130­500 x 10 verified 20.5-51.1% RESULT REF. RANGE 4.8-10.8 x 103 4.7-6.1 x 109 Ae 6-/. oa Negative Negative Negative N/A Negative Negative 0.2-1.0 Negative Gram Stain Occ B Id Other TEST RESULT RPR Mono Source H. pylori Micro Parasites Malaria Negative Negative Negative Negative REF. RANGE
l mm Negative
RBC Morph HCG Negative
Spun Hematocrit Sed Rate Other 42-52% (M) 37-47% (F) Directigetv Cell Count Negative MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED ABO/Rh
TEST RESULT REF. RANGE
9.8-13.6 secs
21-34 secs
D dimer 20 tig/iril
10 ug/m1
REMARKS:
REPORTED BY: LAB ID NO.:

-a •

0)-(f
"7"7""w bc-tuo
-EP.__ j2,
rair-
•41 0W1:0.P.
TEST I RESULT I —REF. RANGE
TEST RESULT REF. RANGE TEST
WB'
RB(
Hgb
Hct
MC
pit
Lyr
Sei
Ba!
Lymph
Atyp
RBC
Morph
Spun
Hemnocrit

APTT
D dimer
FDP REMARKS: REPORTED BY:
Baso lmm
42-5 37-4
21-34 20 ii 10 ti
Color N/A
App N/A
•- • Glu Negative
Bili Negative
Ket Negative
SG N/A
Bid Negative
pH N/A
Prot Negative
Urob 0.2-1.0
10POINT GOAD ANALYZER V4.54
LAL 4005485 09/03/03 03:49 AM

ent ID
!st Name :APTT

;st Result:= 40.5 sec.
•*RESULT NOT RANGE CHECKED***

Apia Type:citrated wh. blood
st Date :09/03/03
st Time :03:46 AM

,rd Lot :030201
•arator t)@)_-7._
.

)POINT GOAD ANALYZER V4.54

:AL #005405 (19/03/03 03:51 AN
• ad ID:
.t Name :P
t Resu11:-, 13.6 sec.
ASH! I NiI HAUT CHUCKED***

•
,W 1.19
;!I

. ;

•• I 11 I
1 ,:•1 .;!
gfirall

.I
DATE:.
LAB ID NO.:
RESULT REF. RANGE
RPR Negative Mono
Micro
Parasites
rr icLB a
VdNF
d'W't
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
ABO/Rh
YPE CROSSMATCH
1V( °
Ward/Section: t L u zUESTING PHYSIC .
,IISTRYRESULTFORM
(Subject to the Privacy Act of 1974) LAST, FIRST, MI. DA TIME SSN/PSEUDO SSN:.1 3
b(6 --U1C.
REISULT.F. RANGE
L PICC 73-118 mg/d1 03/09/03 7-22 mg/di REFERENCE RAN
8.0-10.3 mg/dl
-STAT EC8+ PATIENT #:

0.6-12 mg/dl
GENERAL CHEMI

128-145 nunoU1
PAIN/ VO-11, DISC LOT #:

Pt Name: --- 1.) 3.3-4.7 mioulil
, OPER # : 11111
. SERIAL #: 98-108 mmoIiI 4
,Tiiu 118 mg/dL 1) 18,33mmolA
TL_ ALB 1.3* 3

BUM 17 mg/dL

ALP 154* 2

Na 140 mmol/L

ALT •4• 1 i RESULT REF. RANGE
3.6 mmol/L

AMY 19 1

3.3-5.5 g/d1
.L

-' 106 mmol/L

In, AST 80* 1 26-84 u/1
7 32 23 mmol/L --7 TBIL 1.4 0

10-47 u/1
!-inGap 1e mmol/L BUN ••• 7 37 %Ink/ CA++ 7.5* 8 14-97 till CHOL 61* 1
rIPIE 13 g/dL
0 11-38 u/1
CRE 0.7

*via Md.

IGLU 126* 7 0.271.6 mg/d1
pH 7.342

TP 4.0* 6 5-65 u/1
CO2____ 5 mmHg

6.4-8.1 Wd1
'1 mr401/1. L:=2= INST OC: OK
mm:11/L HEM 1+, LIP

REF. RANGE
.mple Type

128-145 mmol/1
038EP03 07:50

3.3-4.7 mmol/l 3per:IIIIIIII i.
98-108 mmol/1
—er#1111111

JAM5046A

CLEW A93

/LSI., A ,J, ••¦ •• a.j.I., JP A DATE:
3 Sep 03
Eater in above space .PATIENT IDENTIFICATIO N—TREATING FACILITY—WARD NO.-DATE REQUESTING PHYSICIAN'S SIGNATURE REPORTED BY MD
TECH
1111111.11
I k Ix.I I I I I 1 I
: 1( ./
UR ENCY ROUTINE AY .
. PRE-OP STAT .
DATE
Qip
1

SPECIMEN/LAB. RPT. NO.
PATIENT STATUS
.
BED.. AMB OUTPATIENT .

.
NP.. DOM SPECIMEN SOURCE

.
BLOOD

.
OTHER (Specify)

LAB. ID. NO.
0

7
PATIENT'S MED. REC3RD
0
z E
F1
PICCOLO -------8 0 O L
L.3
TRIGLYCE RIDES
O
04/09/03 14:21

REFERENCE Ai

: MALE

PATIENT #:

METLYTE 8

DISC LOT #:

3151AA4

OPER #:

DR #: 000

SERIAL RI/

GLU 122* 73-118 MG/DL
BUN 23* 7-22 MG/DL
CRE 1.8* 0.6-1.2 MG/DL
CK 764* 39-380 U/L
NA+ 11710 128-145 MMOVL
K+ 4.3 3.3-4.7 MMOVL
CL-104 98-108 MMOVL
tCO2 22 18-33 MMOVL

INST OC: OK CHEM OC: OK
HEM 0 , LIP 0 , ICT 0

2t O
b(W-z
Wafcl/Section:4j---_ - • JEST -
Lci
JRATORY RESULT FORM
-. subject to the Privacy Act of 1974)LAST. FIRST, MI.
• • TIME SSNiPSEUDO
4111111s, co.(4 ,_cJ IL-1_
-
Y" 4 4".k4,:. . tV--• 1,:iigif..zscA; . t t .. 'At . 46.‘5k. ,;:ig..,ki.:4%.+ , ...:.??:.c'::::'44`,W.TEST RESUL Ill t 'NGE TEST _____ REF. RANGE TEST RESULT REF. RANGE
.tio-o.. r-ot , ir '!7,*1-, ' ,. `''',. -v1=-"'t .-•I*412:4,4t444i::ii&,. •
Color a N/A RPR Negative App _tt N/A Mono Negative ID./9 (.6)—tV '' '' Glu ve -,.
.' pip ati _ Neg .c..
.i 14=2Q • Al'4?,:lg2,:`,: ...4',W''''f .:::'.-..¦: .t.'.7.
Bili Negative
Source Ket Negative
Gram
:-..Li L. L y.i.:' ,•:. 1. 4, •:. C.,. t-•;:) Stain
SG N/A OCC BId Negative

Bld Negative H. pylori Negative -i 28.8 Pg 27.0 31.0
14 pH.N/A Micro
n:P:1_: sid. .7.0370
.!.:..
Parasites
Pit 5i-:i. _ y.I.Olitt. la 450:
Prot Negative
LY.Z 5 •,-,L 20.F! 51.1 Malaria
Urob 0 & P

0.2-1.0
Negative
Nit Other
Leuk Negative
::!,:i.!.k:A•16... .trORPOPI!qM.rinOTtik4:0,,!-
, ....:1g*k-,'.
WP414;gii;.ati.:::;:t.' , ,`-:::fAcq;V6,is.:,.RBC HCG Negative
Morph
Hematocrit
i;,,..:2,-;,;,...";57.-vz 7, 2,, , .1.g.,..ant.2:2.:,,,,:::wio
" ,-,:,-,.,.'•-isV.:in,,.: -"';:',"-.-
Sed Rate Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen . Negative ABO/Rh
.13.1if4'
,... ,..
TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 sees APTT 21-34 sees
• D dimer 20 ugh-ril
FDP 10 tig/m1
REMARKS:
REPORTED BY: DATE:.. LAB ID NO.:

1 LABORATORY RESULT FORM
REQUEST8G
(6)
.(Suliect to the Privacy Act of 1974)

Y.

ATE TIME SSN/PSEUDO SSN: '91^) tit' I SAtel 046
Misc. Serology
Urinalysis
ematology) CB
REF. RANGE
RESULT REF. RANGE TEST RESULT
TEST TRESULT REF. RANGE TEST
Negative
N/A RPR
Color Negative
N/A Mono
App Negative Microbiology
Glu
Negative Source
Bili
Negative Gram
Ket
Stain Negative
N/A Occ Bld
SG Negative
Negative H. pylori
Bld Micro
pH WA
Parasites Negative Malaria
Prot 0.2-1.0 O&P
Urob
Negative Other
POINT COAG ANALYZER V4.54 Negative ilbscePic:Itriaa L #005485 09/04/03 04:43 AM
Negative
it

ID:11111 10 (C)
t Name :APTT
Resu t := 46.1 sec.
RESULT NOT RANGE CHECKEDU*

Blood Bank
-aloP le Type:citrated wh. blood CSF
est Date :09/04/03

est Time :04:40 AM MUST SUBMIT SF 518 WITH ard Lot :030201 EVERY UNIT REQUESTED aerator :1111111 tl _
en.Negative ABO/Rh
aloodila tiOi•rOSSfitiltdi..

IDPOTNI COAG ANALYZER V4.54 .-• 1AL #00E485 09/04/03 04:44 AM nTST,SUBMIT SF.518.Vvryll EVERY uNrir OF BLOOD .
CROSSM4TCH
lent lj I UNIT TYPE
est Name :PT_1 G)
3st Result 11.8 sec.
4RESULT NOT RANGE CHECKED***
itio = 1.5
oculated 1NR = 1.55

mole Type:citrated wh. blood
est Date :09/04/03

ist Time :04:43 AM
ird Lot :An,
senator :

66) -t{
I
LAB ID. NO.:.

Ward/Section:
CL RESULT FORMI6V3 (Subject to the Privacy Act of 1974) SSN/PSEUDO SSN :
TEST RESULT TEST REF. RANGE
RESULT
Na 138-14A .5 gidi GLU 118 mg/dl
73­K till BUN 7-22 me/vi
CCOLO
Cl
CA++ °*3 mg/d1
Ci"\!)
PH 7. 0A/09/03 ,AA CRE 0.6-1.2 mg/di
35.
PCO2 128-145 mmol/1
NA+
OXEN"( V. IRN 12
PO2 SA 3204 pA *11 IC 3.3-4.7 =mom
,
8°-" ?
23-27 GDO*L. tr. 000
TCO2 CL-98-108 =an
DISC U01 V. HCO3 tCO2 18-33 mmol/1
s o. ass

s02 95-98% # , *or.. ane (-2) _ 0.3 SERI
BEecf A .51. TEST
RESULT REF. RANGE
monmmt
iran95% 26-84
P1--B.

AnGap 1 0.--A7 3.3-5.5 g/dI
ALB
133% 1
1•12.1.32m 26-84 to
Ca
ALP
8-26 in _,c).. MG/a._
BUN 10-47
\A\ -1.-37B ALT
4B\2:* Me/a_
i'-2.0% 0.2-1 .6
5::1: 14-97 un
GLU 070-3_110.520 7-22 Ne/a._ MY 501,‘
Creat cp,k-k 7 .7% 8.0-10.3 11-38 un
36% 100-204 MG/01_
Mk3/a_
pcv
Hct 38_51% 0.271.6 cogicu
L
1 ,3% 0 .6-1
12-17g/dl. 87 73-118 M-3/(3/0- 5-65 to
Hgb
(3\) '3,9% 6.4-8.1 6.4-8.1 gm,
isp C1K‘ .
TEST RESULT REF. RANGE 1.
CV.CiA.
0.
Troponin4
K RESULT REF. RANGE
Drug of CL 128-145 mmoWl Abuse Cij(ev.-^ 1
tC01 3.3-4.7 nunalti
98-108 =nom
18-33 UMW!
IL
REMARKS:
REFORTED BY: DATE: LAB ID NO.:
Ward/Section: REQ LABORATORY RESULT FORM
5 ) -1 il
(Suliect to the Privacy Act of 1974) LAST, FIRST,„Ivif. TIME • SSN/PSEUDO SSN:
4;r41
tology) cpc •Unna sus sc.
GE TEST RESULT RESULT REF. RANGE
Negative
Color App N/A Negative
Glu
Bili
Ket
'N/A Negative
SG
Bid Negative H. pylori Negative
pH
Prot
Urob
Negative
IDPOINT COAG ANALYZER V4.54 Negative rOscOi)it Urias CAL #005485 09/05/03 04:21 AM
Negative
lent ID:
.st Name!". (6) -4
est Result := 13.9 sec.
v*RESULT NOT RANGE CHECKED***

CSF Blood Bank
itio = 1.1 ilculated INR z 1.24 tmple Type:citrated wh. blood MUST SUBMIT SF 518 WITH ;st Date :09/05/03 EVERY UNIT REQUESTED !st Time :04:19 AM
en Negative
ird Lot :010301

aerator amp 6(,) _--2_
1110.1c.Unit,croisinitch":.. . . IUST.SUBMIT SF:518.WITHEVERY up[rt: OI BLOOD DPOINI COAG ANALYZER V4.54 • '.REQUESTED).
;7. •
AL 4005485 09/05/03 04:27 AN UNIT TYPE CROSSAMTCII
ent ID
st Namill bt°-
st Result:. 42.1 sec.

-*RESULT NOT RANGE CHECKED***
mple Type:citrated oh. blood
st Date :09/05/03
st Time :04:22 AM

•
rd Lot : 0201

•
erator

LAB ID NO.:.
Ward/Section: ..STING PHYSICIAN:
' Cit_ .. .Y RESULT FORM
(Subject to the Privacy Act of 1974)
LAST, FIRST, MI. DATE TIME SSN/PSEUDO SSN:

.
•, . _ .
• 40.04 ;
1...:; 'N.t:',..:;,. ' : ",. f'7 ' ':';',';.: e"'?,'".-, :4-':f.:•'...7j..' ,V',---%,:'i:'::..!i..i=.;4;%Zi
TEST RESULT REF. RANGE TEST RESULT REF. TEST RESULT REF. RANGE RANGE Na 138-146 mmoVL ALB 3.5-5.5 edi GLU 73-118 mg/dl
K 3.5-4.9 trunol/L: ALP 26-84 u/1 BUN 7-22 mg/d1
Cl 98-109 mmol/L ALT -10-47 u/1 CA rnedl
pH 731-7.45 AMY 14-97 u/1 CRE (L64.2 mg/di PCO2 35-45 mmHg Cut) AST 11-38 u/I I NA' 128-145 mmol/1
41-51 mroFfir (yea)
P02 80-105 mmHg (art) 'ma, 0.2-L6 mg/dl IC 3.34.7 mmol/1

N/A Neu)
TCO2 23-27 mmot/L (art) BUN 7-22 rug/dl CU 98-108 mm01/1
24-29 mmol!' 1---.1

HCO3 22-26 mm TT, tCO2 18-33 MMOlil
23-28 mat
95-98%
s02 „-=, . lep., .ol,g r#nektimk: ,,-,,:,!.
7 .----7:----
PICCOLO BEecf (-2) — (+: 05/09/03 04 : 2? TEST RESULT REF. RANGE
P --1:7:-:.-'':'.,:::';',.:;V:t.:;•t-i",i',.., :47;.,..,!‘:::,''i:2',12 7',,":',..,:- ''..•.:,:;Z:?:”:. -
nunol/L
REFERENCE= RANG -
AnGap 10-20 nu MALE i ALB 3_3-5_5 g/c11
PATIENT #:

Ca 1.124.3: )9 (6)-9 ALP 26-84 u/1
FETLYTE 8

BUN 8-26 mg 10-47 u/1
LOT #: 31511M .7.7! ALT
DISC .1
GLU 70-105 r OPER # : DR #: 000 AmY 14-97 u/1
SERIAL # :
Creat 0.7-1.5 r . AST 11-38 till

Het 38-51% (LU 1 08 73-118 MG/DL TBIL 0.271.6 men
Hgb 1247 gi BUN -+0•0•2(( -22 MG/DL. I GGT . 5-65 u/I
. . , .,. . -

. • .. -CRE 1.9* 0.6-1.2 MG/DL vt) Tp
..'-.,:. , —,`...'i:3-.Wgi:.'...heillit 6.4-8.1 g/d1
li ;',.. ":fit'..i,'':,-,•.-..;.;: ."-Z :f: ..r.irn:';'1;.: rst.
Ur, 473* U/L ,,In
39-380 ')
TEST RESULT REF. 1
Nit 1C-)5* 128-145 MMOi/L — . 6114:0.ttiii' e .
'
"•!:::.g.,::',-,in:::';:.;•,-::.:::.:?.;;:!.::
•• 7' '
Troponin-1 K + 4 ' 3 3 • 3-4 IviriC.¦/1-1/1 TEST RESULT REF. RANGE
CL-•-44•11298-108 MMOV/1_
Drug of tCO2 25 18-33 MMOR_ kvi Ng 128-145 mmo1/1
Abuse

A K' 3.34.7 nunoVi
I NST OC: OK 0-EM OC : OK HEM 0 , LIP 0 , I C1 1 i
CI: 98-108 mmol/1
tCO2 18-33 mmol/1
REMARKS:
REPORTED BY: 10.:
Ward/Section: REQUE TINCT HYSICIAN:
LABORATORY RESULT FORM
ematol CBC
11,7,-• 0-'9 erg
TEST
Color
App Glu
Bili
Ket
SG
Bld
pH
Prot
Urdh
OMNI COAG ANALYZER . --AL 1005485 09/06/03 06:13 AM
ient VO —
:st Name :F1
1st Result:- 12.4 sec.

*RESULT NOT RANGE CHECKED***
rtio = 1.0
ilculated INR = 1.03
inple Type:Litrated wh. blood

st Date :09/06/03
.st Time :06:11 AM
rd Lot :010301
erator

:am
TIME
6 6,13
Urina
RESULT REF. RANGE
N/A N/A Negative Negative Negative
N/A Negative N/A
Negative 0.2-1.0 Negative
Negative
Negative
.
CSE•
•.:
Negative
(Subject to the Privacy Act of 1974) SN:
Misc. Serology
TEST RESULT REF. RANGE
RPR Negative
Mono Negative

Microbiology
Source
Gram Stain Occ Bld Negative
H. pylori Negative Micro Parasites Malaria
O&P Other
acroscnpic I.rrina '
,..
Blood Bank
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
ABO/Rh
.BloadBank. Unit. crnasanitch -.•.•
COAG ANALYZER V4.54
#005485 09/06/03 06:11 AM IST,SUBMIT .SF,518.WITHEYER .O1 BLOODY
int ID:1111 V6) WIT TYPE CROSSM4TCH
A Name :APTT
A Result:= 38.1 sec.
:RESULT NOT RANGE CHECKED***
.ple lype:citrated wh. blood
t Date :09/06/1)3
t Time :06:13 AM
d Lot :030201
rator lag (0-2—

LAB ID NO.:. .
.MOIL b 54,3.7 b((,) -2_ .•
mt IEDcom 1812,8
-
DOD-031702
Ward/Section: ..:.STING PHYSICIAN:
Ch_.
.Y RESULT FORM
LAST, FIRST, MI. Suliect to the Privacy Act of 1974)
DATE
SSN/PSEUDO SSN:
ST lecti10::.gir ......m-r,,
TEST RESULT REF. RANGE TEST RESULT
REF. TE
RESULT REF. RANGE
RANGE
Na 138-146 mmollL
73-118 mg/cit
K 33-4.9 unnoUL'

7-22 mg/d1
Cl 98-109 mrnol/L

PICCOLO 8.0-10.3 rag/d1
pH • 7.31-7.45

J 06/09/03 06:18
0.6-L2 mg/d1
PCO2 35-415 nmdig(m* I REFERENCE RANGE: MAI F

128-145 rorno1/1
P02 SO405 mmHg (an) PATIENT #:

41-51 =az (ven1
.
N/A (veil) mmukl
METLYTE 8

TCO2 23-27 =not& (art)
24-29 mmol/L (yen) DISC LOT #: 3151AA4 98-108 mmol/1
HCO3 22-26 mmol/L *0 (

23-23 inrix4/L (yen) OPER #IIIII DR # : 18-33 mmo1/1
s02 95-98%

C SERIAL #
Lye u
BEecf (-2) — (+3)
mmol/L GLU 92 73-118 MG/DL RESULT REF. RANGE

Pyc"*." coAO) ,'.")•eppit.••••••ir
AnGap 10-20 mmol/L
BUN 17 7-22 MG/DL 3.3-5.5 g/dt
Ca 1.12-1.32 mmol/L 1

CRE 1.2 0.6-1.2 M(3/DL 26-84 u/I
BUN 8-26 mg/d1 CK 202 39-380 U/L

10-47 u/I
NA+ 122* 128-145 MMOVL

GLU 70-105 rrig/d1.
K+ 4.1 3.3-4.7 MVA_ 14-97 u/1 CL-108 98-108 MMOVL
Creat 0.7-1.5 mg/111
11-38 till
tCO2 26 18-33 MMOVL

Hct 38-51% PCV
0.2-1.6 mg/cit
Hgh 12-17 Wdl

INST OC: OK CHEM OC: OK 5-65 u/1 C HEM 0 , LIP 0 , ICT 1+
TEST RESULT REF. RANGE N
?1,
1.1
Tropon 1
RESULT REF. RANGE
Drug of
128-145 mmol/I
Abuse t(
3.3-4.7 mrnolA
98-108 nuno1/1
18-33 mmo1/1
REMARKS:
REPORTED BY:.
DATE:.LAB ID NO.:
O
5cr .
O

co
CD

(1) -n
O

3

Ward/Sectiou:
1 . /A1-.I ...
.ilLSTRY RESULT FORAI
CJ
OLb ) -2--]
(Subject to the Privacy Act of 1974) TBVX SSN/P
b )-aoo 12 c. -11 45.1(TKO )-.
. r . • ... ,-- -A&%.
'''' .. ...:C* :.:- , ..-.-.„V:-Miik-1
,,.."Z'':n ,,.---I:
TEST.PPRT : TEST RESULT . .-:'..i h:"4:!.-,.. e :"..4!.6REF. ¦,VP "1:,..:!,1;7441'..., ?''.:,,Z:-.7 ?-:2:',::,-.
-t*-c.:,.t:'1,r., -,'... Ll::,!?,.....:, ;::,,,,....-,. , .''.
-,? P 4M

TEST RESULT REF. RANGE
RANGE
ALB 3-5-5.5 841 GLU 73-118 mg/d1 ALP 26-84 u/1
BUN 7-22 mg/dl ALT --10-47 u/1
,-:TAT EG7+ CA4-4 8.0-10.3 mg/dl AMY 14-97 u/I
CRE 0.6-1.2 mg/cif . AST 11-38 u/I
A1111/NA* 128-145 mmol/1 'It Name: .
TBIL 0.2-1.6 mg/ill 3.34•7p
Kt
BUN 7-22 mg/ill
CI: 98-108 mmol/l
r4a .

147 mmol/L

CA** 8.0-10.3med
tCO2 18-33 mmoL'l
.4.0 mmol/L

CHOL 100-200 mg/ill ''.r • - - ...0..
,) ,..:ift,ejr . ..
TCO2 24 mmol/L

Li:t,;.:,.k.',i':,',.--.1:A, -.• ,:;',::',f".-
CRE 0.6-1.2 mg/d0
TEST . RESULT REF. RANGE
.1.24 mmol/L

GLU 73-118 mg/d1 ALE
.32 '.PCV 3.3-5.5 edi TP 6.4-8.1 gill
ALP 26-84 u/1
.11 g/dL

..
f.:
.....Weci:olik ith.
'via Hct ALT 10.47 u/I
TEST RESULT REF.
r AMY 14-97 u/1
,:-- 37C

RANGE
pH 7.273 GLU 73-118 mg/d1
AST 11-38 u/1
0c02.BUN 7-22 mg/d1

49.1 mmHg TBIL 0.2-1.6 mg/d1
.CRE 0-6,1 -2 mg/ill
75 mmHg GGT 5-65 u/I
CO3.,.. CK 39-380 uA (M) TP

23 mmol/L 6.4-8.1 g/d1
30-190 u/I (Ii)
ecf .—4 mmol/L NA* 128-145 ramo1/1

2:02*

92 %

K4- 33-4.7 mmoldl.
. TEST RESULT REF. RANGE
*calculated

_CL-98-108 mmo1/1
NA* 128-145 mmol/I
=1 -Patient Temp

tCO2 18-33 mmol/1 K+
3.3-4.7 mmol/1
PH 7.273

=CO2 49.1 mmHg CL" 98-108 mmol/1
. '

D02 75 mmHg

tCO2 18-33 mmola
Patient Temp: 98.6F

Fi02.

45

-1...
Type: ART

DATE!' LAB ID NO.:
07SEP93.

13:02

•
,Dper:

z.erit

er: J11,4504E41
CLEW A93

Ward/Section: REQUESTING
LABORATORY RESULT FORM I
( G)
(C-.1 (Subject to the Privacy Act of 1974)
LAST, FIRST.„Ml. DATE TIME SSN/PSEUDO SSN:

111( 03 0(1M _Urinalysis Misc. Serology
:
.11111111
E TEST RESULT REF. RANGE TEST RESULT REF. RANGE
Color N/A RPR Negative
App . N/A Mono Negative
Negative
Glu Microbiology
Negative
Bili Source
Negative
Ket Gram Stain SG 'N/A Occ Bld Negative
Bld Negative H. pylori Negative
tology) Manual Differential PH N/A Micro
Parasites
Negative

Malaria
ANALYZER V4.54
RiA l8:3 09/07/03 05:01 AM 0.2-1.0 0&P

Negative
t lent 10:11111P Other
lest :P1
.111-Negative

•. :
lest := 13.7 sec. roseopic .Urina
4*RESULT 1101 RANGE CHECKED***
atio = 1.1 Negative
;alculated INR = 1.21

;ample Type:citrated wh. blood
-

est Date :09/07/03
est Time :04:59 AM
:ard Lot :010301 SF Blood:Bank

perator 11111111
MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
IDPOINF COAG ANALYZER V4.54

Negative ABO/Rh
JAL m005485 09/07/03 05:05 AM
Blood
•:: IUSTSUBMITSF,518.WITH.EVERy UNIT O1 BLOOD .
lent INS

st Name :APTT
• •.r:. 5.•:•••.•."..'s •
st Result:. 40.8 sec.
RESULT NOT RANGE CHECKED*** UNIT TYPE CROSSM4TCH
mole Type:citrated wh. blood
!st Date :09/07/03

ist Time :05:02 AM
and Lot :030201
perator :11111/(0-2.—

FDP 10 ug/m1
I
I
REMARKS:
REPORTED BY:. I DATE: LAB ID NO.:. .
Ward/Section:
RESULT FORM
-((,0 3
2 TIN6 . b (Subjectto theY REPrivacy Act of 1974)
LAST, FIRST, MI. i DATE TIME
(C) SSN/PSEUDO SSN:
— 1"
-.10(c2) i i4012puff. d .. /-
, ..,,
..... •
..-!1.;24iSTATV.,.4' .
3,.,,-.:;.,,,...,,,...,:-..1...-,..,,,,f,

.,. 'I .,-,.,.„, ¦5r-,..:,'. .. . F:,-,„....,..:,,,.....z,f,..,...1:.:,..,,..:,.....,:,r.r.,,,y.::.,--i.::1--=2:;.1..W.-ff.
• REF. RANGE ULT ''
TEST ULT -.:.RF. TEST RESULT REF. RANGE RANGE Na 138-146 mmol/L
ALB 3.5-5.5 g/d1 GLU 73-118 mg/(11 K 3.5-4.9 (ninon' ALP 26-84 u/I
BUN 7-22 mg/d1 CI 98-109 mmoVL --10-47 ull
ALT CA++ 8.0-10.3 mg/di PH 7.3 r-7.45 AMY 14-97 u/1 CRE
0.6-1.2 mg/d1 PCO2 3545 mmHg (art) AST 11-38 u/1
NA+ 128-145 mmOin
41 -St mmHg (Yen)
80-105 mmHg (au)

P02 T 3.3-4.7 nunolel
N/A (veu)
23-27 „mom. Cut)
TCO2
B.' o
9g-ba mmo1/1
24-29 mmon. (yen) ::.:::== == HCO3 Or-PICCOLO _-_77::::::: 18-33 mmovi
LJ
22-26 imn°14' (ET) (C

23-28 inruoUL (ven) SO2 95-98%
°4 :46
RANI-: )1g0..... ifgt..g0t,T-!#...-;..,.:,,. : .
PATIENT
BEecf (-2) -(13) #
RESULT REF. RANGE
mmul/L METLYTE 8 . /1111 I ( REST 10-20 mmoVL
AnGap DISC LOT ft: 33-5.5 gidl Ca 1.12-1.32 mmol/L 0 26-84 u/1
OPER 4': MI 3#14 1 0AA04
. DR
BUN 8-26 mg/d1 SER/AL #:
10-47 u/1 ...............
GLU 70.105 mg/di ...........

GLU Y 14-97 u/1
109

73-118

BUN MG/DL
great 0.7-1.5 mg/d1 1 4 7-22
I' 11-38 u/1
CRE MG/DL 38-51% PCV
Het CK 0.5* 1.2 MG/DL (L 0.2-1.6 mg/d1 ligb 12-17 g/di 130 39-38 0
NA WI_ iT . 5-65 u/1
135
128-145
MMOP/L . 6.44:1 g/dl
• .1•,....;,...-9; .,.,..•;„5. A •.,.:,."...,,tEesi ,,...,, :.. 4•0 3
.3-4.7

MMOtL

TEST RESULT REF. RANGE -:::.: i...::';:
-108 ivimot -.. --
t CO2 •-.:/...:::::, ka t0P40(4.
„-!-..?,,..1,..::-,.,,,i:,:.
24 , A !
18-33 .::-.,...:....);,::-.., --.7.:7.i.,;:•' ¦ •:“ .:,:. .:,
.A...,i,;-.1:,,,-7,...
Troponin-1
IIII°vL tin. RESULT REF. RANGE
INST OC:Drug of OK CHEM OC: OK 128.145 mmo1/1
HEM 0 A+
Abuse ' L IF' 1+ , ICT
1 3.3-4.7 mmol/1
.7.." 98-108 mmolll
tCO2 18-33 mmo1/1
REMARKS:
REPORTED BY: -
,TAT G3=

\9 ((9)

Namp:

)2 mmoliL

41.4 mmHg
. mmHg

emp:

50

cipe Iype_: RRT
04:12

-;TRT G3+

Jf

mmol/L

.7C
7.372
PCO2 43.3 mmHg
82 mmHg
HCO3 25 mmol/L
BEecf 0 mmol/L
z02* 9g

*calculated

Patient Temp

7.368

43.8 mmHg

4 84 mmHg
Temp: 99.1F
F102 : .40
:E.ample Type_: ART

015EPO3 09:23

.JpPr:

rr JAMSO4gA
CLEW A93

( ) _L(
mpom

i-STRT EG7+

-
in 19 1_ 0
DT Name:
149 mmol/L

3.9 mmol/L
;002 24 mmol/L

1.14 mmol/L

31 %PCV
4L -E

11 gicIL
*via Hct

Ht 37C

7.415
:cr12

35.7 mmHg
pn?

84 mmHg
23 mmol/L

acf
-2 mmol/L ,r_P* 97 % *calculated
4t. Patient Temp

pH 7.43q7
P002

PriZ 77 .mreig

Patient Temp: 96.2F
FIO2 : SO

•ample Type_: ART

975EP93 08:38

0=er: IIIII

ohysician:

,eril Oft

Ver: JRM5046A
CLEW A93

,IUESTING
.4ISTRY RESULT FORM (Subject to the Privacy Act of 1974) SSN/PSEUDO SSN:
PICCOLO F - ---- PICCOLO
07/09/03 08:39 i 07/08/03 08:56

REFERENCE RANGE: MALE f REFERENCE RANGE: MALE

PATIENT Cali 10(0_4 - PATIENT #:411111,

(c)-1-1
-METLYTE 8

GENERAL CH. TRY 12 /

DISC LOiliip . DISC lily 3141AM
3142M4

OPER #

OPER #: DR #: 000 DR :
SERIAL #: SERIAL #:

ALB 1.3* 3.3-5.5 G/DL 7 GLU 113 73-118 MG/DL
ALP 108* 26-84 U/L BUN 15 7-22 MG/DL
ALT 72* 10-47 U/L CRE 0.5* 0.6-1.2 MG/DL
AMY 171* 14-97 U/L 1 CK 83 39-380 U/L
AST 77* 11-38 U/L NA+ 137 128-145 MMOVL
TBIL 4.4* 0.2-1.6 MG/DL K+ 4.0 -3.3-4.7 MMOVL
BUN •#. 7-22 MO/DL _ CL-114* 98-108 MMOVL

CA++ 8.0 8.0-10.3 MG/DL tCO2 25 18-33 MOM_
CHOL 124 100-200 MG/DL.
CRE 0.6 0.6-1.2 MG/DL INST GC: OK CHEM QC: OK
GLU 110 73-118 MG/DL HEM 1+, LIP 1+, ICT 1+
TP 3.9* 6.4-8.1 G/DL r

INST QC: OK CHEM GC: OK r.
HEM 2+, LIP 1+, ICT 1+

2
DATE: LAB ID NO.:
5
0 TS
Ward/Secti °n:­C:.0 Mk . -• 17(.(*).--2- Suliect ,IISTRY RESULT FORM to the Privacy Act of 1974
LAST, FIRST, MI TIME SSN/PSEUDO SSN: .

,
,.....2.:...
-7.;:.V:: , -T.. ,..,,-....:.c..:, -.-,;....., ...‘ .., . .OL......;
7.f`t-s--;O:r....-.;:-.,;. ' '1.,-
L4'd

:ICC 9 : ., 0*.bi4 --"a*ri
TEST RESULT REF RANGE TES RESULT TEST RESULT REF. RANGE GE Na 138-146 mmol/L ALR .5-5.5 e/d1 (WSJ 73-118 mg/di
3.5-4.9 'mol/L' 7-22 mg/dl
K
CI 98-109 mmo1/1.. -- . 8.0-10.3 mg/dl
- : PICCOLO =7: - '-- -: -
7.31-7.45 0.6-1.2 mg/dl
pH
08/09/03 07:5
PCO2 35-45 mmHg (art) 128-145 mmol/1
HE. F -1-_ I ?.1: 1,10_ RANGE : MALE
41-51 mmHg (vm) P02 80-105 mmHg (art) PAT I EN T b (4) -1-1
is': #3.3.4.7 mm N/A Neill
CENERAL :'.H1_ I STRY 12
23-27 rornol/L (art) 9s-ios mrpoUl 24-29 mmol/L (von)
TCO2 DiSC L()r #• 3082,6,M
22-26 mmol/L (art) 1 18-33 mmol/1HCO3 23-28 mmoUL (von) OPLR g : DR g : 000 95-98%
802 ' SERIAL # : (PittiWPYi '-: ritiet:1440,
._. . _ . ._.
BEecf (-2) -(+3) T RESULT REF. RANGE mmon
ALB 1.3* 3.3-5.5 6/DL
10-20 mmolfL 3.3-5.5 g/dl
AnGap
ALP 1 1 0* 26-84 U/L
Ca

1.12-1.32 aunol/L
ALT 70* 1
8-26 mg/di 7

BUN AMY 142* 1 AS 1 69* 1
70-105 tnedl
GLU
TBIL 3.9* 0
Creat 0.7-1.5 mg/dl BUN ••• 7
CA++ 8.3 8

38-51% PCV
Hct
CHOL 111 1 00-200 MG/DL
Hgb 12-17 g/dl 5-65 till
CRE 0.8 0 .6-1 .2 MG/DL
6.4-81 g/dl
1.:.1%*::: .Iiiiiiis -,
GLU 108 7
TEST RESULT REF RANGE TP 4.4* 6

Troponin-1 RESULT REF. RANGE
INST OC: OK HEM 2+, LIP
128-145 mmola
Drug of
Abuse --L'S3h9-7-33-4.7 mmolA
,f) ­
k j IX_ I — /
98-108 mmol/1
18-33 romoUl
REMARKS:
REPORTED BY:. ' DATE: LAB ID NO.:
Cc z2 Ward/Sectio 1Q (c)-tk LABORATORY RESULT FORM SuFeet to the Privac Act of 1974
ST,F. I
emato.CBC. Urina

In+.•¦•• TEST
dor.\9 -LI Color
APP
•
1 7.1 Glu
Tic Bili
Ket

P11 SG
. .
Ly Bid
PH
Se) Prot
UrobBa 1---
I
10P0INI [DAG ANALYZER V4.b4
It0H465 09/06/03 1)4:52 AM

ient ID
est Nil!".

.est Result:= 12.0 sec.
**RESULT NOT RANGE CHECKED***
atio = 1.0
alculated INR = 0.97
ample Type:citrated wh. blood
est Date :09/06/03
est Time :04:51 AM

.ard Lot :010301
perator : )9(6) --7,

'LWOW COAL; ANALYZER V4.54
!1AL 1ffl05465 09/08/03 04:56 AM

ient ID: 6M-Li
est Name :WTI
est Result:= 42.5 sec.
**RESULT NOT RANGE CHECKED***

;ample Type:citrated wh. blood

est Date :09/08/03
Cest Time :04:52 AM
:ard Lot :aim

1perator :

.N/A Negative RESULT REF. RANGE Negative Microbiology
PICCOLO 1. 7.•

08/09/03
REFERENCE,RANGE:
PATIENT #:

• METLYTE 8

N DISC LOT #:
OPER Alp
N SERIAL #:

01:25
MALE

3151AA4
DR #: 000

GLU 112 73-118 MG/DL

'T BUN •#• 7-22 MG/DL
CRE . CK NA+
• K+
CL-

0.9 0.6-1.2 MG/DL

71 39-380 U/L ruaa 127* 128-145 MMOVL
1.7 3.3-4.7 MMOVL
10? 98-108 MMOVL

tCO2 22 18-33 MMOVL
. 47sf. INST QC: OK CHEM QC: OK ink .
HEM 0 , LIP 1+, ICT 1+
' 518 WITH
PUESTED
IJSTSIJOI
UNIT oSSAL4TCH

LAB LB NO.:.
„ .
MEDC -
(0 -2-
Ward/Section: 1.1ESTINO PHYSIC
LAST, F T L
TEST RESULT REF. RANGE TEST RESULT
ALB ALP ALT AMY AST
TBIL
BUN
CA++
CHOL
CRE
GLU
TP
W* $
TEST RESULT '
-

POINT WAG ANALYZER V4.54
-AL #005485 09/09/03 04:39 AM

ent ID 47-)

•
.st Name :PT
!st Result:= 13.9 sec.

•
RESULT NOT RANGE CHECKED*
Atli) = 1.1

•
ilculated INR = 1.24
-ample Type:citrated wh. blood
est Date :09/09/03
est Time :04:38 AM
ard Lot :010301

perator (C4)-2_

111111/4

10PDINT COAG ANALYZER V4.54

IAL #005485 09/09/03 04:43 AM

lent IA,
est Name T
est Result:= 41.0 sec.
•*RESULT NOT RANGE CHECKED**+
;ample Type:citrated wh. blood
-est Date :09/09/03

-

:ard Lot • CO

1perator

•est Time :04:41 AM

REF. RANGE 3.5-5.5 01 26-84 u/1 10-47 u/l 14-97 u./1 11-38 u/1
0.2-1.6 _mg/di
7-22 ng/d1
8.0-10.3mg/d1
100-200 rag/d1
0.6-1.2 mg/c11.
73.118 mg/d1 101
REF.
RANGE

73-118 mg/d1 7-22 mg/dl 0.6-1.2 mg/d1 39-380 u/1(M)
30-190 u/1 (F)
128-145 mmo1/1
13-4.7 mmolII
98-108 mmol/1
18-33 nuno1/1
LAB ID NO.:

_dISTRY RESULT FORM
Sub ed to the Privac • Act of 1974)
SSN/PS
61)
G

j64o). ao w a
TEST RESULT REF. RANGE
GLU 73418 mg/di
BUN 7-22 mg/di
FIccot_O

1-1 -1,4(:),: 1-:ANGE_ : . MALE
PKI TENT # :

I ['troll_ 8
L.01 #:

31 41 A,44
•
:214 .P

:i DR If : 000 # :
9' K3-1 i . mu/LA
BUN "‘41-r16 -- 2 mu•oi_
CRL 0 . 0 113,-DL
1 CK LUL
NA F 132 12R-- 1 1 Mfi.4/1
K+ 4.6 .7 MMOVL
CL- 1i2 98-108 MMOt4._
tC07 24 18-33 MMO•UL

INST QC: OK CHEM QC: OK
.„. HEM 1+, LIP 1+, ICT 1+

L
W di ti n... ..
.v.I.ISTRY RESULT FORM iitiect to the Privacy Act of 1974)
LAS , EltST, 4 T
SSN/PSEUDO SSN:
_ •

rip
44'...4.. ---•

.10!:IiiiiA.::p.'.

,. „,J.60.14y„041mISTV!,,-,

TEST RESULT REF. RANGE .
'ST RESULT REF. RANGE
Na 138-146 nunol/L
f 73-1 l8 mg/dl
-PICCOLO
K 3.54.9 unnol/L: == -----
7-22 mg/dl
r

09/09/03

08:20 ,

Cl 98-109mmdl
REFERENCE R _ _

AN(,E:

MALE

7.31-7.45
PH • PATIENT #: illa 1,/,)
,.v.,,a,..¦...LI1
PCO2 35-45mmlig(mt)
GENERAL CHEMISTRY 126-t45 mmol/1
12 80-105 mmHg (an) DISC LOW"41-51 nudist yen)
P02 3142AA4 3.3-4.7 mmolA
WA (yen)
OPER #

TCO2 23-27 tnniol/L Out DR #: 000
9t[ 108 mmoln
24-29 mmol/L (yen)
SERIAL #:

HCO3 22-26 rnmol/L (art) .
18 33 lttmoUl
IIIIIIIIIIIII/1
23-28 nunol/L (yen)
95-98%
s02 ALB 1.4* 3.3-5.5 G/UL AY# BEecf (-2)— (+3) ALP 127* 26-84 U/L
ST R E S i;IT . REF. RANGE
rnmol/L
ALT f.• 10-47 U/L

AnGap 10-20 unol/L
3.3-5.5 g/dl
AMY 108* 14-97 U/L 1

Ca 1.12-1.32 nunol/L 26-84 u/1
AST 84* 11-38 U/L BUN 8-26 mg/d1 TBIL 2.9* 0.2-1.6 MG/DL ' 10.47u/ BUN •s• 7-22 MG/DL
GLU 70-105 mg/d1 14-97 oil
CA++ 8.5 8.0-10.3 MG/DL IT Creat 0.7-1.5 mg/dl CHOL 85* 100-200 MG/DL , 11-38 &I

Het . 38-51% PCV CRE 0.6 0.6-1.2 MG/DL 0.27 1.6 mg/di(IU 106 73-118 MG/DL
12-17 g/dl
Hgb I 5-65 ull
TP 4.5* 6.4-8.1 G/DL

• 2.5,V14.' . .- WS. ' --- 6.4-83 g/d1
.

TEST RESULT REF. RANGE INST QC: OK CHEM QC: OK ._
"e014-' Oil

M 1 +) LIP ICT 0.‘4,-.;,., :s-„,-

fo 06 h! 04. :

Troponin-1
ovict 6Le ST RESULT REF. RANGE
Drug of -128-145 mmol/1 Abuse dye -1.0 44 P — 1#8 '41
33-4.7 mmol/1
98-108 mmol/1
2 18-33 mmoUt
REMARKS:
•
REPORTED BY: DATE: LAB ID NO.:
9 ,Sept o3
6(0

-STAT G3+

P':41111

P' Name:

TA2 26 mmol/L
t 37C
7.279
PCO2 52.0 mmH;
75 mmHg
-:03 24 mmol L
:Eecf -2 mmol L
93 %

*calculated

rt Patient Temp
PH

7.271

53.3 mmHg
a02

77 mmHg

aitient Temp: 99.6F
: 50
Sample Type_: ART

195EPO3

16:39
pper11111
Physician:
5?r#111111

JAM5046A
CLEW A93

i-STA G3+

1

Pt:41111F

Pt Name:

TCO2

27 mmol/L

mmHg
-r-4

112 mmHg
25 mmol/L
BEecf

-2 mmol/L
s02*

97
*calculated

;!t Patient Temp

7.259

55.9 mmHg
Poa

112 mmHg

aent Temp: 98.6F

: 50
3aApie Type_: ART

09SEP93

12:28

Oper:

ahysician:

Ser*

Ver: JAM5046A
CLEW R93

t Name:

TCO2

26 mmol/L

:It 37C

7.417

39.3 mmHg

120 mmHg
HCO3

25 mmol/L

1 mmol/L

99
-_31culated

3ample Type_:

115EP03

06:23

1111111

iciafl

JAM5046A

CLEW A93

Ward/Section: wi.) .KEytJESTING PHYSICIA BORATORY RESULT FORM I
LAS S'Ith TIME Subject to the Privacy Act of 1974) \ SSN/P Li
( e
ems o TEST • I RESULT REF. RANGE TEST Color !.s I RESULT I REF. RANGE Negative
App
Glu =PICCOLO 7
Bili Ket 10/09/03 04:26 REFERENCE RILL, / MALE PATIENT #: MIN (6)_LI
GENERAL CHEMISTRY 12
SG DISC LOT #: 3204AA4
Bid OPER #: R #: 000
SERIAL #:
ii PH
Prot ALB 1.3* 3.3-5.5 G/DL ALP 133* 26-84 U/L
Urob ALT 1$' 10-47 U/L
AMY 161* 14-97 U/L
AST 60* 11-38 U/L
, OPOINI WAG ANALYZER V4.54 AL 0005485 09/111/03 04:15 AM TBIL t.0* 0.2-1.6 MG/DL BUN 444.'67-22 MG/DL CA++ 8.2 8.0-10.3 MG/DL
ent ID CHOL 143 100-200 MG/DL
st Name :PT CRE 0.8 0.6-1.2 MG/DL
st RE-it:. 14.1 sec. GLU 107 73-118 MG/DL
*RESULT NOT RANGE CHECKED .*** TP 4.9* 6.4-8.1 G/DL
tio = 1.2
iculated INR = 1.26 INST QC: OK CHEM GC: OK
mple lype:citrated ash. blood 3t to :09/10/03 t. HEM 1+, LIP 1+, ICT 0
3t ime :04:12 AM -d Lot •010301
!rator Min 6(6)-1, iZ"EP133
POINT COAG ANALYZER V4.54
L 0005485 09/10/03 04:18 AM
Flt. ID: t Name :APT 46)
t Result:= 42.5 sec.
RESULT NOT RANGE CHECKED***
)1e Type:citrated MI. blood
t Date :09/10/03
Time :04:15 AM i Lot : 002 ' i9 (
•-ator

Ward/Section: tNII.M.i 1'11Y sitAAN:
1 LABORATORY RESULT FORM I.(Sub ect to the Privacy Act of 1974)LAST FIR DATE
i 21ecto..3 TIME 0_ , SSN/PSEUDO SSN..• •'....(Hemato CBC • Urinalysis .. Misc. Serology
7E TEST RESULT REF. RANGE TEST RESULT REF. RANGE
Color N/A RPR Negative
ow App ... ' INV.A. Mono Negative

Glu Negative Microbiology
Bill Negative '
Source
Ket Negative Gram
Sta SG N/A .
00
PICCOLO -------

IN Negative IL
11/09/03 t 03:54

d : pH N/A Nil REFERENCE RANGE:.MAL
Iis¦=mm 1 I.\
• )-

pfl 3 GENERAL CHEM 2 DISC LOI.L 3204AA4
PICCOLO

Ur.
OPER #:1111

11/09/0
SERIAL #:

RLET_RENCL RANGE:MALE j PATIENT tt: 1111111
DPOINI COAG ANALYZER V4.54

ALB 1.1* 3.3-5.5 3/DL

METLY1E 8

AL 1ffl05485 09/11/03 03:58 AM
ALP 149* 26-84 U/L

DISC LOT #:.3111AA1

ALT 27 10-47 U/L

lent ID:1111111 1"2(4) --, OPER #:.DR #: 000

AMY 96 14--97 U/L

st Name :Pi SERIAL #:

•s. U/L

st Result:.12.8 sec. AST 11-38 g*RESULT NOT RANGE CHECKED*** GLU 125* 73-118 MG/DL TBIL 1.8* 0.2-1.6 MG/DL itio.1.0 CA++ h/V*7-22
BUN MG/DL

BUN 444140.7-22 MG/DL
doulated I :: 1.08 8.6 '8.0-10.3 MG/DL

CRE 0.7 0.6-1.2 MG/DL

imple Type:citrated oh. blood CHOL 114 100-200 MG/DL
CK 70 39-380 U/L

•!st Date :09/11/03

CRE 1.0 0.6-1.2 MG/DL

NA+ .4441411.28-145MMOVL

•?st Time :03:57 AM

GLU 129* 73-118 MG/DL

K+ 4.5 3.3-4.7 -01..

ird Lot lam
E
TP 4.8* 6.4-8.1 G/DL

CL-108 98-108 MMOVL
( 31 1-2' t002 26 18-33 MMOVL

INST QC: OK CHEM QC: OK
DPOIN1 WAG ANALYZER V4.54 MIST QC: OK CHEM QC: OK HEM 1+, LIP 2+, IC) 0
At 11005481) 09/11/03 04:01 AM HEM 0 , LIP 2+, 101 0

oerator

ent H11111111

t Name :APT I
sec.
;Nil I RANGE CHECKED***
iipe:citrated wh. blood
st One :09/1-1/0-3
lime :03:58 AM

iLI Lot.:100212
,erator

41.11,17A• • A. • .1 A.' 1. •
Ward/Section: LAST, FIRST, ML STING PHYSICIAN:
AY RESULT FORM (Subject to the Privacy Act of 1974) SSN/PSEUDO SSN:
,KF,4,. , 40:01#!4ra:40:
:',.-. .4...-..,,.J.::.tie ::5'.7.-....y...:Li::_:41. TEST RESULT REF. RANGE
GLU 73-118 mg/di BUN 7-22 mg/di CA++ 8.0-10.3 mg/d1 CRE 0.6-1.2 nag/d1 NA+ 128-145 mmol/1
K+ 3.3.4.7 mmol.1
Cr 98-108 mmol/1
tCO2

18-33 mmol/1 ....,;7, (kkcii yilii,o.... knit piiii.,..
TEST RESULT REF. RANGE
ALB 3.3-5.5 g/d1
ALP 26-84 u/1
ALT 10.47 till
AMY 14-97 u/1
AST 11-38 IA TBIL 027 1.6 mg/r11 GOT 5-65 ull TP 6.4-8.101
'
... ..
TEST RESULT REF. RANGE
NA* 128-145 mmol/1 r 3.3-4.7 mmol/I CI; 98-108 mmolll tCO2 18-33 rnmo1/1
TEST
Na
K
PH PCO2 P02 TCO2 HCO3 s02 BEecf
AnGap Ca BUN
GLU
Creat
Hot Hgb
:-,
TEST
Troponin -1
Drug of Abuse
.!ST
RESULT REF. RANGE
138-146 =non
3.5-49 nunol/L:
98-109 =non
7.31-7.45 35-45 mmHg (art)
41-51 rnmila (Yen) 80-105 mmHg (art) N/A (veu) 23-27 mma1/1. (art)
24-29 =non (yen)
22-26 romol/L (art)
23-28 namol/L (yen)
95-98%
(-2)— (-I-3) namol/L 10-20 mmol/L 1.12-1.32 mmol/L
8-26 mg/dl
70-105 mg/di
0.7-L5 mg/di 38-51% PCV 12-17 g/di
..ii‘44 *".:Wi
-::.: -.17. 2,',:ig!:t. :]':'•,:t.i,;:;? ,.,....‘,. RESULT REF. RANGE NA+
K4
_CL -tCO2
TEST
ALB
ALP
ALT
AMY
AST
TBIL
BUN
CA++
CHOL CRE
GLU TP
TEST
GLU
BUN CRE CK
REMARKS: REPORTED BY: DATE:
Yr^ S
DATE TIME
Iram
RESULT
tec40 At .
.)= :,
....:7.i.:',
RESULT
REF. RANGE
3.5-5•5 8161
26-84 &I
-• 10-47 u/1 14-97 u/I 11-38 u/1
0.2-1.6 mg/d1 7-22 fid]
8.0-10.3med
100-200 mg/d1
0.6-1.2 mg/d1
73.118 mg/dl
8.1 g/dl
..::.:-•.:1';',
REF.
RANGE

73-118 mg/dl 7-22 mg/dl 0.6-1.2 mg/di
39-380 u/l(M) 30-190 u/1 (F) 128-145 mmol/1
33-4.7 mnao1/1
98-108 mmoYl
18-33 mmol/1
LAB ID NO.:
Ward/Section: JES.
IAN:
Cu 3 ,RATORY RESULT FORM I
OulYect to the Privacy Ac! of 1974)
DATE'.TIME S.N:
. I7
il
r r¦ b.(6) _Li I
' 1311111111111111
PICCOLO = 7-7 :7::

12/09/03

App 04:50
-* PRINT CANCELLED **

HEN:FART RANGE:

MALE

Glu
PATIENT

/7(04

Bili 311111111 (iENFRAL CHF. ISTRY 12 DISC LOT #:.
3142AA1

Ket
OPER #:11111

i-STAT EC8+ DR #: 000

SG SERIAL #:
Bid
ALB 1.1* 3.3-5.5 G/DL

7,+ Name:

PH ALP 132* 26-84 U/LALT 11 10-47 U/L
Prot G1u .
89 mg/dL
AMY 75 1A-97 U/LUrob le mg/di.. AST 69* 11-38
U/L 136 mmol/L IBIL 1.4 0.2-1.6 MG/DLNit 4.3 mmol/L BUN -4117/47-22 MG/DL
CA+4 8.2 8.0-10.3 MG/DL

C1

107 mmol/L

CHOL 172 100-200 MG/DL

• 101301N1 COAG ANALYZER T'02 27 mmol/L CRE 0.9 0.6-1.2 MG/DL
JAL 11005485 09/12/03 04:25 AM ,:tfiGap 6 mmoi/L GLU 94 73-118 MG/DL.
Hct

24 %ACV TP 5.3* 6.4-8.1 U/DL

lent ID.
HE* 8 g/dL

est Name :PT
INST UC: OK CHEM OC: OK

est Result::: 13.3 sec. *via Nct.
HEM 1i, LIP li, ICI 0

**RESULT NOT RANGE CHECKED*** pH .7.510
atio.1.1

002 32.6 mmHg

alculated INR = 1.15
ample Type:citrated wh. blood W.03 26 mmol/L
est Date :09/12/03 BEccf

3 mmol/L

ast Time :04:23 AM
and Lot.: 10301 sample Type_:
ierator

b (.0
125EP03

05:03

[JPO NT COAG ANALYZER V4.54 . uper:1111111
Al. #005485 09/12/03 04:29 AM
P7i,sician:
dent 10:1111. (.62)-11

est Name :APTT E.E.r#11111111111
est Result:- 35,4 sec. JAM504614
CLEW A93

**RESULT NOT RANGE CHECKED*** ample Type:cilrated wh, blood est Date :09/12/03 est Time :04:25 AM aril
Iperator
Lot ilia= 17(10-2-
Numberof attachedsheets :
-r! car-
U)

z Z
n)
3 3
rn P.
•
r"--•.
0
•¦• • 0
0
Co

CD
0 CD
0 9 07 -n O
3
C

Ward/Sectio
LA.ORY RESULT FORM
b(6
(Su u.to the Privacy Act of 1974)
LAST, FT
•I TIME is
¦0
tipt,
OA, .460441.44,V,V10,1 4r!:rno. Misc Sel
44400 ,t,,,..wA0P111AFfgaMtlht-Aiki,,L,
TE..RESULT TEST RESULT REF. RANGE TEST RESULT REF. RANGE
Color N/A RPR Negative
App N/A Mono Negative
Glu Negative
crabiologr:42-,
Bili Negative
Source
Ket Negative
Gram Stain SG N/A Occ Bld Negative
Bld Negative H. pylori Negative
prH N/A
Micro Parasites Prot Malaria
Negative
Urob
0 & P
Nit Negative
Other
Leuk Negative
0000
6' •
Negative
MN! COAG ANALYZER

t 4005485 09/13/03 04:15 AM
0 an '44i

int ID:

--ave:p

**45,:if
st Name :PT

MUST SUBMIT SF 518 WITH
st Result:- 13.3 sec.

EVERY UNIT REQUESTED
*RESULT NOT RANGE CHECKED***

Negative
ABO/Rh
Aho = 1.1
ticulated INR = 1.15
imple Type:citrated wh. blood 10:2=?Aglig0,;­
•t kri
rist Date :09/13/03
ast Time :04:13 AM

TYPE CROSSMATCH
r

ard Lot :0 I –.
perator
DPOINT COAG ANALYZER V4.54
#005485 /09/13/03 04:19 AM

.ent ID \D (0 -9
st tuidAll
st Result: 31.5 sec.

—
1

LAB ID NO.:
*RESULT NOT RANGE CHECKED***
mple Type:citrated wh. blood
st Date :09/13/03
st Time :04:16 AM

-rd Lot -100212
orator

SPECIMEN/ LAB RPT. NO.
MISC
DPW-411///1/ (°-
URGENCY PATIENT STATUS
. BED.. AMB
OUTINE
PATIENTS MED. RECORD._
OUTPATIENT . T DAY .
.
NP..DOM

.
PRE-OP SPECIMEN SOURCE (Specify)

STAT .
Enter in above space PATIENT IDENTIFICATION—T REATING FACILITY—WARD NO.—DATE
REPORTED BY MD DATE

LAB ID NO.741.1111 7 qttacey
TECH
REMARKS

ITIS)EN TAKEN TIME A.M.
,
ES
"71
J-K ------- PICCOLO

13/09/03

16:15

RE SULTS
REFERENCE RANGE:

MALE

PATIENT #:
A

BASIC MET. t,q -1/1

- -,
._..
DISC LOT

3145AA4

C, .R #: Mill,

DR #: 000
SERIAL #:

GLU 118 73-118 MG/DL
BUN ### 7-22 MG/DL
CA++ 8.4 8.0-10.3 MG/DL
CRE 0.9 0.6-1.2 MG/DL
NA+ +4. 128-145 MMOVL
K+ 4.7 3.3-4.7 MMOVL
CL-103 98-108 MMOVL
tCO2 27 18-33 MMOVL

INST OC: OK

CHEM OC: OK
HEM 0 , LIP 0 , ICT 0

S 1-

8L.4.4 -

SPECIMEN/LAB RPT. NO.
MISC
URGENCY XENT STATUS BED.EAMB
0 ROUTINE OUTPATIENT . TODAY . ONp
.
DOM

.
PRE-OP

SPECIMEN SOURCE (Specify)
STA
Enter in above space.
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE 4REOU
TURE1D4).
REPORTED BY
MD DATE LAB ID NO.
TECH
REMAR
F F
pef2_5-6
17,
PATIENT'S MED. RECORD
I
AISC
URGENCY
. ROUTINE TODAY .
0 PRE-OP STAT .
lz9/(-#3
E nter in above space
PATIENT IDENTIFICATION—TREATING
FACILITY—WARD NO.—DATE
R
EQUESTING PHYSICIAN'S SIGNATURE
REPORTED BY
MDI DATE
TECH rtafs/.rOf
SPECIMEN /.LAB RPT. NO.
PATIENT STATUS El BED .AMB
OUTPATIENT .
.
NP.

.
DOM

SPECIMEN SOURCE
(Specify)
LAB ID NO.
--I
r-t 01 01
QE = E = E

_27 mmol/L
__3 mmol/L

A't E a
E.
R, co 1-I-
0.1 ...., I ..4-
¢, 73
al ••
......
a,
I
20:
...-•
C1.1
7-•.•
• .. T,
-
eI3 0
.I- 2
..-1
0-
0
1n
•- 7 71
M C.
1.) I-CS.
i'D.:E W
:-. 0-.••-•.
2 ..J LI7i.7-'.•
IT V ....I 1.0.
0.1 • ¦-•
* * a. . -.7
O n.1 L..Ill.4*.•••
0.1 a
C.) -•- Lu in a,771.L L. Ci. Ct. a. rI0.1.•2.,
O...0.
SPECIMEN/LAB RPT. NO.
MiSC111111 616)-L( URGENCY STBIEE NDT STATUS AmB
. ROUTINE OUTPATIENT .
Icy
TODAY 12
. NP..Dom
. PRE-OP
SPECIMEN SOURCE (Specify) _STAT
Enter in above space PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE REOUE7
ATIJRE REPORTED BY7
MD DATE
LAB ID NO.
TECH REMA
V(9)
Cfti71Z¦ I-
-
A
PICCOLO -- -=-
13/09/03

04:11 REFERENCE RANGE: MALE PA =NT #1111111111 icit\t
GENERAL CHEMISTRY 12
DISC LOT #:

3204AA4
OPER #:

DR #: 000
SERIAL #:

ALB 1.2* 3.3-5.5 G/DL
ALP 161* 26-84 U/L
ALT 4.. 10-47 U/L
AMY 87 14-9? U/L
AST 88* 11-38 U/L
TBIL 1.3 0.2-1.6 MG/DL
BUN t,411117-22 MG/DL
CA++ 83 8.0-10.3 MG/DL
CHOL 123 100-200 MG/DL
CRE 0.9 0.6-1.2 MG/DL
GLU 97 73-118 MG/DL
7-5.6* 6.4-8.1 G/DL

INST OC: OK CF-EM OC: OK
HEM 1+, LIP 0 , ICT 0

PATIENTSMED. RECORD

Microbiolony Report
aboratory7
Name:7., (0 _ 7 Specimen:7 Status:7Final
Patient ID:7

Source:7
Sputum7 Collected:
Ward/Rm: /7

Ward of Iso:7 Attd. Phys:
Acinetobacter baumannii/haemolyticus Status: Final
1.Ac baumann/haem
Drug7 MIC
lnterps Drug MIC
Interps
Amox/K Clay (c)716/8
Amp/Sulbactam (c)716/8
Ampicillin7 16
Aztreonam7

16
Cefazolin7 16
Cefepime716
Cefotaxime (c)732
Cefotetan732
Cefoxitin7 16
Ceftazidime (a)716
Ceftriaxone (c)732
Cefuroxime (b)716
Cephalothin716
Chloramphenicol716
Ciprofloxacin72
ESBL.-a Scrn74
ESBL-b Scrn71
Gatifloxacin74
Gentamicin78
Imipenem (c)7=4
Levofloxacin74
Meropenem (c)7=4
Moxifloxacin74
Nitrofurantoin764
Norfloxacin78
Piperacillin (a)764
Tetracycline78
Ticar/K Clay (a)764
Tobramycin78
Trimeth/Sulfa72/38

S7= Susceptible7
N/R = Not Reported7
17= Intermediate7

Blank = Data not available, or drug not advisable or tested
—7= Not Tested7
R7= Resistance7

ESBL = Extended spectrum beta-lactamaseTFG = Thymidine-dependent strain 7
Blac = Beta-lactamase positive
MIC = mcg/ml (mg/L)
R'7
= Resistant due to extended spectrum beta-lactamases (ESBL) EBL? =
Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases. IB7
= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs.
Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)
Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.

(b)

Breakpoints based on parenteral dose. For cefuroxime axetil (P0) use (8=S, 8-16=1, 16=R). Footnote (c) applies to this drug.

(c)
For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.

(d)

For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints
are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints.For S. pneuinontae, cefotaxime and ceftriaxone breakpoints are based on isolates from patio .
ith meningitis. For non-meningitis infections, use 2=S, 2=1, 2=R.
Name:
Specimen:7
Status:7Final
Patient !D.7
Source: Spu7
Collected:
Ward/Rm. \O (6)
Ward of Iso:
Req. Phys:
Printed 14-Sep-03 08:04:04
Page 1 of 1
Tech: MEDCOM - 18151
1.6)-
Li-
DOD-031725
1—TAT G3+
Pt Name:

T002 29 mmol/L
37C
7.424
P02.. . HCO3 BEecf 42.1 mmHg 71 mmHg 28 mmol/L 3 mmol/L 94

*calculated

:* patient Temp

7.415

43.3 mmHg
74 mmHg

Patient Temp: 99.7F
: 50
rample Type_: ART

145EP03 1057

ne, 7i

11110

.
'--:-' trilig
T7
1-5TAT u:J+

P : 11111111111,

Pt 4ame:

TC32 27 mmol/L

Rt 37C

p: 7.434
P 39.2 mmHg
poa 69 mmHg
HCO3 26 mmol/L
BEecf 2 mmol/L
5023-94 %

-calculated

AT Patient Temp

pH 7.433

P c'l 39.4 mmHg

P02 69 mmHg

Patient Temp: 98.8F

= : 50

:ample Type_:

115EP03 15:44

CperWO

EerA1111111
er: J9M5046A

CLEW A93

MEDCOM -18152

1-STAT G3+

-t Mame:

1CO2 28 mmol/L

¦
t 37C
ph 7.3“

47.0 mm-i;
PO2 119 mmHg
hi:03 27 mmol/L

:)2.

sEecf 72 mmol/L
a-02* 98
*calculated

Pt- Patient Temp

77.356 Dcoz 748.2 mmHg 202 123 mmHg
7-atient Temp: 99.7F
F102 : 50
mple Type_: ART

13SEP03 08:35

)er:1111111
fp-

lysician:

er4111111

¦,¦
r: JAMSO46R

CLEW A93

SPECIMEN/LAB RPT. NO
MISC

47%ff#11111
URGENCY PATIENT STATUS 0 BED.. AMB
. ROUTINE
OUTPATIENT 0 TODAY .
. NP.DOOM
. PRE-OP
SPECIMEN SOURCE (Specify)STAT .
Enter in above space.PATIENT IDENTIFICATION—TREATING FACILITY—WARD
7 Na—DATE REQUESTING PHYSICIAN'S SIGNATIIEF I DC1:1,07C, ev
:: ..--. 14-C) 7C Z C7 C7 CO G7 - GO CD CD :K 7D D; - .'

1-9 Z C7 I— + D 7C DD CZ I— -m m -. 179 D ffl I II

7K GO CD 1 + m Z. CZ - 7D ri GO --1 --I '1 -,.. m

Cl ---i DJ C7 1--,--. m Cl I ¦
-D - Cl ;o (JD .I

o . __ :
-' c) -P •

N C) 7 _ li (.0 c) --k - -CD 71—I ".2 CD ::
W CO •7N -7co :1, P: C'')
I— CD

(7.) ' -0
.---, 7K ...
-0 VI 1:1 1-6

C7

co7C) -NI -NI - z n
PATIENT'SMED. RECORD
, r° o7cp
+ 9° W CO I ED f¦) (t) : m 1—
CO i rcijinj--

CD

0,.) -.[.. --,. CO

in co 4, Cl o7,
,-. :' V1Fo m -.Ti Cl i

C)). -P
4,t S.-2 1:7-7, I
CD .7K :K =K ]E Li ,,,

CD CD CD CD CZ ', -,. ', -,.......-• j2,.

1 r

0

F rf, -, CD CD C.: -

I—

l r.,..,

r-

(..-, .

r-I—

r-1--r--

SPECIMEN/LAB RPT. NO.
PATIENT STATUS
.
BED7. AMB OUTPATIENT .

.
NP7. DOM

SPECIMEN SOURCE
(Specify)
LAB ID NO.
PATIENT'SMED. RECORD
En ter in above space REQUESTING P
RE MARKS
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
.
R PORTED BY MD .--7_,_. TECH
1°(‘
MISC
URGENCY
. ROUTINE TODAY .
. PRE-OP STAT .
DATE
I it fO3
1.9. r...2. J 1 :: , .

ri- C7 77 Z C7 C: 7f "pc • r.,_0 ',. (e; Cz0 :__,

7C ---, --. D ?, , . 41, , 1

• Cl -O•

E2 - 9 r,— - '.,, 1,d'1 )„) (----•
6-7, 1

.--, N

2( - . _....7
(D r­
o 714: r- -'s z_ .7 C
- - CD 7?

c;7-a ... c) 007.-,--.
— r),.) 4t ---.. • . -',

PO CD - ...

--; -t hr.
--I=. CC (V. ... ---\.: - L=. r,..) -....(.1
1,1 -tt7-0
I— CD

7.:
a D C7 ,
7 4 Cl
CD W ---s. Cl OD -.I -NI

CD

CD 00 CO - N -1 CO

I I W 00 CD Cl PO , c--)71+1 1—
C

— Cl W --1 , 1 N -

_... .

W Cl -..4' =C Cl OD -(71

C) -,..j ul N 73
co7-• I:
G..:

J ts—
CD

:K :K .7K • 6 1-....,
C7 :=4" CD

.

C CD 6"N 7
Cl

CD C: CD CD 73 Cl 5 ....../ 14= . ,
7C r-r-t M

4:...

i -STRT G3+
CO -4
Name: 7
Tc-!2 30 mmol/L
St 370 .7.462
.40.5 mmHg
.78 mmHg
.29 mmol/L
.5 [owl&
.96 % *calculated
Patient Temp .7.441 pc:n2. .42.9 mmHg
.85 mmHg
Pat ient Temp: 101.0F =1. .: 100 -1mple Type_:
4SEP03.21:21
17er: 111111i
CLEW R93
REMARKS:
REPORTED BY:
STIN
TEST
ALB
ALP
ALT
AMY
AST
TBIL
BUN

CA++
CHOL CRE
GLU TP
TEST
GLU
BUN

CRE
CR

NA÷

IC
..CL"
tCO2
DATE:
RESULT
REF. -- -RANGE
3:5-5.5 g/dl
26-84 an
10-47 u/1
14-97 u/I
11-38 u/1
0.2-1.6 mg/di
7-22 mg/dl
8.0-10.3mg/d1
100-208 mg/di
0.6-1.2 mg/di
73-118 mg/di 6.4-8.1 pi&
t
TEST
GLU BUN CA" CRE NA+
IC

CL" tCO2
RESULT REF .AMY
CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
RANGE
73-118 rneldi 7-22 mg/d1 0.6-1.2 mg/dl 39-380 u/1 (M)
30-190 u/I (F) 128-145 mmol/1
3.3-4.7 mmol/1
98-108 mmoln
18-33 mmol/l
LAB ID NO.:
AST TBIL GGT TP
TEST
NA+
CE
tCO2
••.•----
(Pictolo Liver Paucl Plus
RESULT REF. RANGE
73-118 mg/di
7-22 mg/d1
8.0-10.3 mg/dl
0.6-1.2 mg/di 128-145 mmo1/1
' a.
mmoUt 98-108 mmol/1 18-33 mmol/1
• •.•
TEST RESULT
ALB ALP ALT
REF RANGE
3.3-5.5 g/d1 26-84 u/I
10-47 u/1
14-97 u/I
11-38 u/1 0.2-1.6 mg/d1 5-65 u/1
g/dl
eiemopotio'.e
RESULT REF. RANGE
128-145 mmol/I
3.3-4.7 mmol/I 98-108 mmoUl 18-33 mmoUl
QC 2-6
F(&4 yy

Pet-pg..
TRT
SIX
(
7 F. ;Off!

• .77ffIff
i-STAT G3+

9111110

-

7-t. Name:

7CO2 28 mmOl/L
At 37C
7.441
P, _ 39.9 mmHg
P02 103 mmHc;
HCO3 27 mmol
EEecf 3 mmol/L
=02* 98

*calculated

At Patient Temp
pH 7.441
PCO2 39.9 mmHg

1:112 104 mmHg
2atient Temp: 98.7F
: 40
Sw4ple Type_

13SEP33 15:58
Oper: 0
Physician:

er#11111111
'er: JAM5046A
CLEW R93

Ha

136 mmol/L

4.2 mmol/L

29. mmol/L

1.17 mmol/L
-:r

20 %PCV
7 g/dL
ia Hct

7.459

38.8 mmHg
149 mmHg

~ --03 7
28 mmoI/L
4 mmol/L
99 %
*calculated

,31ple Type_:

1‘3EPO3

04:43

111111/
7—.ysician:

JAMSO46A

CLEW R93

:DRY RESULT FORM
to the Privac Act of 1974)
77:ZRT
,
r'121:irtrgt 1:15r
TT-CT.Rr.CTJT T RFF RANGE
6 (6) -
1419-03
04:22
Patient

Wits KC 10.6 H x101/4 4.5 10.5 AIE 2.53 L 110•6/4. 4.00 6.00 Itb 7.2 L ght 11.0 18.0 Ha 22.9 L i 35.0 60.0 ICU.90.6 t 80.0 97.9 HCH 3.5 P9 27.0 31.0 IDE 31.5 L 9/d. 33.0 37.0 Plt 624. H x101/4. 150. 450. LYZ 17.9 *1 X 20.5 51.1 LY1 1.9 * :1014 1.2 3.4
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED

Hkvx

TINC P
).RY RESULT FORM
/Pflarg
o the Privac Act of 1974)
\f) 6 9 . 11,29%,ZWA IPitrfl. SSN:
Ward/
LAST, FIRST,
TEST
111111 tt.) --,1 1549
14:1 Patient
Limits
UBC 20.0 H z10"3/uL 4.5 10.5
RBC 2.90 L x10'6/u1 4.00 6.00
Hgb 8.5 L g/dL 11.0 18.0
Hrt 26.6 L Z.35.0 60.0
1V) 91.6.ft.80.0 99.9
l'ICH 29.3.pg 27.0 31.0
MCHI 32.0 L g/dL 33.0 37.0
Plt 733. Fl x101/u1 150. 450.
LYX 9.7 tZ 20.5 51.1 LYII .1.9 * x10"3/uL.1.2 3.4
Spun
Hematocrit Sed Rate
REPORTED BY:
InnaJyi .
','!;tA?,,444.01',Wrkk144Z03,‘, RESULT REF. RANGE
HE PRINT CANCELLED **

-,

Ill
5TAT G3+

, Name:

3

-

oa*

cl

___33 mmol/L

7.4,;9

-mmHg

150 rf.T(Mg
32 mmol/L

7.5 MAO
99 %

*calculated
-- Patient Temp 7.4¦;3
44.5 mmHg
-oa 153 mmHg

--ent Temp: 99.4F

Type_: ART

It5EPO3 0922

4
-Misd Semi° •
TEST RESULT
RPR /1ono
ource
iram
tain
tee Bid

pylori
hero
arasites
lalaria

& P
then
R.F.F.RANGE
Negative Negative
Negative
Negative

ioroigoti¦ curin.01$/os
„
UST SUBMIT SF 518 WITH VERY UNIT REQUESTED
30/Rh
Wfir
CROSSMATCH
CHEMISTRY RESULT FORM
b (6) -z_
(Subject to the Privacy Act of 1974)
TEcl' ;RgiirT I REF RANGE TEST 4u
Na K
WB 07:18

Cl
Patient
Limits

pH

WBC 11.4 H x10"3/uL 4.5 10.5

PC(
RBC 2.30 L x10"6/uL 4.00 6.00
FI)2 Hgb 6.7 L g/dL 11.0 18.0
Hct 20.7 L Z 35.0 60.0
TC( MCV 90.1 ft. 80.0 99.9
MCH 29.0 pg 27.0 31.0

HCI
HCHC 32.2 L g/dL 33.0 37.0
s()2 Pit 714. H x10"3/uL 150. 450.
LIZ 15.7 *LZ 20.5 51.1
BEc LY9 1.8 * x10"3/uL 1.2 3.4

An
Ca

BU)
GLU 70-105 mg/dl.TEST
0.7-1.5 medl.GLU
Creat
Hct 38-5114 PCV BUN

Hgb 12-17 edi CRE
CK.
TEST RESULT REF. RANGE NA+
Troponin-1
Drug of _CL-
Abuse

tCO2
REMARKS:
REPORTED BY: DATE:
ATE.TIME SSN/PSEUDO SSN:
ç4c18 G
iS oc)
7' REF. RANGE
.PICCOLO --------73-118 mg/d1
15/09/03 08:21 7-22 mg/dl REFERENCE RANGE: MALE 8.0-10.3 mg/d1 PATIENT #: MIN Vc)_Li
0.6-1.2 mg/d1
METLYTE 8

DISC Lila 3141AA4 128-145 mmo1/1
OPER #: DR #: 000 33-4.7 mmult1
SERIAL #: 98-103 mmol/1
18-33 mmoUl

GLU 108 73-118 MG/DL
BUN 12 7-22 MG/DL
CRE 0.6 0.6-1.2 MG/DL
47 39-380 U/L

CK 3.3-5.5 g/d/ NA+ 133 128-145 MMOM_
26-84 u/1
K+ 4.5 3.3-4.7 MMOVL

10-47 u/1
CL- 106 98-108 MMOVL tCO2 24 18-33 MMOVL 14-97
11-38 ull

INST OC: OK CHEM OC: OK HEM 0 , LIP 1+, ICT 0 0.2-1.6 mg/d1
5-55 un
6.4-8.1 01
128-145 mmo1/1
3.3-4.7 mmol/1
98-108 nunal
18-33 mmoIll
LAB 11) NO.:
CHEMISTRY RESULT FORM
Suliect to the Privac Act of 1974)
i4-044
_Orr'
TFKT °gym-T.
,CVT A PRTILT REF- RANGE

4 I1 GLU
----------------------- BUN
ID 11111\.0 (,6) - 4 16-09-03
04:TS CA
WH 3.-STAT EG7+
Patient
Lieits

NA

UDC 11.4 H x10"3/al 4.5 10.5
RDC 3.00 L x10A6/11 4.00 6.00 M Pt HaMe: ------------Hgb 8.6 L g/dL 11.0 18.0
M.0 60.0
Hct 27.0 L X.. CL"
i)
fL.80.0 99.9
ra 89.9.. C.11 a _________ 136
pg.27.0 31.0
ISH 28.7. 4 r:. -______---4.3 MMOPL tCO2
WIC 31.9 L g/dL 53.0 37.0 'Cl,
mmol/L
Pit 795. H x10"3/uL 150. 450. TCOZ ________ 34
20.5 51.1
LYX 18.8 *L X.
1Ca _______ 1.07 mmol/L
L11%.2.1 * x10"3/uL.1.2 3.4
________ 26 /.PCV ALB 9 g/dL ALP
oll!
ALT
*via Hct

- • -
.11LJA`s
37C

70-105 mg/dl
`m__--__ 7.550

AST
0.7-1.5 mg/d1
DCO2 ______ 37.8 mmHg IBiI 38-51% PCV .,2_______ 175 mmHg
GGT
12-17 g/dl ,C73 ________ 33 Mt40111. mmol/L
:EaCf _______ 11
REF. RANGE F02* _______ 100 Y. *calculated
At Patient Temp
Drug of
Abuse pH_______ 7.553
PCOZ ____37.S mmHg CI: 174 mmHg
.at-ient Temp: 98.3F
50

--TOE____----:

REMARKS:
,ample Type_:

cc-
05:12

65E1203

REPORTED BY:
C=er: 111111

7-70,0,10 cie, 3

Ward/Section: REQUESTING 1HYSICIAN
CHEMISTRY RESULT FORM/c° /,L 3 10: _( 6) -2" (Subject to the Privacy Act of 1974) T, MI. TIME SSN/PSEUDO SSN:
LAST.IME
Z.421
T 44:o141:diiiil S
TEST .RESULT .REF. RANGE TEST RESULT - • REF.
• RANGE
Na. 138-146 mmol/L ALB 3.5-5.5 g/dl GLU 73-118 mg/dl
K. 3.5-4.9 rnmoVL ALP 26-84 u/1 7-22 rug/d1
BUN
Cl. 98-109 mrnoUL ALT 10-47 u/I cA++ 8.0-10.3 mg/dl
p1-1. 7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 mg/d1
PCO2.35-45 mmHg (art) AST 11-38 u/1 NA+ 128-145 rnmo1/1 41-51 Frantic (ven) P02. 80-105 corn148 (art) TBIL 0.2-1.6 mg/d1 3.3-4.7 mmulil N/A (von) TCO2.23-27 mmol/L (art) T2T 98-108 mmol/124-29 mmol/L (yen) HCO3.22-26 mmoVL (art) 18-33 mmoV1
23-28 mrnol/L (vcn)
s02. 95-98% ======== PICCOLO ;kr 010 P anel 17/09/03
BEecf (-2)- (+3) 06:12
:ST RESULT REF. RANGE
mmol/L
REFERENCE RANGE:

, MALE

AnGap 10-20 mmol/L 3 3.3-5.5 g/d1
PATIENT #4/1U(._4)..4

Ca 1.12-132 nimol/L 26-84 u/I
METLYTE 8 BUN 8-26 mg/c11 DISC LOT #: 3152AA4 10-47 u/1 OPER All. DR #: 000
GLU 70-105 mg/d1 Y 14-97 u/1
SERIAL #:

Creat 0.7-1.5 mg/d1 11-38 u/1
GLU 98 73-118 MG/DL

Hct 38-51% PCN' 0.2-1.6 mg/dl
HO. 12-17 g/d1 5-65 u/1
CRE 1.0 0.6-1,2 MG/DL

c.' '.
:':SfaC.;O.t.Iiiiiii 6.4-8.1 g/d1
BUN 14 7-P2 MG/DL

CK 333(v2,?9-380 U/L
TEST RESULT REF. RANGE NA+ allEbt '128-145 MMOVL
K+ 4.5 3.3-4.7 MMOL'L
Troponin-1 CL- 98 98-108 MMOVL ST RESULT REF. RANGE
Drug of tCO2 22 18-33 MMOVL 128-145 mmol/1
Abuse
INST OC: OK CHEM OC: OK 3.3-4.7 =loin
HEM 0 , LIP 0 , ICT 0
98-108 mmolll

1 8-33 rnmoUl
REMARKS:
REPORTED BY:
SPECIMEN/ LAB RPT. NO.
411 MISC
PATIENT STATUS
BED.O AMB ROUTINE URGENCY
OUTPATIENT 0 TODAY 0 . NP.ODOM
0 PRE-OP SPECIMEN SOURCE (Specify)
STAT 0
PATIENT IDENTIFICATION—TREATING FACILITY—WARD NO.—DATE
Enter in above space.
MD DATE LAB ID NO.
REQUESTING PHYSICIAN'S SIGNATURE.

REPORTED BY.
401111. b(-0
69 ) 17-09-03
05:12 Patient
Liaits WIC.11.4 H x10"3/BL 4.5 10.5 RFC.3.02 L x10'6/uL 4.00 6.00 Hgb.8.6 L g/dL 11.0 18.0 Hct.27.1 L Z M.0 60.0 hCJ789.6 1 80.0 99.9 MCH.28.6 pg 27.0 31.0 ttlIC.31.9 L g/dL 310 37.0 Plt.870..H x10"3/aL 150. 450. Lyx.16.8.*L 20.5 51.1 LY14.1.9 * x109/ul 1.2 3.4
PHY SICIAN'SCOPY
MEDCOM - 18161

SPECIMEN /LAB RPT. NO.
MISC
URGENCY PATIENT STATUS
litb(.0
.
BED.DAMS

.
ROUTINE

OUTPATIENT :I..
m
TODAY .
0 NP.[:=I DOM 0
ti
. PRE-OP SPECIMEN SOURCE.se
-E-ev,J.I 0 5 . g
(Specify) 0
STAT 1:1 ea
Enter in above space7PATIENT IDENTIFICATION-TREATING FACILITY -WARD NO.-DATE
REQUESTI REPORTED BY MD Drq LAB ID NO.

TECH / REMARKS
4,1
4 a
"' 4) -LI
F
18-09-03
S ID:1111111g.
141+. 04:38 Patient
Lisits 1411C 10.7 H.x10'3/uL 4.5 10.5 RBC 3.01 L.x1056/11 4.00 6.00 Hgb 8.7 L.g/dL 11.0 18.0 kt 27.1 L.X 35.0 60.0 HD) 70.1.fl 80.0 99.9 1111 28.8.pg 27.0 31.0 rEHE 31.9 L.g/dL 33.0 37.0 Plt 921..H.x10"3/tIL 150. 450. LYZ 17.1.*I_ Z 20.5 51.1 LYN 1.8 *.x10'3/111 1.2 3.4
SPECIMEN/LAB RPT. NO.
10 (0' L1 1

URGENCY PATIENT STATUS
. BED..AMB
MAIO MISC
. ROUTINE
OUTPATIENT . TODAY .
. NP..DOM
OPRE-OP SPECIMEN SOURCE
CO__3
(Specify)
STAT .
Enter in above space PATIENT IDENTIFICATION-TREATING FACILITY-WARD NO.-DATE
R E.REPORTED BY. MD DAT (9,7B ID NO.

CH
(4)
Hari 194}.,(19-09-03
04420 Patient
181 11.0 H x10'3AtL.4.5 10.5
Gds
R1a 3.05 L x.10'6AL 4.00 6.00 Hgh.8.7 L gidL.11.0 18.0 Hct 27.1 L X.35.0 60.0 ria/ 88.8.ft.90.0 99.9 NCH 28.6.1)9727.0 31.0 ICH. 32.2 L g/dL 33.0 37.0 Pit 921. H x10'3/111. 150. 450. LYZ 20.0 *I. 7: 20.5 51.1 LA.2.2 * x10'311.1L.1.2.3.4
MEDCOM - 18162
151 .1.53 .1
TAKENrTIME A.M.
P. M.
I703iS3PICAN
RES ULTS
DOD-031736

Ward/Section:
\. l_.) 5

b(4,--t,
LAST F DAT . TIME 0 9 )-( DJ
b 6) — 1/
„.,.7.,7
,i.cgo. -
._ts....,..,..... J,,.
,keip, g „ . _.......,..t:

TEST RESULT REF. RANGE TEST RESULT N
REFG. RANGE
Na 138-146 mmoVL ALB -3.5-5.5 g/d1
K 3.5-4.9 tomoUL . ALP 26-84 u/1
Cl 98-109 rnmoVL ALT 10-47 u/I
PH 7.31-7.45 AMY 14-97 u/1
PCO2 35-45 mmHg (ut) AST 11-38 u/I
41-51 mmHg (veal
P02 80.105 mmHg (art) TB 0.2-1.6 mg/di
N/A (veal
TCO? 7-22 mg/d1

HCO: 8.040.3mg/d1
===--==

100-200 mg/di
s02 PICCOLO
======.'
18/09/03

BEec 0.6-1.2 mg/c11
REFERENCE RAIL,

04 :161:ALE

AnG PATIENT #: 73•118 mg/d1
NEIL YTE 8 6.4-8.1 ectl

Ca 11111111.1r
(6 ) —1/
DISC

DISC LOT #:

3152m4 ..:.-,:; Y . .,,1,10I;,'!: -.
Bin'
# : 11111

DR #:

:: ;:tLLREF. RANGE
GLI.SERIAL_ #: 000 :.::? REILT-:. .
.......................

73-118 mg/d1
Cre.GLU
113 •
73-118

Ha BUN 10 MG/DL 7-22 mg/d1
7-22

MG/DL

.ii CRE 0 .6-1.2 mg/d1
0.7

0.6-1.2

.=, rK MG/DL
47 39-3 80 IAN)
39-380

U/L 30-190 u/l(F)
EL NA+
7 4*, I 341 28 - 145 MMOK. 128-145 mmol/1
K+

4'.5

3.3-4.7

MMOVL

.h-r.ri CL-
s74( 98_108

mmovi_ 33-4.7 rrIrnolil tCO2
22

18-33

MMOVL

Di 98-108 mmol/1
Al

1NST OC: OK

CHEM OC: OK 18-33 mmol/1
HEM 0 ,

LIP 0 ,

ICT 0
•

I
,TE: LAB ID NO.:
CHEMISTRY RESULT FORM (Suliect to the Privacy Act of 1974) SSN/PSEUDO SSN:
K010):*140.1041100iir:
,,,,:,.„,::. .4,:c,,,,.1ti'7.7,16;:?,--:,:7,
TEST RESULT. REF. RANGE
GLU ' 73-118•mg/d1 BUN 7-22 mg/d1 CA++ 8.0-10.3 mg/dl CRE 0.6-1.2 mg/dl NA' 128-145 rnr.noV1
IC
3.3-4.7 mmo14 CL-98-108 mmol/1 tCO2 18-33 mmo1/1
(Piccolo) Lif PanOTIOS.1;:;.;
TEST RESLZ " T REF. RANGE
ALB 3.3-5.5 g/c11 ALP 26-84 u/I 10-47 di
ALT AMY 14-97 u/1
AST 11-38u/1 TBIL 0.271.6 mg/dl GGT 5-65 u/I TP 6.4-81 g/d1
,. ' ' . 'ilt0IPitti. :, 11...1
TEST RESULT REF. RANGE
NA{ 128-145 mmol/1
3.3-4.7 mmol/1
CL-98-108 mmol)
tCO2 18-33 mmoUl
7,
.
Ward/Section:
CHEMISTRY RESULT . FORM
.I e-0 (Subject to the Privacy Act of 1974) LAST, FIRST TE TIME SSN/PSEUDO SSN:
o1..:iC gtali0 is 00c
TEST RESULT REF. RANGE TEST RESULT ..REF. TEST RESULT REF. RANGE
• RAN
GE
Na 138-146 mmol/L 3.5-5.5 g/dl773-118 mg/c11

ALB GLU
K 26-84 u/I7BUN 7-22 mg/c11

CI 10-47 un7CA 8.0-10.3 mg/dl
== PICCOLO - - - -

pH 14-97 un7CRE mg/c11.19/09/03.04 : 18PC 11-38 u/17128-145 mmol/)
ilrE.Ratt RANGE :.NA+
PO 0.2-1.6 mg/c11 3.3-4.7 mroutit

PATIENT #:.b MALE
TC NE -UTE 3 7-22 mg/dl.CL-98-108 mmol/1
DI SC LOT #.3141AA4

H( 8.0-10.3mWdl.tCO2 18-33 mmol/1
OPER # :.
DR #: 000
sO 100-200 mg/d1
SERIAL #: BE 0.6-1.2 mg/di TEST RESULT REF. RANGE
Ar GL . 0.97.73-118.MG/DL 73-118 mg/d1 ALB 3.3-5.5 girl!
BUN.15 7-22.MG/DL

Ca Wd1.ALP 26-84 u/I
ORE.0.5* 0.6-1.2 MG/ DL

Bt 10-47 on
CK.35* 39-880.U/L ALT
GI NA 4;04433128-145 MMOL T F..AMY 14-97 un
K+.4.7.2.3-.4.7 MMOI/L RANGE
Cr CL7100 98-108 MOM_ . 73-118 mg/di.AST 11-38 u/1

ie4"te02 26 18-33.MMObt__ 7-22 mg/d1.TBIL 0.2-1.6 mg/d1
111. 0.6-L2 mg/d1.GGT 5-55 u/I
:•: I" CSC : OK.CF-EM QC : OK
39-3S014 (m) TP 6.4-8.1 g/dl HEM 0 , LIP 0 , I C I 0 30-190 un (F) 7 128-145 mmol/1
Pii0010e0.061
In 33-4.7 mmoVI7
TEST RESULT REF. RANGE
At 98-108 mmol/1 NA+ 128-145 minoln
Al
18-33 mmol/1 3.3-4.7 mmol/I
CL" 98-108 mmol/1
tCO2 18-33 mrnoln
REPORTED BY: DATE: LAB ID NO.:
Cr
__•
0
-s
0
a-5" 0
CD .0
C
CD
Cl)
n
0 ­
3

:speqs petpe4e in Jeq wnN
)(Y)/)—
Name:7 b(0— t,1 Specimen:7 Status:7Final
Patient ID: Source:7Blood7 Collected:
Ward/Rm: Ward of Iso:7 Attd. Phys:
Staphylococcus epidermidis Status: Final

17S. epidermidis Druq7 MIC Amox/K Clay (c)74/2 Amp/Sulbactam (c)7=8/4 Ampicillin7 8 Azithromycin74 Cefazolin7 16 Cefepime716 Cefotaxime (c)732 Ceftriaxone (c)732 Cephalothin7=8 Chloramphenicol7=8 Ciprofloxacin72 Clindamycin72 Erythromycin74 Gatifloxacin74 Gentamicin7=4 Imipenem (c)78 Levofloxacin74 Linezolid7 =2 Moxifloxacin74 Nitrofurantoin7=32 Norfloxacin78 Ofloxacin7 4 Oxacillin7 2 Penicillin7 8 Rifampin7 =1 Synercid7 =1
Tetracycline7=4 Trimeth/Sulfa72/38 Vancomycin7=2
S.= Susceptible. 1.= Intermediate. R.= Resistance. MIC = mcg/m1(mg/L)
Interps Druq R R BLAC R R R R R R S R R R R S R R S I
R
R
BLAC
S
S
S
R
S
N/R = Not Reported.
--.= Not Tested.
TFG = Thymidine-dependent strain .
MIC lnteros
Blank = Data not available, or drug not advisable or tested ESBL = Extended spectrum beta-lactamase Blac = Beta-lactamase positive
= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.

18.= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs. Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)
Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.

(b)
Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1, .16=R). Footnote (c) applies to this drug.

(c)
For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.

(d)
For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints. For S. pneumonia°, cefotaxime and ceftriaxone breakpoints are based on isolates from patients with meningitis. For non-meningitis infections, use 2=S, 2=1, 2=R. _
Name:
Patient ID:7

LI7Ward/Rm: 7
Printed 9/19/2003 10:48:05 AM7
Specimen:7 Source:7Bloo7 Ward of Iso:7
MEDCOM - 181667
Status:7Final Collected: Req. Phy
Tech:
DOD-031740

-Lt
O
05=10
. .
Patient —STR7 ci.3+ Limits RC.11.314 x10'3/EL.4.5 10.5 t 1111 64) RC 7.88 L x10'61111.4.00 6.00
P Name

Hgb.1 3 L.11.0 110
HO; 25.7L 1.35.0 6•.0
Fe1.1.fL..00.0 99.9

TCO2 .32 mmol/L
riCH.29,0.pg.27.0 31.0
rICHC 32.5 L gidL 33.0 37.0
it BO. H x103/L 150. 450. qj 37C
La 17.8 LX 20.5 51.1

pH .7.470
LA.2.0 * X103/UL.1,2 3.4 PCO2 .42.6 mmHg
96 mmHg
PO2 .
HCO3 .31 mmol/L
3Eecf .7 mmol/L Atyp Imm
sOE* .98
*calculated

RBC
Morph

At Patient Temp

Spun
42-52%(M)
DH .7.454
Hematocrit 37-47%(F)

7CO2 .44.6 mmHg
Set Rate
103 mmHg
Other Patient Temp: 100.5F
FIO2 .: 35
oagwat 8 :“ample Type_: ART
IYA

,
W044 205EP03.05:11
TEST RESULT REE RANGE
.pert,
11111
PT 9.8-13.6 secs
APTT 21-34 SESS
39,-4111111i
D dimer 20 ug/ml e(....101430461:1 CLEW 1:192
FDP 10 ug /m1
REMARKS:
REPORTED BY: DATE: LAB ID NO.:

1RATORY RESULT FORM
,bject to the Privacy Act of 1974)
102_,Aro.wow**
TEST RESULT REE RANGE
RPR Negative
Mono Negative
401We5M,
Source
Gram
Stain
Occ Bid Negative
H. pylori Negative
Micro
Parasites
Malaria
O&P
Other
molviwat

Macroscopic
WpOr':
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED

ABO/Rh
TE CROSSMATCH
I7.s C
Ward/Section: REQUESTING PHYSI CAN:
LAST, FIRST,MI.
1 ,,*..4,.m ,f .44C' '..'"3
. Alitaer7AP , ;-TEST RESULT REF. RANGE
138-146 mmoUdL
Na
3.5-4.9 mmoUL

K
98-109 mmoUL pH 7.31-7.45 35-45 mmHg (art)
PCO2
41-51 mmHg (ven) 80-105 mmHg (art)
P02
N/A (ven) 23-27 nunoUL (art)
TCO2
24-29 mmol/L (ven) 22-26 mmot/L (art)
HCO3
23-28 mmol/L art SO2 95-98% (-2) - (+3)
BEecf
mmol/L
AnGap 10-20 nunoUL
Ca 1.12-1.32 nunoUL
BUN 8-26mg/di
70-105 mg/d1

GLU
Creat 0.7-1.5 Ing/d1
Hct

38-51% PCV Hgb 12-17 g/d1 teritiV ,..,,l' i AVM
4,..;* tway./ s S,5t, . ,w? 5,,,ovh.,
TEST RESULT REF. RANGE
Tropoin-1
Drug of
Abuse

•
REMARKS:
REPORTED BY:
DATE TIME
I

diilti) milli.,,,, ;.y
Il .iamitrAg*: ' '',
TEST RESULT REF:
RANGE
ALB 3.5-5.5 e/d1
ALF

CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974) SSN/PEEUDO SSN:
00 10.04,06)1.0i*., .7,
,,. .,:,.-.x:,....:.:::,, ,, , ,, .-.-,,,,
TEST RESULT
''' U
N
AL1 PICCOLO = -7- - - - -.++ 20/09/03 05:55
E
AM.REFERENCE RANGE:.
MALE .
BU
, ./
RESULT
MG/DL
TP
tCO2724718-337MMOtIL
GL Y
L
CR T

,, iT RESULT
K4.
CI
tO
DATE: LAB ID NO MEDCOM 18168
-
REF RANGE
73-118 mg/d1 7-22 ing/t11 8.0-10.3 mg/d1 0.6-1.2 mg/d1
128-145 rnmoUd1
3.3-4.7 inmo1/1
98-108 nuno1/1

18-33 numoUl
,,itAd J
,
ib
REF: RANGE
3.3-5.5 g/d1
26-84 u/1
10-47 u/1

14-97 u/1
11-38 u/1
0.2-1.6 mg/dl
5-65 u/1

6.4-8.1 g/d1
io.L
:: ,.* -'.1,-.. -''''' REF. RANGE
128-145 mmol/I
3.3-4.7 mmoI/1
98-108 nuno1/1
18-33 mmo1/1
.
Ward/Section: 'ES
'MISTRY RESULT FORM
6( -2
Abject to the Privacy Act of 1974) F DATE TIME SSN/PEEUDO SSN:
Cf
iccolo) Chemist
1,cc,g10)-
TEST RESULT REE RANGE TEST RESULT .REE TEST RESULT REE RANGE RANGE
Na 138-146 nunoUdL 73-118 mg/dl
GLU
K 3.5-4.9 nunol/L

7-22 mg/di
BUN
.PICCOLO
98-109 mmol/L 8.0-10.3 mg/dl
21/09/03 04:30 CA ++
pH 7.31-7.45

REFERENCE RANGE: MALE CRE 0.6-1.2 mg/d1 PCO2 35-45 nualg (art) PATIENT #: b0_1(
128-145 minol/d1
NA
41-51 mmHg (yen:
METLYTE 8

P02 80-105 mmHg (art)
N/A (yen) DISC LOT #: 3141AA4 K 3.3-4.7 mmolll TCO2 23-27 mmoUL (art) OPER #11111
DR #: 000 CL-98-108 nunoUI24-29 mmoUL (ven
SERIAL #:

HCO3 22-26 mmoUL (art) 18-33 mmoUl
tCO2
23-28 mmol/L (art
SO2 95-98% GLU 100 73-118 MG/DL

1101McgOK
BEecf (-2) - (+3) BUN 14 7-22 MG/DL
TEST RESULT REF RANGE
mmol/L
CRE 0ii5* 0.6-1.2 MG/DL

AnGap 10-20 mmol/L ALB 3.3-5.5 g/d1
CK 155 39-380 U/t.

Ca 1.12-1.32 mmol/L ALP
NA+ 4-#433128-145 MMOVL 26-84 u/1
BUN 8-26 Ing/d1 K+ 4.7 3.3-4.7 MMOVL ALT 10-47 u/I
CL- 102 98-108 MMOL

GLU 70-105 mg/d1 AST 14-97 u/I
tCO2 25 18-33 MMOVL

Creat 0.7-1.5 mg/di
AMY 11-38 u/1
INST OC: OK

CHEM DC: OK

Het 38-51% PCV
HEM 0 , LIP 1+, ICT 0 TBIL 0.2-1.6 mg/411
Hgb 12-17 g/d1 GGT 5-65 u/I

.6:440 0441 TP 6.4-8.1 g/dI
TEST RESULT REE RANGE ik4.10 604WIR44i4,'
100tikr v-ptoz Tropoin1 TEST RESULT REF RANGE
-
Drug of
NA 4" 128-145 mmol/l
Abuse
3.3-4.7 mmoUl
CL-98-108 mmoUl
tCO2
18-33 mmoUl
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
Ward/Section: REQUESTING PHYSICAN: LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
LAST, FIRST, DATE TIME SSN/PEEUDO SSN:
iat
TEST 1RESbLF-fliEE TEST RESULT REF RANGE TEST RESULT REF RANGE
Color N/A RPR Negative App N/A Mono Negative Glu Negative
4.1K ttiold
Bili Negative Source
Ket Negative Gram
Stain SG N/A • Occ Bid Negative Bld Negative H. pylori Negative
N/A
Pit riL H pH Micro
Parasites

2 *L
Prot Negative Malaria
Urob 0.2-1.0 O&P
Nit Negative Other
Atyp Negative t
I Imm.I Leuk croscp
HCG Negative

RBC
Morph

Spun
42-52%(M)
Hematocrit
37-47%(F) Cell
Set Rate MUST SUBMIT SF 518 WITH
Count
EVERY UNIT REQUESTED Other Dircctigen Negative ABO/Rh
"•,f,*
r sinIA w
. 4
TEST RESULT REF RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APTT 21 734 SESS
D dimer 20 ug/ml
FDP 10 ug /m1
REMARKS:
REPORTED BY: DATE:
—FAB ID NO.:
WardlScction:
/CZA 3
LAST, FIR
TEST RESULT REF: RAP
011111
22-09-03 vs.0047 Patient
Limits IARC 11.8 H 1109/aL 4.5 10.5 RDC 3.24 L x1046/11 4.00 6.00HO 9.3 L g/dL 11.0 18.0 Hct 29.0 L Z 35.0 60.0 ILV 89.4 IL.80.0 99.9 ICS 28.8 pg 27.0 31.0 MC 2.2 L g/d1 33.0 37.0 Plt 1016. +H z101/d. 150. 450. LYZ 20.2 *L Z 20.5 51.1 1T8 2.4 * x101/IL 1.2 3.4
RBC
Morph
Spun
42-52%(liHematocrit
37-47%(
Set Rate
Other
PT 9.8-13.6 secs
APTT 21-34 SSSS
D dimer 20 ug,/m1
FDP 10 ug /rut
REMARKS:
REPORTED BY: -1UESTI 1RATORY RESULT FORM
abject to the Privacy Act of 1974)
6 W -2_ 7L
DATE TIME SSN/PEEUDO SSN:
arl‘50
Zr.,5

g'eg/4g''

O Wt.
GE TEST RESULT REF RANGE
------- PICCOLO 7:

RPR Negative
22/09/03 04:54

Mono Negative
REFERENCE RANGE:-MALE

4:
PATIENI #:•11141111, )9(6)_ I eithiolo
, ,
METLYTE 8 Source
DISC LOT #: 31-11AA4

Gram
OPER AIM DR #: 000

Stain
SERIAL #: IIIIIIIIIII,

Occ Bld • Negative
H. pylori Negative
GLU 95 73-118 MG/DL
BUN 14 7-22 MG/DL Micro

Parasites
CRE 0.2* 0.6-1.2 MG/DL
CK 64 Malaria

U/L
NA + tell-A( 13-) 28-145 N1MOU_
K+ 4.5 3.3-4.7 NT Oi/L O&P
CL -99 98-108.11M0f/L. Other
tCO2 25 1 8 33 MMOVL

-
'Or KO 10
INST QC: OK CHEM DC: OK
HEM 0 , LIP 0 , ICT 0

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED
ABO/Rh
? In
TYPE CROSSMATCH
DATE:
LAB ID NO.:
gue
le:

7.23

____40.9
70 mmHp
f%4 mmol/L
11 mmol/L

%
'_J.culated

: 31
. Type_: RRT

. P03 04:40

-.cian: .
111111
„.1mse4eR

R93

=.t Mame:

7CO2 28 mmol/L

Rt 37C
7H 7.413
PCO2 42.3 mmH:-5

57 mmtic,
-iCOn 27 mvp7.:1.
3Eecf 2 rio10_ ,. .
c02* 90 %

*calculated

Patient Temp
?il 7.410
,,G02 42.6 mmHg
DO2 58 mmHg

ritient Temp: 35.iF
':02 : 50
aample Type_: APT

025EPO3

-per:

physician:

1.er# 111111

.?r: JAMSO46A
CLEW A93

7002 28 mmol/L

Ht. 37C
-H 7.399
:1-02 43.0 mmhz

62 65 mmHg
0.-03 27 mmol/L
2 mmol/L
=02* 92 %
*calculated

.

:=;t Patient Temp
pH 7.390
P, 44.2 mmHg
PO:r! 68 mmHg

Patient Temp: 99.7F
=r1-12

: 50
Sample Type_:

025EPO3 06:5:

Jper:11111

ohysician:

5er#

.er: JAM50 b CLEW A93
AC INETOBAGTER BAUMANN
IU HAEMOLTICUS
0-
0
as
0
Cl)
CD
3
CD

eport
Name:7 ( co)7 Patient ID:7."7 Ward/Rm: I. pecimen: Source: Ward of Iso: Blood aboratory Status:7Final Collected: Attd. Phys:
Staphylococcus epidermidis Status: Final

S. epidermidis
Drug7 MIC
Amox/K Clay (c)74/2 Amp/Sulbactam (c)7=8/4
Ampicillin7 8 Azithromycin74 Cefazolin7 16 Cefepime7 16 Cefotaxime (c)732 Ceftriaxone (c)732 Cephalothin7=8 Chloramphenicol7=8
Ciprofloxacin7Clindamycin7Erythromycin7Gatifloxacin7Gentamicin7Imipenem (c)7Levofloxacin7Linezolid7 Moxifloxacin7Nitrofurantoin7Norfloxacin7Ofloxacin7 Oxacillin7 Penicillin7 Rifampin7
Synercid7 Tetracycline7Trimeth/Sulfa7Vancomycin72
2
4
4
=4
8
4
=2
4
=32
8
4 2 8 =1 =1 =4 2/38 =2 Interps Drug
MIC Interps
R R BLAC R R R R R R S R R R R S R R
S I
R R BLAC S S S R S
S7= Susceptible7
N/R7= Not Reported
Blank = Data not available, or drug not advisable or tested
= Intermediate7
= Not Tested
ESBL = Extended spectrum beta-lactamase
R7= Resistance7
TFG = Thymidine-dependent strain
Bloc = Beta-lactamase positive
MIC = mcg/m1(mg/L)
Ft'7= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB7
= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases: potentially they may become resistant to all beta-lactam drugs. Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)

Use maemum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.
(b)

Breakpoints based on parenteral dose. For cefuroxime axetil (P0) use (8=S. 8-16=1, 16=R). Footnote (c) applies to this drug.
(c)

For streptococci refer to penicillin interpretations. For amoicillin/K clavulanate or empicillin/sulbactam with enterococci, refer to the penicillin interpretati
(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Spartioxacin (for Gram Negative isolates) and moitioxacin are based on FDA appr
For S. pneumoniae. cefo - e and ceftriaxone breakpoints are based on isolates from patie 7. lbs. For non-meningitis infections, use 2
Name: 1....(c) ....4 Specimen: ..tz 4":. i"fii,
glib ...---. Li7
Patient ID:
Source:7Bloo Ward/Rm: /7 • • 7• -MEDCOM - 18174
DOD-031748

eport
aboratory
Name:
Specimen:,7
Status:7Final
Patient ID:
Source:7Blood7
Ward/Rm: Collected:
Ward of Iso:7
Phys:
17
Staphylococcus epidermidis
Status: Final
1 S. epidermidis
Drug7
MIC Interps
Drug
MIC
Amox/K Clay (c)74/2 R Interns Amp/Sulbactam (c)7
=8/4 R
Ampicillin7

8
BLAC
Azithromycin7

4
R
Cefazolin7

16
R
Cefepime7

16 R
Cefotaxime (c)7

32 R
Ceftriaxone (c)732

R
Cephalothin7

=8 R
Chloramphenicol7

=8 S
Ciprofloxacin7

2
R
Clindamycin7

2 R
Erythromycin7

4 R
Gatifloxacin7

4 R
Gentamicin7

=4 S
Imipenem (c)7

8
R
Levofloxacin7

4
R
Linezolid7

=2 S
Moxifloxacin7

4
I
Nitrofurantoin7

=32
Norfloxacin7

8
Ofloxacin7

4
R
Oxacillin7

2 R
Penicillin7

8
BLAC
Rifampin7

=1 S
Synercid7

=1 S
Tetracycline7

=4 S
Trimeth/Sulfa7

2/38 R
Vancomycin7

=2 S
S7= Susceptible
NIR = Not Reported
I7= Intermediate
—7 Blank = Data not available, or drug not advisable or tested
= Not Tested
R7= Resistance ESBL = Extended spectrum beta-lactamase

TFG = Thymidine-dependent strain
MIC = mcg/ml (mg/L) Btac = Beta-lactamase positive
R"7
= Resistant due to extended spectrum beta•lactamases (ESBL)
EBL? 7 Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB7
7 Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs.
Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.

For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)

Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenia or serious infections.
(b)
Brealmoints based on parenteral dose. For cefuroxime axetil (PO) use (8=8, 8-16=1, 16--Q).

(c)
FOr Footnote (c) applies to this drug. streptococci refer to penicillin interpretations. For anithicillin/K clavulanate or ampicillin/sulbectam with enterococci, refer to the penicillin interpretation.

(d)

FOF non beta-lactamase producing enterococci, refer to the peniciltin interpretation. Footnote (a) also applies to this drug.
Inter;: 0,t) breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and mot floxacin are based on FDA approved bre For r.r. r:rirromortiae, cefotaxme and ceftriaxone breakpoints are based on isolates from patio 7meningitis. For non-meningitis infections, use 2=S. 2
Name.
Specimen:
Patient ID: 1111P7(0 -117
Source:7B oo
Ward!Rni: /7
w. MEDCOM - 18175
MO A mnry) 44. 01. nA A R A
DOD-031749

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Mic.Report.I dyd,_
.Laboratory7‘19
Name:.C\.

Specimen:.
Status:.Final
Patient ID:.z 19( 6) -7Source:rine;.
Collected:
Ward/Rm:7
Ward of Iso:7
Attd. Phys:
Acinetobacter baumannii/haemolyticus Status: Final
17Ac baumann/haem
Druq. MIC lnterps Druq

MIC Interns
Amox/K Clay (c).16/8
Amp/Sulbactam (c).16/8
Ampicillin. 16
Aztreonam. 16
Cefazolin.

16
Cefepime. 16
Cefotaxime (c).32
Cefotetan. 32
Cefoxitin. 16
Ceftazidime (a).16
Ceftriaxone (c).32
Cefuroxime (b).16
Cephalothin. 16
Chloramphenicol.16
Ciprofloxacin.2
ESBL-a Scrn.4
ESBL-b Scrn.1
Gatifloxacin. 4
Gentamicin. 8
Imipenem (c).=4
Levofloxacin.4
Meropenem (c).=4
Moxifloxacin. 4
Nitrofurantoin.64
Norfloxacin. 8
Piperacillin (a).64
Tetracycline. 8
Ticar/K Clay (a).64
Tobramycin. 8
Trimeth/Sulfa.2/38

S7= Susceptible7
N/R7= Not Reported7
I7= Intermediate7

Blank = Data not available, or drug not advisable or tested
--7= Not Tested7
R7= Resistance7

ESBL = Extended spectrum beta-lactamaseTFG = Thymidine-dependent strain7
Blac = Beta-lactamase positive
MIC = mcg/ml (mg/L)
= Resistant due to extended spectrum beta-lactamases (ESBL)
EEL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB7
= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases; potentially they may become resistant to all beta-lactam drugs. Monitoring of patients during/after therapy is recommended. Avoid other/combined beta-lactam drugs.
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a) Use maximum doses of drug with an aminoglycoside for R aeruginosa in patients with granulocytopenia or serious infections.
(b) Breakpoints based on parenteral dose. For cefuroxime axetil (PO) use (8=S, 8-16=1, "16=R). Footnote (c) applies to this drug.
(c) For streptococci refer to penicillin interpretations. For amoxicillin/K clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.
(d) For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002. Sparfloxacin (for Gram Negative isolates) and moxifloxacin are based on FDA approved breakpoints.For S. pneumoniae, cefotaxime and ceftriaxone breakpoints are based on isolates from pall .
with meningitis. For non-meningitis infections, use =S, 2=1 2=R.
Name:
Specimen:.
Status:.Final
Patient ID:.)0 6)—( .
Source:.rl7
Collected:
Ward/Rm:7
Ward of Iso:.7
Req. Phys:
.
.
Printed 9/25/2003 9:58:49 AM
Page 1 of 1
Tech:
MEDCOM - 18176
DOD-031750

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Name:7) 0-117pecimen:7 Patient ID:7 Source:7Sputum7 Status:7Final Collected:
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Staphylococcus epidermidis Status: Final

S. epidermidis
Druq7 MIC Amox/K Clay (c)74/2 Amp/Sulbactam (c)7=8/4 Ampicillin78 Azithromycin74 Cefazolin716 Cefepime716 Cefotaxime (c)732 Ceftriaxone (c)732 Cephalothin716 Chloramphenicol716
Ciprofloxacin7Clindamycin7Erythromycin7Gatifloxacin7Gentamicin7Imipenem (c)
Levofloxacin7Linezolid7
Moxifloxacin7
Nitrofurantoin7
Norfloxacin7Ofloxacin7Oxacillin7 Penicillin7Rifampin7Synercid7 Tetracycline7Trimeth/Sulfa7Vancomycin7
7
S7= Susceptible I7= Intermediate7
7
R7= Resistance MIC = mcg/rnt (mg/L)
2 2 =0.5 4 8
4
4
4 64 8 4 2 8
=1 2 8 2/38 16
Interps Druq R R SLAC R R R R R R R R R S R R R R
BLAC
R.
7
N/R7= Not Reported
7
—7= Not Tested
7
TFG = Thymidine-dependent strain
MIC Interps
Blank = Data not available, or drug not advisable or tested ESBL = Extended spectrum beta-lactamase Blac = Beta-lactamase positive
R•7= Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.

IB7= Inducible Beta-lactamase. Appears in place of Sensitive with species known to possess inducible beta-lactamases: potentially they may become resistant to all beta-lactam drugs. Monitoring of patients cluing/after therapy is recommended. Avoid other/combined beta-lactam drugs
For blood and CSF Isolates, a beta-lactamase test is recommended for Enterococcus species.
(a)
Use maximum doses of drug with an aminoglycoside for P. aeruginosa in patients with granulocytopenie or serious infections.

(b)
Breakpoints based on parenteral dose. For cefuroxime axetil (P0) use (8=S, 8-16=1, 16=R). Footnote (c) applies to this drug.

(c)
For streptococci refer to penicillin interpretations. For amoxicillinM clavulanate or ampicillin/sulbactam with enterococci, refer to the penicillin interpretation.

(d)
For non beta-lactamase producing enterococci, refer to the penicillin interpretation. Footnote (a) also applies to this drug.

Interpretive breakpoints are based on NCCLS M100-512 Jan 2002. Sparfloxacin (for Gram Negative isolates) and mo itioxacin are based on FDA approved breakpoints For S. pneumoniae7me and ceftriaxone breakpoints are based on isolates from patients For non-meningitis infections, use 2=S, 2=1, 2.R.
Name: Specimen:7 Status:7Final Patient ID: -1 Source:7Sputum7 Collected:
)7
Ward/Rm: Ift/nrr4 nf len•7 (7-2-
Req. Phys:7
MEDCOM - 18179
DOD-031753

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