Medical Report: 35-Year-Old Iraqi Male re: Gunshot Wound to the Head

17179 - WO3CI3l41
LABORATORY RESULT FORM Sub'ect to the Privac Act of 1974)
.B106411 BaiikUOit .croisigitch-
ST.SUBMIT SF_
E
.518. WITH EVERY UNIT OF. BLOOD
RE VESTED
DOD-028830

Ward/Sect-o :
LABORATORY RESULT FORM
(Sub
-ect to the Privac Act of 1974)
14-18 Wcil (M)

12-16 -dl 42-52% (M) 37-47% (F)
80.94 fl (M) 81-99 fl (F)
.Blotid: Ralik Unit Croisinatch"
(MOST.Se13111111: SF :
518 Wfai EVERY UNIT OF BLOOD .
• RE rt (JESTED. ):
MEDCOM - 15442
DOD-028831
Cit,...ASTRY RESULT FORM
Sub'ect to th e Privacy Act of 1974)
80-105 mmHg (art)
N/A (yen) 23-27 mmol/L (art) 24-29 annol/L (yen)
MEDCOM - 15443 •
DOD-028832
128-145 rnmo1/1
3.3-4.7 mmol/1 98-108 mmol/1 18-33 n1/1

MEDCOM - 15444
DOD-028833
—

PICCOL
02/08/03
I?PkNGE

#:
MEFLYIL 8
DISC LOI "31t,r)AA1
OPER #: [)R #: 00u

SLRIAL #:

131_c.) 111 73-118 M(3/ Di_
BUN • • • 7 22 MG/I/
CRE 3.1* 0.6-1.2 MG/
CK 637* 39-380 U/L
NA 131 128 115 MOLL
3.6 3.3-4.7 MM01,1_
CL 121x 98 108 r
t CO? 21 18-33 MMObt

N`.-; i ()X: : OK Cl-UN : OK HEM 0 , 14, TL:1 ij
98-108 mmo1/1
MEDCOM — 15445
DOD-028834

7.3I-7.45
35-45 mmHg (art) 41-51 =Art yen)
80-1O5 mmHg (art) N/A (Yen) 23-27 mmol/J.. (art)
24-29 mmoi/L (yen) 22-26 romol/L 23-28 rnmoL/L (yen) 95-98%

CHEMISTRY RESULT FORM
Suliect to,the Privac Act of 1974)
PICCOLO
02/08/03

REFERENCE RANGE:

PATIENT #:

JA

METLYTE 8

\p(C0-

DISC LOT Al:.

3152AA4

OPER #:

#: 000 n:
SERIAL

GLU

99 73-113 MG/DL

Pi00*

BUN *.# 7-22

MG/DL

TEST

CRE

3.1* 0.6-1.2 MG/DL
CK 664*. 39-380

-U/L 'LB
64...*@immuswoolo5iimmoik,

WV_ IT
MM(JVL
tCO2 26 18-33

MOM_ .MY

MEDCOM - 15446
DOD-028835
CHEMISTRY RESULT FORM
SuIf ect to the Privac Act of 1974)
.

RESULT
Na
ALB
K
CI
REF. RANGE

AnGap
Ca ALB

1.12-1.32 nunol/L ALP
BUN
8-26 mg/d1

ALT 111111111M11111
10-47 till 70-105 mg/d1
RESULT
14-97 till 0.7-L5 mg/di 73-118 mg/d1
AST
11-38 till

38-51% PCV 7-22 mg/dl
TBIL
1-1gb GGT
5-65 till

CK
TP
6.4-8.1 g/d1

TEST REF. RANGE
NA+ Troponin-I
TEST REF. RANGE
_CU
98-108 mino1/1
NA+
33-4.7 mmol/1

CL"
98-108 =All

tCO2
18-33 mmo1/1

MEDCOM - 15447

DOD-028836

-
-
t....rar_dv...

___1111111111--
li_LNUL 1 1,
LAST, 1 "• • .. - - - ---------- - - OR NI
I
____L_Lsabiect to tjle Privacy Act of / 974'
1 TIME
..'- DATE f 1§1¦1/PSFAJDC,
1 .-.. ',CH-:.........TA 1 D400.

:!•7.(11-it \ (
Cheiwst- 12
. 7_
111' &91:11., 7 ' e
I -•li TEST RE,Crli.T
TEST RKSt. 11.7' REF. RA
:
138-146 o-anc
GLU
CotrTA. -T
PICCOLO ------- 73-L

BUN
98-W9 rnpjoj 02/0 -0,3 04:11 "7-22 Ing/d1
MALE .T;;;;;JI---35A ---;t-PATIENT #: pill : 0.6-1.2 67;4-----
REFERENCE-,UANGE: aTo.­
-t;IIF.Te,
3 _`._
____41.51 ratraig (t 80-105 imnlig ( GENERAL CHE 12 -118-1-1511-66611
(e S_ ___.
DISC LOT #: 3142AA4

TC'Oi"_
23 .7 itult01/1- 3.3.4 .7 rniou
—__ gt ._
2-29 Hanoi&.1 ( OPER #: DR #: 000
1 -1CO3 -22-26 inm0VL ( -98-108

SERIAL #:

1CO2;O2 95-98%
Riof ALB off 3.3-5.5 G/DL (Piccolo)11,1ver Panel
(-2 ) (+3)
111011 ¦ 1/1. ALP 48 26-84 U/L
A TEST RESIII.T REF
0-20 tarnold
nGap ALT 14 10-47 U/L
Ca ALB
1.12-1.32 nin-i AMY 579* 14-97 U/L 3.3-5.5 eit-11 - --- • -•-•
ALP
IN 8-26 ma/d) AST 89* 11-38 U/L
TBIL 2.1* 0.2-1.6 MG/DL ALT

10.47 WI
(NU
1 037ritc lt
70-BUN 35* 7-22 MG/DL
AMY
14..47 WI
CA+4 9.6 8.0-10.3 MG/DL -_ti
0.7-1.5 mg/dI
CHOL 79* 100-200 MG/DL

Hct AST
38-I% PCV WI
_ CRE 2.7* 0.6-1.2 MG/DL

1 tgb_ TBIL
' -0 2-_-5.6inv,11
GLU 70* 73-118 MG/DL F
G GT
44.0. Clke1140073: TP •f4 6.4-8.1 G/DL 5 -15 WI
•
TP
t
TEST .RESULT REF RANG
INST OC: OK CHEM QC: OK
HEM 1+, LIP 0 , ICT 0 • --• • ; _ , ,

TEST kESL11.,7' REP. RANG1:
of •
128-14.i
" • ._..._•
9:0. 8. 701.1
tCO3_
18-33
MEDCOM - 15448
DOD-028837
Ward/Section:_
,_REQUES G_
N:
• 11.-N,t4 LABORATORY RESULT FORM (Suliect to the Privac Act of 1974TIME_SSN/PS_• SSN:046°
RESULT TEST RESULT
Lymph % Segs Bands 42-52% (M) 37-47% (F) 80-94 11 (N) 81-99 fl (F) 130 -500 x 10 verified 20.5-51.1% Mono Eos Negative N/A Negative H. pylori Micro Parasites Gram Stain Occ Bld Negative
Lymph
RBC Morph Negative
Spun Hematocrit Sed Rate Celi Count Directigen
• Stood. Baiik thiit Croisinitch-ormsT suBmiT SF 518.WITH EVERY MTOF BLOODRE NESTED

MEDCOM - 15449

DOD-028838

MEDICAL RECORD - ANESTHESIA
For usI
s form, see AR 40-66; the proponent agency is the
..
............

0 _i
(/) mminumm
Z TOTALS
'nompoommtaxii rTh1111

QUO infttiv
CVO nvi
6-Z
rL TAL ORIN:
CC (/) Z
F-

Eutawismal
(/5 — (f)
D Z z AT C
% del
-
z Lt-II AGENT % e.t.
t
Z AIR L/Min

CRYSTALM:v CG OU N20 L/Min 02
COLLOIDa2 SINGLE DOSE DRUGS-MARK ON GRID %.),¦241-WITH NUMB.
& ENTER IN REMARKS
BLOOD-.
C
LINE site
.
Warmed

.
Warmed

CA-IIMMIIIMEN"P"
11=1ztic° !el
. Warmed 3001.
Code drugs with numbers,
.
Warm d ev th lettters EST BLOOD
LOSS ..11) 1)-(
4g 16 36-
arammomm
.WFAINIMMIIEZZII

menIEMIIIMPT
1
f°' c-30 4 TiAtZtak.70
,:SYMBOtS;:::

L FitallM7111121111FMNIIIMIKIMI
220

IIIMIIMIEFIMITMEMS111212111alkiMallISMINM
4113:" BP by cuff 116/4211M11 IVADFUIPIWM WM ILTECI
.
200 FECIAIIFEMILSIIREJLIMINIAIRIMWMAIMINI 4(1 I.Aw't.e-ib
V 111MAILT41111111111111111111 s
*I0gOrni:
A_ 180
Heart rate 160
•
BP-Resp rate 140

iFT
16-. 120 Lila
ALTAFINIEN EIRE liailiZZOLUMIZZ 27-Z211111PNWINIFIN
HR-BR MINIIIIIIIICailMEIMIINIE1111.11111 M. 216111
11111adirallaltILILZ Nati(transduced) 100 InirmiSZNairiZA NEIN
11111111111111.1
-1-
80 MEIMMININE
11111111111111111111
wiffiratta)
• OK?-
TOURNIQUET 60 =Wm
• PArg0. r-rf INNAIllalillbUtdilHERVICTZE11111111EXEMMISEIMEN -
40 MNIVENWirliglillilli1111111.1111111
, OK for PROCEDU
ti

ANES- x-x
20
TIME-PRO C- 0_0
VT - ml

MAMA 610 7112116763
f - breaths/min
cb Keninsumura
o Hottl
Peak inf pres / PEEP
/ 3 MUM
MODE -.on) Alssistl, Clon) MIMI 23 P11411111MIMIIIIMMIIIPAIMINNIF4111
WAWA c_
BP/Auto Cuff ET CO2 (torr)
BP/oth

F102 (Frac or %)
MIIIIMIEVAIR11111EMEDIENIIMIIIMME1111111M1111MI
ART line PACU .(Specify) Steth- PC/ES
Sp02 (%)
Th-tav 1/7.0M21 '00.vreawanforda too
ECG OTHER MD
mira sr.
Gas analyzer ILUNIMIIVAIIKIIIRENIMI1 Sr •
CONDITION:
IMILVNIIMIll t.
N-M Block (T/4)
10"1611VA 0 0 IMIUMPAIIMIRLVIVIOLT11111/111
RESP-
Sp02-
7? 10.111=11M117/411MICLVEYLI BP-!0 HR-
1
\ 9 EST Ea ...:M.19.P.f.P4
ff
,VC:f to Start Room End Cony warmer
1 Mark with letters & symbols,
EVENTS__,._ Z 64
explain under REMARKS
Position Ready Begin End
PROCEDURES and CPT Codes:
0--{/UO _6(67(10 0#10
ANESTHETIC TECHNIQUES:
Describe block technique under Remarks
15A ,,Ay-v 6141)9-
PATI4
IDEfATIFICATION:
Typed or written entries: Name, Grade/Rate,
AI,Ay MAN
pENTNTi
Medical facility
Intubatioc route, blade, technigue, coere4
(.ic Ll(±)66S0drcoz.,
SURGEONS: PROCEDURE
-
4111111.
LOCATION: O A.,/
DATE:
36.Lx53
DA FORM 7389, FEB 1998 PAGE.OF
ME 450
EDICAL RECORD
USAPA V1.00
DOD-028839

VIEDICAL RECORD - ANESTHESIA
agency is the TOTALS
oponent
form. see AB 4O-66 the pr
for use_ jeostaiiii:.
¦0011111oas0111111110)•01.
111101 ig
imigamouoiesw
uniarilow¦­
1111111111111111
1¦11111111111
1111111¦•¦•40M11¦
ti
r. -.41¦161131ratiom
(45 Igg fterir arag Alail,¦141
cc
....10
1114,91000111111111101115011MWSS11001111.
Z60 1-2
0
IltallOWIMOR
ummaW10111111110111111110
AGENT
sZ iamlek:7"
0
Lu4. Ial Ma, ml _ P I:I
e
ll minnow • sr,
,)(,) I I MITI ri 100111 Coe drugs '7
events with ettters
ar
111111"'"°11.1.41.1 omin
tiNGLE °°E DRUGs44Acat ON GRID
S
WITH NUMERs EuTER t/.)c)41,----
.-
REMARKS
,0001.
*11644.4 warmed ffiver40,011iMIA'41k 404..Di)
114yll;• "t
.41_T
:Niato ov,,,,med.11111111W .41 1 WI K41°
IVAI
11 /
1111WVI
IllbV4414 I Warmed
0 warmed SajaWalliarglia0111011111111000
,100000.011111010
;14Y
IfYs; amisiviiiiom011111111111-0-
ose DAcla
HiSOrp
011101
otr
:111111111
:1111711
10:11011
liallia
W001.11011001101A14
111.11111011rA
774" 10
yv 11111111ossoomme
•11111111
,1111111
6111/11
111101111111101""Soon111111r
1:1111111:01r1"

;111.10arglri:11[
efix.c
,40‘"
PACU ICU OTHER
Sp02
HR-
02 ltorrl
p0
121,R°D1
. 111111
11.011
Bec
%01110"...-111000111W1111001111011Tifrallalligirli....
—4151
'.-'"•¦
"zing wanner ENT S
l
Position
:k"--ithierters & symbo
urier REMARKS
EDuRES and CPT Codes:
111 I •
111
CRY STALLOID
•
DC' 4.•
e fun:ereR i/rnar:j
ibn:4,:ock techdnei:tue
trt
I•1100;ES. :irvitDescomo
P OCEDURF
-1. ¦ LOCATIO
1 DATE:
141.
ill.
_1111111114611
EDICAL RECORD
CO
fl\ S/
EDCOM - 15451
rnpM 131
DOD-028840

MEDCOM - 15452
DOD-028841
flEDICAL RECORD - ANESTHESIA
For use
form, see AR 40-66; the proponent agency is the
DRU

TOTALS
0 (
in
Z CI .r4n 3o
till R mem (wt MEM
z
URI21--a_ ,
ra
w co
DZZ
0 0
8!QtA: WILIIINEKEALIF4.
Z" II A0.00-% e.t.
F.:
ow AIR L/Min CRYSTALLOID-
N20.L/Min COLLOID-
U
02.L/Min 2- 2
SINGLE DOSE DRUGS-MARK ON GRID
WITH NUMBERS & ENTER IN REMARKS

.44. BLO
. Warmed
%Mum"'
. Warmed mumni r 32, 0 coo
. Warmed Code drugs with numbers, events with lettrers
. Warmed
EST BLOOD LOSS
LOSSESl 3000
UR NE
TIME elxv VP0
Et.
220
BP by cuff =MEM
200 IMMO
111111111111111111111111111111111111111111111111111111111.111111MIENIIIIII
V
A
180
Heart rate
160
4—
Resp•ate 140
I
t120
BR
(transduced) 100

80
TOURNIQUET 6 1P2511111111111111111111611FAMINESE111111111
T —4/
40
OK for
PROCEDURE?
ANES- x-x
20
TIME-PROC-Cy0
VT ml
06 a, 406
f - breaths/min • 740
Peak inf pres / PEEP

30 34 30 3(0
MODE - S(pon), A(ssist), Clan)
e. C
BP/Auto Cuff T CO2 (torr)
3Z 3 -391 R E coyE R
BP/oth 102 (Frac or %)
PACU ICU
ART line

p02 (%)
Steth- PC/ES

OTHER
Gas analyzer EMP-site
LTIONTIMPIEFRI
-M Block (T/4)
ratramoirmans
0,0.1g0
Warming blkt LU Start Room End
2
Cony warmer
Mark with letters & symbols,
EVENTS___._
Ready Begin
explain under REMARKS End
Position
O
cc
PROCEDURES and CPT Co
s:
ANESTHETIC TECHNIQUES:
Describe block technique under Remark
Ti`:l Iv% US v.....1
PATIENT IDENTIF ATION:
Typ96 or written entries: Name, Grade/Rate,
AIRWAY MANAGE.
T: Intubation route, bled
Medical facility echnique, comme
SURGE
PROCEDURE
( LOCATION:
DATE: 30 .3ui
ANE
C bcc4Z.
-
PAGE 2‘ OF t
DA FORM 7389, FEB 1998
COPY 1 - PATIENT'S MEDICAL RECORD
MEDCOM USAPA V1.00
DOD-028842

kge DAYS MOS YRS
L PROPOSED PROCEDURE: SURGICAL SERVICE ASA Phys .— WT: ct4te, 1
NPO SINCE: ALLE
HABITS:
TOBACCO: . PREOPERATIVE
ETON: DRUGS:. PAST MEDICAL HISTORY/SYSTF_NIS REVIEW Cardiovascular: Hypertension.H
:.'URRENT MEDICATIONS: ) = ordered as premed Angina.N MI. N V CVA.N Y
Other. N Y .
Pulmonary System:
Asthma
Bronchitis/URI
COPD
Other
Renal System: Pain ie liG
DROVEDICATIONS: None Yes (0.Hrs) /CC mg IV IM PO Acute/Ch ni Gastroint Hepatitis Hiatal Hernia HEENT - Teed) T monea Ti6Q/Necii: Oroptisirrirs:
mg IV IM PO mg IV IM PO PUD/GERD Endocrine System: CHEST: Wares
.ABORATORY STUDIES: Diabetes Steriods CARDIAC:
riB/FiCT: . U/A: . DTHER: Thyroid Neurological: Seizures Neur IV Access:
Other Ulnar
Gynecol
Preg BACK:
Other Significant Hx: OTHER:

Familial HX
NPO Since
ANESTHETIC PLAN: { LOCAL. { MAC
{ Regional (Specify): .
intubatid,
INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have
discussed with the patient/legal guardian. .
bcw,c_ been expiaitiei
The patten agrees. Questi
Signed Date:
Time: THEMA EVALUATION AND NOTE (NON ASU) ( ) NO APPARENT ANESTHETIC COMPLICATIONS.SEDATION KEY:
} OTHER
1.
MINIMAL (Araioiysis) Patient responds nonnatly to verdzi Signed: commands
2. MODERATE (conscious seu.r.: Patient responds purposefully
Yeri3ai commands alone or accorroanied by light tactile. stimulation. Airway assistance riecess.afy.
Patient Identification: (Ward) 3. DEEP SEDATION/ANAL:id:
Patient responds purposeitiiiy folic:owing repeatc-d or painiu:
cti) ctiQU
stimuiation_ Airway assistance
MEDCOM - 15454
DOD-028843
518-124
MEDICAL RECORD NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
COMPONENT REQUESTED (Check one) SECTION I — REQUISITION
TYPE OF REQUEST

(Check ONLY if Red Blood Cell
RED BLOOD CELLS Products are requested.) REQU ICIAN (Print)
FRESH FROZEN PLASMA
LJ TYPE AND SCREEN
El PLATELETS (Pool of DIAG

units)
CROSSMATCH
. CRYOPRECIPITATE (Pool of
units)
Sir Ex
/ ,jaga.
Rh IMMUNE GLOBULIN
I have collected a blood

specimen on the below. named patient, verified the
OTHER (Specify) DATE AND HOU REQUIRED name and ID N. of the
patient and verified the specimen tube
correct. —Ta•ck to be
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSIONREACTION (Specify) SIGNATURE OF VERIFIER
ML
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIE RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN? TIM
PIED
SECTION II —
UNIT NO. PRE-TRANSFUSION TESTING
TRANSFUSION NO.
TEST INTERPRETATION
PREVIOUS RECORD CHECK:ANTIBODY SCREEN CROSSMATCH
PATIENT NO.
DONOR RECIPIENT
.
ABO CROSSMATCH NOT REQUIRED FOR THE COMPONENT Q
REMARKS: DATE

a.,44
Rh 11/1.-03
SECTION III —
RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA
TIME/DATE COMPLETED/INTERRUPTED
?(A.V.3
AT (Hour)
BLOOD PRESSUREIDENTIFICATION
I have
examined If reaction is suspected—IMMEDIATELY:
informati• . - • the Blood Component container label and this form and I find all
The reci the container with the intended recipient matches item by item. 1. Discontinue transfusion,

treat shock if present, keep intravenous line open.
on e person named on this Blood Component Transfusion Form and 2. Notify Physician and Transfusion Service.
ion tag.
3. Follow Transfusion Reaction Procedures.
1st 4.
Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF REACTION
URTICARIA
. CHILL . FEVER
PAIN OTHER (Specify)
OTH...,; • IES (Equipment, clots, etc.)
YES (Specify)
ERSON NOTING ABOVE
(.6
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name— Lrate; hospital or medical facility) rade; rank;

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

Mile.Oulnovia.rn
MEDCOM - 15455
Medical Record Copy
DOD-028844

518-124 _ NSN 7540-00­634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

COM ONENT REQUESTED (Check one)_
RED BLOOD CELLS_
FR_H FROZEN PLASMA_
PLATELETS (Pool of _units)_
CRYOPRECIPITATE (Pool of_units)
Rh IMMUNE GLOBULIN
OTHER (Specify) _

VOLUME REQUESTED qf_plicable)_
TYPE OF REQUEST (Check ONLY if Red Blood Cell
Products are requested.)
TYPE AND SCREEN_ CROSSMATCH
DATE_REQUESTEg,_1_03 3.-J_ DATE AN66.1-ITAEQUIRED Up_
KNOWN ANTIBODY FORMATION/TRANSFUSION
REQUES ING PHYSICIA ) _ /
_( DIAGNOSI_OPERATIVE PROCEDURE
h¦ ';_1 4 Oil.14_-I have collected a blood specimen on the below
named patient, verified the name and ID No. of the

patient and verified the specimen tube Zabel to be

correct.
SIGNATURE OF VERIFIER

II)./t L._ ML_
REMARKS. _ IF PATIENT IS FEMALE, IS THERE HISTORY OF: _DATE VERIFIED_f

_
REACTION (Specify)
UNIT NO.
DONOR ABO Rh
(05
RhIG TREATMENT? DATE GIVEN:_ 04./5 til•FA,
HEMOLYTIC DISEASE OF NEWBORN? _ TIM_RED
SECTION II - PRE-TRANSFUSION TESTING
TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH 0 RECORD_ NO RECORD
PATIENT NO. SIGNATURE OF PE

RECIPIENT CROSSMATCH NOT REQUIRED FOR THE COMPONN-REQUESTED DATE ABO REMARKS:
r/I-e 03g1
-5
Rh
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
INSPECTOD AND ISSUED BY (Signature)
)0 (ct-. 1-
A our) IDENTIFICATION ON (Date 17 6

I have examined the Blood Component container label and this form and I find all information identifying the container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form and on the p. ification tag.
1st re)
-
PR TEMP. PULSE
DATE OF TRANS liON
PATIENT IDENTIF1_ION—USE EMBOSSER (For typed br written entries give: Nam _ rate; hospital or medical facility)
POST-TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED/
LC/P.44c— ML rg3Z / (-)/19'0 REAC ION TEMPERATURE_PULSE_moo PRESSURE
. SUSPECTED
NONE / -Ze'V 111/6-7
If reaction is suspected—IMMEDIATELY:
1.
Discontinue transfusion, treat shock if present, keep intravenous line open.

2.
Notify Physician and Transfusion Service.

3.
Follow Transfusion Reaction Procedures.

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

DESCRIPTION OF REACTION URTICARIA_0 CHILL 0 FEVER 0 PAIN
OTHER (Specify)
OT ES (Equipment, clots, etc.) YES (Specify)
SON NOTING ABOVE
lotti,V-
, rank; WAR
BLOOD OR BLOOD COMPONENT TRANSFUSION
ppo
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

Medical Record Copy
MEDCOM - 15456
DOD-028845
518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I – REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Celt REQUESTING Products are requested.)
p
2,
RED BLOOD CELLS
,(FRESH FROZEN PLASMA TYPE AND SCREEN
............,

PLATELETS (Pool of units) CROSSMATCH
CRYOPRECIPITATE (Pool of units)
DATE RII6ED_ I_have collected_a blood specimen on the_below Rh IMMUNE GLOBULIN ...h) )_0) named patient, verified the name and ID No. of the DATE AND HOUlt pVIDD
patient and verified the specimen tube label to be OTHER (Specify)
correct.
VOLUME REQUESIED (If apkic hie) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF VERIFIER REACTION (Specify) I t..""1
ML
REMARKS:_ IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED
RhIG TREATMENT? DATE GIVEN:
OC(L TIME V_RED_

HEMOLYTIC DISEASE OF NEWBORN?
5
SECTION II – PRE-TRANSFUSION TESTING
UNIT N TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
RECORD_10 RECORD PATIENT NO. SIGNATURE OF PERSON PERFORMING)TEST
14C6
DONOR RECIPIENT AlCROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTE DATE ABO ABO RE ARKS:
46 x2' 3 5G,-/ 40 -.ge 0.5-00
Rh Rh
0,96
SECTION III – RECORD OF TRANSFUSION
PRE TRANSFUSION DATA POST-TRANSFUSION DATA
AMOUNT GIVEN
INSPECTED AND ISS
C:R_ML
ka (GLY-k_ REACTIO TEMPERA1U/E PULSE •
AT (Hour) ON (Date) 0_7 NE [1 SUSPECTED 0
IDENTIFICATION If reaction is suspected—IMMEDIA ELY:
I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock it present, keep intravenous line open.

information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag. 4. Do NOT discard unit. Return Blood Bag. Filter Set, and I.V. solutions to the Blood Bank.

1 DESCRIPTION OF REACTION URTICARIA_LI CHILL_LI FEVER_LI PAIN
OTHER (Specify)
_
OTHE FFICULTIES (Equipment, clots, etc.)
TEMP.
3
DATE OF TRANSFUSION_ TIME STARTED
0/ 03_0705—
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, rate; hospita or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION
4A) 'se
\ Medical Record
191 cf,
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
Medical Record Copy
MEDCOM - 15457
DOD-028846
518-124
MEDICAL RECORD
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
COMPONENT REQUESTED
(Check one) SECTION I - REQUISITION
TYPE OF REQUEST
.
RED BLOOD CELLS (Check ONLY if Red Blood Cell
Products are requested.)
.....tA
FRESH FROZEN PLASMA
. TYPE AND SCREEN
. TELETS (Pool of units) . CROSSMATCH
. CRYOPRECIPITATE (Pool of units)
. Rh IMMUNE GLOBULIN
. OTHER (Specify) VOLUME REQUESTED( plicable) DATE ANIelOttfED I have collected a blood specimen on the below named patient, verified the name and ID No. of the patient and verified the specimen tube label to becorrect.
KNOWN ANTIBODY FORMATION/TRANSFUSIONREACTION (Specify) SIGNATURE OF VERIFIER
REMARKS:_as__
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN: DATE VERIFIED
HEMOLYTIC DISEASE OF NEWBORN? VERIFIED
U TRAN SFUSIO NO.N SECTION II -PRE-TRANSFUSION TESTING

TEST INTERPRETATION ANTIBODY SCREEN PREVIOUS RECORD CHECK: PATIENT NO. CROSSMATCH LJ RECORD
0 RECORD
DO R
SIGNATURE OF PERS RECIPIENT
ABO 4/..11 ROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
REMARKS:
Rh
SECTION HI
PRE-T -RECORD OF TRANSFUSION INSPECTED AND
INTERRUPTED AT (Hour)
zi/ D-3
IDENTIFICATION BLOOD PRESSURE
I have examined the Blood Component container label and this form and I find all If reaction is suspected—IMMEDIATELY: (.7
information identifying the container with the intended recipient matches item by item.
The recipient is the same person named on this Blood Component Transfusion Form and 1.. Discontinue transfusion, treat shock if present, keep intravenous line open.

on the patient iden • 2.
Notify Physician and Transfusion Service.
3.

Follow Transfusion Reaction Procedures.
4.
Do NOT discard unit. Return Blood Bag, Alter Set, and I.V. solutions to the Blood Bank.
DESCRIPTION OF REACTION
. URTICARIA
. CHILL
. FEVER . PAIN
. OTHER (Specify)
OTHER_CULTIES
(Equipment, clots, .etc.)
TEMP.
NO
.
YES S. • ,
DATE OF TRANS
PATIENT IDENTIFICATION—USE EMBOSSER (For _rate; hos typed or written entries give: Name—Last,
pital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION
I/DC (4-i/ Medical Record
STANDARD FORM 518 (REV. 9-92) Prescribed by GSA/ICMR. FIRMR (41 CFRI
MEDCOM - 15458
11.4edir'
DOD-028847
518-124
MEDICAL RECORD NSN 7540-00-634-4159
55 W 45089
BLOOD OR BLOOD COMPONENT TRANSFUSION
CO PONENT REQUESTED (Check one) RED BLOOD CELLS SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood CellProducts are requested.) REQUESTING PHY Print)
FR SH FROZEN PLASMA
. TYPE AND SCREEN
. PLATELETS (Pool of units) , 0SSMATCH DIAGNOSIS OR OPERATIVE PRO - • URE
. CRYOPRECIPITATE (Pool of units) DATE REQUESTED 7ct
Rh IMMUNE GLOBULIN
C I have collected a blood specimen on the below
VOLUME . OTHER (Specify) R UESTED (I ap, licable) DATE AND HOUR RE Ul named patient, verified the name and ID No. of thepatient and verified the specimen tube label to becorrect.
• ML KNOWN ANTIBODY FORMATION/TRANSFUSIONREACTION (Specify) SIGNATURE OF VERIFIER

REMARKS:
IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED RhIG TREATMENT? DATE GIVEN:
A HEMOLYTIC DISEASE OF NEWBORN?
FIED
•

UNIT SECTION II - PRE-TRANSFUSION TESTING
TRANSFUSION NO.
TEST INTERPRETATION ' )_ PREVIOUS RECORD CHECK:
1111111

ANTIBODY SCREEN CROSSMATCH
PATIENT NO. . RECORD_
=t-/NO RECORD
SIGNATURE OF PERSON PERFORMING TEST DONOR
NT
C 07-
_0
ABC . CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
ABO _
REMARKS: DATE
0

O
Rh
Rh /.)5
SECTION III - RECORD OF TRANSFUSION
PRE-T INSPECTED AND POST-TRANSFUSION DATA
TIME/DATE
INTERRUPTED
310 30, LA (03
AT (Ho BLOOD PRESSURE
IDENTIFICATION
I 13/4 9
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all
information identifying the container with the intended recipient matches item by item.
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
The recipient is the same person named on this Blood Component Transfusion Form and 2. Notify Physician and Transfusion Service.
on the patient identification tag.
3.
Follow Transfusion Reaction Procedures.

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

DESCRIPTION OF REACTION
( LA\
. URTICARIA . CHILL . FEVER . PAIN
. OTHER (Specify)
PRE-TRA SFU
nUSIO OTHER DIFFICULTIES (Equipment, clots, etc.) NO
TEMP._ '7 5 BP (CI' (/ iZ . YES (Specify)
PULSE_ DATE OF TR
SFUSION TIME STARTED
Li
30 ass lo i ce
ab.
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Las rate; hospital or medical facility) irst WARD
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 15459
Medical Record Copy
DOD-028848
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell
R ' t)Products are requested.)
g RED BLOOD CELLS
o( (.1, -2
FRESH FROZEN PLASMA TYPE AND SCREEN_fr4.
D_ URE
OP° 5
PLATELETS (Pool of units) CROSSMATCH
CRYOPRECIPITATE (Pool of units) DATE REQJIEficp
. I_have_collected_a_blood_specimen_on the_below Rh IMMUNE GLOBULIN 5e) j named patient, verified the name and ID No. of the
DATE AND HOUR REQUIRED patient and verified the specimen tub_label to be OTHER (Specify) correct._
A-54-P
(..(..4._' VOLUME REQUESTED (Ifsepplicable) KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
L V
ML
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
30 (Jill .0 3
TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
ill 6
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO.
TEST INTER PRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
RECORD_ NO RECORD
PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST
Mai

4973-7/e.
DONOR RECIPIENT
1111.11.111Ft0 Ot) Z
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED DATE 3 0 Tog,
ABO ABO REMARKS:
c2

Rh Rh_16'0 -5
SECTION III - RECORD OF TRANSFUSION
INSPECTED AND ISSUED BY (Si PRE-TRANSFUSION DATA AMO UAtAN TIME/DATE C • MPLETED/I POST-TRANSF ERRUPTED
3 a
TION_ TEMPERA PUL2E0 9, BL0 SURE
AT (Hour) / ON (Date) 3 '3"r., /a3 NONE_SUSPECTED_Cif 1 b
IDENTIFICATION If rea on is suspected—IMMEDIATELY:

I have examined the Blood Component container label and this form and I find all _1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. _2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and _3. Follow Transfusion Reaction Procedures.

on the patient identification tag. _ 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.

1st VERIFIER DESCRIPTION OF REACTION

URTICARIA_El CHILL . FEVER_0 PAIN
_. OTHER (Specify)
DATE TIME ST:A
/
PATIENT IDEN El_ION—USE EMBOSSER (For typed or written entries give: Name—Last, f rst rate; hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
STANDARD FORM 518 (REV. 9-92i Prescribed by GSA/ICMR. FiRMR (41 CFR) 201-9.202-1
MEDCOM - 15460 es,
Pa•nrri r.nnu
DOD-028849

_
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTIN_P_rint) )12
( (-1,---
Products are requested.)
RED BLOOD CELLS
.
tXrTYPE AND SCREEN
‘
5...'FRESH FROZEN PLASMA OPERATIVE PROCEDURE
DIAGNO_
)ttr—elter3ttvfX1V1
PLATELETS (Pool of units)
e \ce
CRYOPRECIPITATE (Pool of units) DATE REQ_TED
I have collected a blood specimen on the below Rh IMMUNE GLOBULIN
named patient, verified the name and ID No. of the
0
patient and verified the specimen tube label to be
DATE AND HOUR RE_D
correct. ..._
OTHER (Specify)
VOLUME REOLIESTED (If applt Ile) KNOWN ANTI ODY FORMATION/TRANSFUSION SIGNATURE OF VERIFIER REACTION (Specify) . (..3 I¦Jj-°c ML V
.s
IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERI ED
REMARKS:
RhIG TREATMENT? DATE GIVEN: TIME 4 ED
'.
HEMOLYTIC DISEASE OF NEWBORN?
1
SECTION II — PRE-TRANSFUSION TESTING
UNIT NO. /ANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH Ej RECORD_el2r•NO RECORD
PATIENT NO. SIGNATURE OF PERSON P
DONOR RECIPIENT
OSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED _ I DATE
ABO ABO REMARKS: t 3 1 03

5)L 03 30
Rh Rh
SECTION III — RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANS TA AMOUNT GIVEN TIME/DATE_MPLir •INSPECTED AND ISSUED BY (Signature)
ML RPACTIO TVATUcz.I PULS BLOOD PytESSURE NE SUSPECTED
AT (Hour) c, 3 5-ON (Date) ( iaD
IDENTIFICATION If reaction is suspected—IMMEDIATELY:

I have examined the Blood Component container label and this form and I find all 1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.

on the pa ' ation tag. 4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1st V DESCRIPTION OF REACTION
URTICARIA_111 CHILL_. FEVER_PAIN
I=1 OTHER (Specify)
2nd VERIFIER (Sig

OTHER D_S (Equipment, clots, etc.) NO_YES (Specify)
.
DAT
PATIENT IDE_ON—USE EMBOSSER (For typed or written entries give: Name—Last, first, m WARD
rate; hospital or medical facility)

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

MEDCOM - 15461 Medical Record Copy
DOD-028850