Medical Report: 39-Year-Old Iraqi Civilian, Abu Ghraib Prison, Baghdad, Iraq re: Gunshot Wound to Pelvis - Death (Homicide)

.
Ward/Section: UE - G HYSICIAN: (ippo) .._, •
TEMISTRY RESULT FORM
1.--e..,.. ".1
Subject to the Privacy Act of 1974)
LAST, F • T MI. DATE TIME
SSN/PSEUDO SSN: (, c - • . i't'66114cliirniS 'Igc010):WOOkr,or.
-
TEST RESULT REF.
TEST RESULT REF. RANGE RANGE
Pt:
Na ALB 3.5-5.5 g/d1 GLU 73-118 mg/d1
Pt
namP•
K ALP 26-84 u/1 BUN 7-22 mg/di

Cl tia 157 MITt01/"L ALT 10-47 u/1 CA+ 8.0-10.3 mg/d1 pH K 2. 8 mmol. / L AMY 14-97 iiii
CRE 0.6-1.2 rng/d1 PI Fiol.IL
PC1 Trij2 2'3 AST 11-38 u/1 NA-128 145 mmol/1
Hct 32 ''.PCV ­PO. TBIL 0.2-1.6 mg/di KT 3,3-4.7 minolii

Hb* 11

g/cIL

TC i.,, a Hc t BUN 7-22 rug/d1 CI: 98-108 mmol/1
HC CA-"` 8.0-10.3mWd1 tCO2 18-33 mmolll
Fit 370
sa pH 7.413 CHOL 100-200 mg/dl
. (Piccolo) lY.Of gth,4-ploss ,,.:- --BE pcoz 43.2 mmHg
CRE 0.6-1.2 mg/d1
. TEST RESULT REF. RANGE
P02 58 mmHg AO Hon:.. FA PI 0 1: L.. I 73-118 mg/di ALB
-_ = GLU 3.3-5.5 g/d1 Ca 3Eecf. 3 TP 6.4-8.1 g/d1 ALP 26-84u11
Niiriol/L

BU -3,,,'
-0. ,-..,!3.."!-!::-ALT 10-47 u/I
i40161M71
— .- -
_a._.. _d

GL
TEST RESULT REF. AMY 14-97 Lill Rt. Pa . . ent Temp RANGE
Cre
GLU 73-118 mg/dl AST 11-38121
H 7.3• 4 Hct pooz 45.7 rfaftHg BUN 7-22 mg/dl ---] TBIL 0.2:1.6 mg/di
Hgt PO2 mmHg i CRE 0.6-1.2 mg/d1 GGT 5-65 u/1
i CK 39-380 u/1 (M) TP 6.4-8:1 g/d1
,i. ,. Patient Temp: 100.9F
30-190 u/1 (F)
F102.: : 50 . NA+ 128-145mmo1/1 ,

.'-eiliro.)'EleCtit.olji::: ..aff!pie Type_:
Trot + 3-3 4.7 mmol/1
TEST RESULT REF. RANGE
02NOVO 07:28 -
Dru 0 per are----.., _CI.; 98-108 mmol/I NA+ 128-145 mmol/1 Abt
Prlysician: (L)(‘)e) tC O2 18-33 mmol/1 K-3.3-4.7 mmoV1
• CL 98-108 mmolll
s'''r4141111111

tCO2 18-33 rnmoUl
I .
REMARKS:
fib sl

REPORTED BY: DA' LAB ID NO.:
DOD-035817

Ward/Sectio R • CIAN:
ATORY RESULT FORM
C—A... ,. --.-
kt-Put., ,,l U./ UJG1-11 ,/c1.1. ACC 01 LY/4)
LAST, FIRS MI. 00 ((a) i
DATE TIME SSN/PSEUDO/S11:
(..) K_Ce)
. — 0 ogY Urinalysis
TEST illtArda • . RANGE
WBC v . _
RBC
Wgb
Hct
MCV

Pit -Lymph %
(Hematology) Manual Differential
Segs Mono Bands Eos Lymph Baso Atyp Imm RBC Morph
TEST
Color App Glu Bili Ket
SG
Bid
pH
Prot Urob Nit
Leuk
HCG
RESULT

REF RANGE
N/A N/A Negative Negative Negative
N/A Negative
N/A . Negative 0.2-1.0
Negative
Negative
Negative

TEST
RPR
Mono
Source
Gram Stain OCc Bld
H. pylori Micro
Parasites Malaria
Other
RESULT REF. RANGE
Negative Negative
Nficrob:ology
Negative , Negative
.1, c.i.o. /I • —..--
Hematocrit 3747% (F)
Sed Rate Cell MUST SUBMIT SF 518 WITH
Count EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
.131oi­.4Baitic. Unit•CrOSsmatclf.
(MUST SUBMIT .SF,518.WITH EVERY UNIT OF. BLOOD .
TEST RESULT REF. RANGE UNIT REQUESTED)' TYPE CROSSM4TCII
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
F DP 10 ug/m1
REMARKS:
REPORTED BY: DATE: LAB ID. NO.:.
MEDCOM -22242

DOD-035818

Ward/Section: STING P
'IISTRY RESULT FORM Y(2)'C to the o Act of 1974)
, ecstsNRs N : LAST, FIRST DA TIME
' • ,
r )) 4 _ TA: .•, r(6614;PlieriiS.
-.." . 4.0o10 .Q OtiOatiell. Two/ r c t IT' T 'P FP
P.4 AIGE TEST RESULT REF. TEST RESULT C REF. RANGE RANGE
VL ALB 3.5-5.5 g/dl GLU 73-118 mg/dl: -- -t Name: L ALP 26-84 u/1 BUN 7-22 mg/d1
L

ALT 10-47 u/I CA" 8.0-10.3 mg/di Na 157 f1010 1SL
AMY 14-97 u/I CRE 0.6-1.2 mg/d1 L 3. 0 mmol " L art) AST 11-38 u/1 NA' 128-1.45 mmol/1 T C na 29 MMOISL
0 -rt) TBIL 0.2-1.6 mg/di K mrnolif
Hct 4 ,1'. %PCV
Hb* 1;;: •/dL . in) BUN 7-22 mg/dl CL" 98-108 mmoln
is n)
*v 1 a Hct:

ri) CA++ 8.0-10.3m dl 18-33 mmoUl
tCO2
mT0
Rt 37C CHOL 10o-200113g/di

•!.C610MiSr
.:Of raner P 10;--
--• ,'•:;7;:':.':11-..7r.:::;,','::...":• i:I.'-'..Lrr,: .• '..'•
pH 7.410
0.6-1.2 mg/d1
CRE TEST RESULT REF. RANGE
PCO2 44.4 mmHg P02 74 mmHg GLU 73-118 mg/d1 ALB 3.3-5.5 g/dl HCO3 2 .6 TAMOPL )11L. TP 6.4-8.1 g/dl ALP 26-84 u/1 BEecf 3 fl mo 1 /L ,
ecOl±iY:Si 1 e 8 ALT 1047 till
*.zalcu1ated TEST RESULT REF. AMY 14-97 u/1 RANGE
y, GLU 73-118 mg/d1 AST 11 -38 u/I
Pat i ent Temp H 3 BUN TBIL 0.27 1.6 mg/d1
7.91 7-22 mg/(11
P002 47.0 mmHg CRE 0.6-1.2 mg/di GGT 5-65 WI
P02 81 mmHg

";.! CK 39-380 u/1(M) TP 6.4-8:1 g/dI
_:.7

30-190 u/I (F)
Patient Temp: 100.9F E NA 128-145 mmol/1 -

. ri000Zleetiii) .
FIO2 : 50
+

Sample Type_: RRT 334.7 mmo1/1
TEST RESULT REF. RANGE
0 2N0'.108 10: 11

_CL -98-108 mma1/1 N• i-128-145 mmol/1 ...
°per: ari(0(0
ICO2 18-33 mmol/1 IC 3.3-4.7 mmol/1 Physician:
• CL" 98-108 mmolll
tC 02 18-33 mmoUl
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
DOD-035819

Ward/Son: RE ISE TIN HYSICIAN:

CHEMISTRY RESULT FORM CA-4_ b Sub'ect to the Privacy Act of 1974) LAST, MST MI. DATE TIME
SS 0 SS
(0)

.1c.colo -. ,raiel •
TEST RESULT REF. TEST RESULT REF. RANGE RANGE
ALB 3.5-5.5 g/d1 GLU 73-11S mg/di Pt Name:
ALP 26-84 u/1 BUN 7-22 mg/d1
ALT 10-47 u/1 CA+4 8.0-10.3 rug/d1 Na i53 mmnIsL
AMY 14-97 u/1 CRE 0.6-1.2 nag/d1
3 . 3 mictOI/1.

AST 11 -38 u/1 NA' 128-145 mmo1/1T002 2 mmol/L. TBIL 0.2-1.6 mg/dl K.4 3.3 -4.7 mruo1/1
Hct 27 BUN 7-2.2 nig/di CL-98-108 mmol/1
Hb* 5 q/di. Hct CA4+ 8.0-10.3mg/d1 tCO2 18-33 mmo1/1
,•
.
CHOL 100-200 raWd1 Pi ó1o)Livei ranei
HT. 3 7C
CRE 0.6-1.2 mg/d1

PH TEST RESULT REF. RANGE
p c 0 2 4 2. 8 mmHg

ALB 3.3-5.5 g/d1
ez mmHg

ALP 26-84 IA
'

rico 3 28 mmo I /L

ALT 10-47 u/1
•

BEecl 4 WI 0 1
TEST .RESuLT REF AMY 14-97 u/1

s 0 2*

RANGE
calculated

GLU 73-118 riled' AST 11-38 u/1
BUN 7-22 mg/dl TBIL 0.2-1.6 rag' Patient Terp •
CRE 0.6-1.2 mg/di GGT 5-65 u/l
7. 4 1 0

CK 39-380 u/1 (M) TP 6.4-8:1 g/dI
44.8 mmHg 30-190 u/1 (F)
NA+

POZ: ¦; 7 mmHg

Patient Temp: 100.5F 3.3-4.7 mmol/1 TEST RESULT REF. RANGE
F102 ' 50 LU 98-108 mmo1/1 NA 128-145 mmol/ISample Type_: ART
tCO2 18-33 mmo1/1 3.3-4.7 mmol/i
92movc1,3 12:13

CL" 98-108 mmolll
° Per:1111101(4601--

tCO2 18 -33 nuno1/1
Physic Ian:
32-# 420 1 1

REPORTED BY: DATE: LAB ID
72,41vr'.? j

DOD-035820

Ward/Se59n: RE "SICIAN: (cv((9)?.... I LABORATORY RESULT FORM
—CA-1 1 LAST, FIRST, MI • , (._6 1 ft\ . !... ) CBC (Subject to the Pr ivacy Act of 1974) , DA" I TIME --.1.2_...1___ 1 t 4.300 SSN/PS _ DO S M. (to Urinatysis • c. Serology:
TEST TEST RESULT i REF. RANGE TEST RESULT REF. RANGE 1
WBC Color I N/A RPR Negative
RBC App N/A Mono Negative
Hgb Giu isleltive Microbiology
Hct - Bili Negative Source
MCV Ket Negative Gram
Stain
Pit SG N/A OCc Bld Negative
Lymph % Bld Negative H. pylori Negative
(DematOlagy) Manual Differential pH N/A Micro
• . Parasites
Segs Mono Prot Negative Malaria
Bands Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative • . icroscepic UriOn.sls '
,.. .,
RBC HCG Negative Morph ,
Spun 42-52% (M)
CSF , • Blood. Bank.-
Hematocrit 37-47% (F) Sed Rate
Cep. MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen Negative I ABO/Rh
Celagulation Studies. : -, .B104 Bank that Crassm'ateh ... (MUST,SUBMIT Sr5I8 WITH EVERY UNIT OF BLOOD . •
-' '.' :1.:REQUESAD).,--
TEST RESULT REF. RANGE UNIT TYPE CROSSILL4TCH
PT ' 9.8-13.6 sees APTT 21-34 secs
s . D dimer 20 uml • , FDP 10 ug/ml
REMARKS: — —...., ' REPORTED BY DATE: LAB ID NO . '
DOD-035821
Ward./S -tion: RE UES1 SICIAN: 04(4)
CHEMISTRY RESULT FORM sph;ent to the Privacy Act of 1974) LAST, FIRST MI
(b' 0)

"DM

TE cf

Pt ‘'

Pi 'Ja me: PICCOLO TT Na
1 ,:.0 mmolA

02/11/03 16:16

t-5

REFERENCE RANGE : r, MALE K 3 .:1; mmol/L

Giu Ng: dL

T

TCO2

PATI ENT # : Imp v‘ok.),L1

22 mm olsL

E;UN 40 mgsdL

METLYTE 8 TI Hct

Na 159 mmol/L

DISC LOT #: 3151AA4 17A7 Hb*

::, 9/dt_

t.

3.8 mmolsi, OPER #' DR #: 000 74,-
, Hct

12e mmol/L RAL J1....,_

Trma 28 mmolsL V‘0AY")--J7J- At 370
GLU 105 73-118 MG/DL CCp H

HnGap 11 mmol/L 7.409
BUN 444 7-22 :,-.

MG/DL _,-:.

Hri 23 %PCV Pena

41.8 mmHg

CRE ICT 0.6-1.2 MG/DL 1.._
Hb* 8 q/dL

CK 2874* 39-380 U/L Ti 59 mmHg

*via Hct NA+ 140 128-145 MOH_ 7r :3 2.:. mmol/L PH 7.89e K+ ICT 3.3-4.7 MDR_ AL 5Eecf 2 mmol/L pi:n7 42.8 mmH•; CL-120* 98-108 MOM_ f''°2 soz* 90 %
HCO3 tCO2 ICT 18-33 MMOt/L A

2e mmol/L *calculated

BF-pcf 1 mmolsL

INST QC: OK CHEM QC: OK A5
HEM 1+, LIP 0 , ICT 3+ At Patient Temp

Sample Type_:

pH

02NOVOS 1e:33 ti P002 43. mmHg

PICCOLO Pn2 R --; mmHg

Oper: 1011 (40; --

02/11/03 16:18 Tl Patient Temp: 100.0E
REFERENCE RANGE: MALE

Physirian:
PATIENT #: FIO2 e0

LIVER PANEL Sample Type_:
DISC LOI 3153AA7
OPER #: 02NOVOS 1e:1e

DR #: 000 Fr Abuse SE IAL #
oper 16) (G) D—

(b) (-6) ALB 1 .6* 3.3-5.5 G/DL K ALP 61 26-84 U/L ALT ICT 10-47 U/L AMY 48 14-97 U/LAST ICT 11-38 U/L _
REMARKS:
TBIL 21.0* 0.2-1.6 MG/DLGGT 9 5-65 U/LA-6c.11 , 0 TP ICT 6.4-8.1 (3/DL
REPORTED BY:
INST DC: OK

CHEM OC: OK
HEM 1+, LIP 0 , ICT 3+

DOD-035822

Ward/Secciag: REQUESTING HYSICIAN:
Pt qame:
Ha ie0 mow . 7 m rop L

TCOE F; o 1 IL
HO, 42 :.;;PCV
Hb* 1 gidL
*via Hct

it 37C
pH 7.420 PCOZ 41.7 mmHg 4 riciHg Huvi 14c11/L REPcf
*calculated
Ht Pat lent Temp pH 7.404
43.7 mmHg P02 rcifHg
Patient Temp: 100.5F F1 0:1 : so sample Type_: ART
eaNOVC13 14;a7 oPer :m
PhySifian :

REMARKS:
REPORTED BY:
)
DA E TIME
a Mu cl
(Piccolo) Chemlstr) 12
TEST RESULT REF. RANGE
ALB 3.5-5.5 g/dl
ALP 26-84 IA
ALT 10-47 u/1
AMY 14-97 u/1
AST 11-38 u/I
TBIL 0.2-1.6 mg/d1
BUN 7-22 ng/d1
CA++ 8.0-10.3mg/d1
100-200 mg/di
CHOL
CRE 0.6-1.2 mg/di
GLU 73-118 mg/d1
TP 6.4-8.1 g/dI

TEST RESULT RANGE
GLU 73-118 mg/di BUN 7-22 mg/d1 CRE 0.6-1.2 mg/d1 CK 39-380 (M)
30-190 u/l (F)
NA+ 128-l45 mmol/1
K+ 3.3-4.7 mmol/1
LU 98-108 mmolli
tCO2 18-33 mmol/1
CHEMISTRYRESULT FORM (Subject to the Privacy Act of 1974) SSN/PSEUDO SC:
-)
TEST RESULT REF. RANGE
GLU 73-118 mg/c11 BUN 7-22 mg/di
CA++ 8.0-10.3 mg/di CRE 0.6-1.2 mg/d1 NA+ 128-145 mmol/1
3.3-4.7 mrnolil

CU 98-108 mmol/1 tCO2 18-33 mmoUl
Ficolf,071.,likef-PaiterPlus .!;,
TEST
ALB ALP ALT
AMY
AST TBIL GGT TP
TEST
NA+
CL" tc02
4 s
RESULT REF. RANGE
33-5.5 g/d/
26-84 u/1
10-47 u/I

14-97 Lill
11-38 u/I
0.2-1.6 ragfdl 5-65 u/I 6.4-8.1 g/d1
ccolo.j•Electi e
RESULT REF. RANGE
128-145 mmo1/1 3.3-4_7 mmol/1
98-108 mmol/1 18-33 rmnolil

Ward/Section:
i LAST, FIRST, MI.
P Name:

Na 164 mmol
4.3 wimoi/L
Tcoa :30 mmol SL
1-1(' 24 ;PCV •
g/dL
*vi. Hct

HT, :J7C
pH 7.144

77. mmHg

Pn2 E' rimHg
HCO3 as mmol/L
BEecf -1 mmo 1 iL

81 %
*.--a 1 cul at ed

Rt Pat i ent Temp
pH 7.156
PCO2 80.0 mmHg
PUS g.3 mmHg

Patient Temp: 100.0F
F102 : 100
Sample Type_ ART

02NOV03 23: 03

Oper

hqsician:

• • ..•-t a_no•-•......• •

REPORTED BY:
REQUESTING :
" -
(e) DATE TIME
TEST RESULT REF. RANGE
•
Pt:
Pt Name:

TCO2 31 mmol/L

Ht 37C
PH

82.5 mmHg
pnz 44 mmHg
HCO3 22 mmol/L
EEecf -I mmol/L

Cal cu I at ed
Rt. Pat i ent Temp
pH 7.130
PCO2 86.0 mmHg
P02 68 mmHg

Patient Temp: I00.3F
F102 : 100
sample Type_ ART

02NOV03

Oper:
PhLisiciAn:

Ser# ea((6)

A-13
DATE. LAB ID NO.:
CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974) SSN S
Al O (-

TEST RESULT REF. RANGE
GLU 73-118 m4/d1 BUN 7-22 mg/d1 CA+4 8.0-10.3 rogial CRE 0.6-1.2 mg/dl NA' 128-145 mmoU/
3.3-4.7 mmolil CL 98-108 mmol/1 tCO2 18-33 mmoUl
Panel
,

TEST RESULT REF. RANGE
ALB 3.3-5.5 g/dl kLP 26-84 u/1 .LT 10-47 u/I
AMY 14-97 u/I
LST 11-38 WI MIL 0.2-1.6 cog/d1 3GT 5-65 oil CP 6.4-8.1 g/dl
le4ro

TEST RESULT REF. RANGE
4A'r 128-145 mmol/I
3.34.7 mmol/1
98-108 nimolll

CO2 18-33 mmoUl
DOD-035824

REQUESTING HYSIC1AN:
LABORATORY RESULT FORM
(Hematology) Manual Differential
Mono Eos
Baso
Imm

Spun 4252% (M) Hem atocrit 37-47% (F)
-

Sed Rate
-..

Other
Prot
Urob
Nit
Leuk
HCG
• Cell
Count
Directigen
DATE
ttCli

Urinalysis
N/A N/A Negative Negative Negative N/A Negative N/A Negative 0.2-1.0 Negative Negative Negative
. CSF
Negative
(Subject to the Privacy Act of 1974) SSN/PSEL1D0 S
AGA._
Misc. Serology.

RPR Mono Negative Negative
IlEcrobiology
Source
Gram Stain Occ Bld Negative
H. pylori Micro Parasites Malaria Negative
0 & P
Other

Microscopic Urinalysis
• Blood Bank

MUST SUBMIT SF 518 WITH EVERY IT REQUESTED ABO/Rh
Coagulation Studies :. ..

- -Blood Bank Unit Crossmatch -....-".
-.•
(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
,. -

REQUESTED)
TEST RESULT REF. RANGE UNJTf TYPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1

..

i FDP 10 ugiml REMARKS:
il 0 VDC1172 -r r n. r.'tf_
. • ----
DOD-035825

Ward/Section:
Ct

Pt:
Pt Name:

Ha mmol/L
3.9 mmoisL

Tmm2 31 mmoi/L
Hct 23 7.:PCV

Hb* S gsdL *via Hct
At 370

pH 7.331
54

P002 mmHg
p02 88 mmHg

H003 29 mmol/L

BEer:f 5mmol/L

ralculatPd

,7--Jtient Temp

P02 8e mmHg

Patient Temp: 98.0F

FIO2

'Sample Type_:

03NOV03 11:0e

°Per: III/

••¦¦¦•¦•¦•Avawn.

REMARKS:
REQUESTING PHYSICIAN: /6)// 1111!"
DATE TIME I
(PieColo)(Iiiii)iiti-:'::::::'. 1
TEST I RE,STIT.T 1 PPP I
PICCOLO ===

-03/11/03 11:06

_ REFERENCE RANGE: nMALc
PATIENT #: WO)

MEILYTE 8

-DISC LOT #: 3151AA4
OPER #: DR #: 000

MOM
CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 19 .74)
SSN/PSEUDO SZ(‘,/
1. (IICcolti):. 1414Olie/'.iiitY-:-.'::".::::-.7 i:'..':
TEST RESL'LT RE F. RANGE
GLU 73-118 mg/dl BUN 7-22 rag/d1 CA4' 8.0-10.3 Toed' CRE 0.6-1.2 nag/c11 NA. 128-145 mmol/1
K4 mmolfl
CI: 98-108 mmol/1
ca 53.8 mmHg

- OLU BUN CRC CK NA-' K+ 108 38* ICT 2136* 155* ICT 73-118 7-22 0.6-1.2 39-380 128-145 3.3-4.7 MG/DL MG/DL MG/DL U/L MMOVL MMOVL tCO2 TEST ALB ALP 18-33 mmo1/1 RESULT REF. RANGE 3.3-5.5 gjd1 26-84 u/1
CL-tCO2 120* ICT 98-108 18-33 MMOVL ALT MMOVL 10-47u/I
AMY 14-97
INST GC: OK HEM 0 , LI P 0 CHEM GC: OK , ICT 3+ AST 11-38 till
TBIL 0.2-1.6 mg/dl
GGT 5-65 Lill
TP 6.4-8.1 gicIl

Pt Name:

()(
C.rea 2. mg/di_

DATE: LAB ID NO.:

DOD-035826

. 1-51-1=IT EGe+

P1::: 111111
Pt Name:
,
!:!'

Ha le4 mmol/L

K 4.e mmol/L

TCO2 30 mmol/L

Hct 22 PCV

ci

Hb* 10 /dL
*via Hct

Rt 370

pH 7.180

PCn2 74. 1 mmHg

Pn2 7F mmHg

Hi:03 28 mmol/L

BEecf -1 mmol/L

.702* 90 %
*calculated

Rt Patient Temp

pH 7.172
PCO2 7e.3 mmHg
POZ 75 mmHg

Patient Temp: 59.8F
FIOZ :

8ample Type-: PRT •

03NOV03

Oper:

Physician:

Ser#
Ver:

(6)0'1)

1 -3TRT G270//...-

P t ; 111111
Pt N ame:

Tuu2 :!,. 1 mmol/L

Rt 37C
PH 7.241
pc:n2

e,,-„.R mmHg
mH
Pn2 77 mmHg

PCO3 25 mmol/L

BEprf

1 mmol/L
s2* %
*calculated

Pt Patient Temp
pH 7.235
PCO2 G7.8 mmHg
P02 79 mmHg

Patient Temp: 594F

.
FIn2 : 20
sample Tqpe: PRI-

_

elf3NOV03 Os: 25

°Per

lc
Phq,71e-, An:

•
Cc')
1,1
0 0 MEDCO
N., Pt NaMP:
Pt: MR Pt Name: , Na !!..:1J2 c 1!,:! mmol/L 4.2 mmol/L !!%0 mmol/L
r 7CO2 Pt 37!­: '29 mmol/L 7.01, *via Hrt :2'-'.. %PCV ln g/dL
;:t1 7.255 EEeci 1 mmol/L s 2* ‘7 _- % *ra rulatPd * ?CO2 55.9.:m g pu.f 7(=. mmHg H°03 27 mmol/L Pt 37"­_! 0muu:i iy,f BEecf s* PH P02 52 028 mmol/L 0 mmol/L 52 % 7.224 “,--... mmHg 78 mmHq
-8ample Tupe_: *calculated
03NOV03 OG:07 Pt Patient Temp
°Per:111110 R +D 7° P1PCO2 7.224 -ee.5 mmH
Pnqsician: PO2 73 mmHq
5er#11111111 Patient Temp: 58.g.F FIO2 : 70
sample Type-:
t Yg .10

a, E co cr, a., •I -C.,• ifs a
M - 22251 0 1_ C1., !--_-••••-

DOD-035827

Pt Name:

Ha 1.;1 mmol/L

3.7 mmol/L
T402 29 mmol/L
hict 22 PCV
Hb* 7 q/dL

*via Hct

Ht 37C
PH 7.29=5

45.1 mmHg

ei mmHg
HCO3 28 mmol/L
SEecf 3 mmol/L

s02* -=11
*calculated

Sample Type_:

02NOV03 18:07

OPer:111,

Physician

i-STAT G3+

Pt:
Pt Name:

TCO2 mmol/L

Rt 37C
pH 7.281
PCO2 .S1.0 mmHg
Pn2 39 mmHg
HCO3 23 mmol/L
ISFecf mmol/L

*calculated

At Patient Temp

pH
PCO2 mmH9
PO2 95 mmH9

Patient Temp: 100.4F
FTnz

100
Sample Type_: RRT

OSNOV03 00.01
Ir ''----2._ 'h5 TS1
°Per: I-1u Physician:
S er#

\O. ())(Vi

Pt Name:

1i;„3 mmoisL

Na
K 4.4 mmol/1
30 mmol/L
nct 22
Hb* 7 9sdL

*via Hct

Pt 71-1
PH 7.a“
pnnil ea.4 Ecoig
P02 84 mmHq
HOn2 38 mmoisL
BEeci' 1 mmolsL

sou* 94 %
*.calcCilated

At Pa 'ent, Temp
PH .7.251

'g
prn2 4.R.3 mmHg
P02 90 mmHg

Patient Temp: 100.F,F
FIO2 :
Sample Type-:

03H0:02 01:22

Pt Name:

Na lee mmol/L

4.4 mmol/L TCO2 ow mmol/L Hct 27 %PCV Hb* 9/dL
*via -Hct

At .370

PH 7.224
PCO2 -“72 mmHg
P02 82 mmHg

HCO3 28 mmol/1
BEerf 0 mmol/L
s02* %
*calculated

Rt Patient Temp

PH 7.21.;
P003 NmH9
PO2 8C, mmHg

Patient Temp: =.9. -7
FIO= : 90
Sample Type_: ART

03110VO:=,

°Per: 4.114C165.641
Physician:

Ver;

DOD-035828
(
1-5TAT G3+ :-:TT G3+, 1-5TRT G3

: 11111

Pt :
111111
Pt: 1111/
Pt Name: Pt Name: Pt. Name:

Pt

Ea ffimol/L

* 27 mmoi/L Pt 370 Pt S7C At 370
Rt 37C
pH 7.43e

PH 7.41,1

FUIJ mmHP P002 P002

40.8 mmhg

46.7'mmlig

Pry‘f 5.7 mmHg • PO2 57 mmHg P02

79 mmHg

PO2 5.7 mmHg

H003 22 [O1/1_ HCO3

27 mmol/L

hOO';

ae Rimel/L

T--;5Pci mmo1/1_ BEecf 1 mmol/L BEecf

3 mmoi/L

REp&

I mmol/L

-91 %
.702+ 93 %
raruiated *calculated *

,-alculated

*ralrulated

At PatiPnt

Temp Pt Patient Temp
Pt Patient Temp
PH 7.412 pH 7.455
pH 7.424

Pc:02

411.6 mmHg P003 33;•e mmHg
p002 33'.3 mmHg

Pn2

51 mmHg P02

• 72 mmHg

pn2

e3 mmHg

Patient Temp: 95.7F Patient Temp:

. .e. 3F

Patient TPmp: '37 IF

FIO2 : es
1-102 : 70

Sample Type_:

Sample Type_: ART

Ser# 111111
Sample Type_: RRT

ver: 03 i•-4 CA) 0 3 20: 37 0:-INriV03
• 21:27
03NOV03

Optr:

Oper:

Oper: Imp
Pnqsician:

Pnysician:
Pr, siclan:

1111111111
F,pr#

Ver:
X 1 10X(0) (.
Cr, 2 Cr)
(S.
C. 0
* .. V) ...-:, C
ID
•.../ .T1
.-I
u

Z • .-I
Ili

.7.,.. a• -11
!.... 1._

U. ..1:--a. a.
.-CLI: a.

Ward/Section: RE Q PHYSICIAN: (40 GI.
LABORATORY RESULT FORM

i cLu

-,
LAST, FIRST, Ml. MO i i (0 DATE
TIME SSN/PSEUDO Sr: , v o o-5 -6. v65-6(1'00
• ...-----,
(Hematcilogy

CBC :1\.-Urinalysis.. . Misc. Serology..•,
TEST '-'"""'" ' '"---"-TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC Color N/A RPR Negative
RBC App N/A Mono Negative
Hgb Glu Negative
Microbiology

Het Bili Negative Source
. .
MCV Ket Negative Gram

Stain
Plt SG N/A Occ Bld , Negative
V

.

Lymph % Bid Negative
H. pylori Negative
(Hematology) Manual Differential pH N/A Micro
V.

Parasites
Segs Mono Prot Negative Malaria v

Bands. Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative
' Microscopic Uriàalysis'

RBC HCG Negative
Morph

.
pen 7
CSF., Blood Bank
Hematocrit 3747% (F) •
Sed Rate Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh tV
Coagulation Studies Blood.Bank Unit Crossmatch. ' (MUST SUBMIT SF.5I8 WITH EVERY UNIT OF BLOOD.
-.. - REQUESTED) .-
TEST RESULT REF. RANGE UNIT TYPE CROSSiti4TCH
PT 9.8-13.6 secs
APTT 21-34 sees
D dimer 20 ug/m1
FIYP 10 ug/m1
REMARKS:
REPORTED BY . I DATE: LAB m NO.: .
DOD-035830

t

(t9Y(P)

Pt. Name:

Na mmo I /L

mmol/L
TCU2 30 mmol/L
Hrt 25 %PCV

Hb* 9 q/dL *via Hct
At 37C
pH 7.378
PCO2 48.4 mmHg
PO2 73 mmHg
H003 29 mmol/L
8Eecf 3 mmol/L

94 %
*calculated

At Patient Temp
pH
PCO2 47.7 mmHg
PO2 72 mmHg

Patient Temp: 98.0F
FIC2
Sample Type_: APT

05N0v03 14:1'3

OP
Physician:
• • .1,-1,1,11.. la •

REPORTED BY:
(b)1(6)

TEST
ALB ALP ALT AMY AST TBIL BUN
CA". CHOL CRE
GLU TP
GLU BUN CRE CK
NA+
+ K
.CL-
1E02
Flo
DATE:
. .
iccoIo)Cheinistrvl2 :. '7 .
RESULT REF. RANGE
3.5-5.5 g/dl 26-84 u/1 10-47 u/1
14-97
11-38 WI
0.2-1.6 mg/d1
7-22 mg/d1
8.0-10.3mg/d1
100-200 mg/dl
0.6-1.2 mg/d1
RESULT REF. RANGE
73-118 mg/c11
I 7-22 mg/dl 0.6-1.2 mg/d1 39-380 u/I (M) 30-190 u/1 (F) 128-145 mmo1/1
334.7 mmol/1
98-108 mmol/1
18-33 mmol/1
LAB ID NO.:
CITEMISTRY RESULT FORM (Subject to the Privacy Act of 1974) SSN/PSEUDO SN•
‘0.)( (P) ‘.1 •

•iec§10)J:„Metabolic
TEST RESULT REF. RANGE
GLU 73-118mg/c11
BUN 7-22 mg/di
8.0-10.3 mg/c11
CRE 0.6-1.2 mg/d1
128-145 mmol/1

3.3-4.7 mmo1/1

CL 98-108 mmol/1
18-33 mmoUl

tCO2
TEST RESULT REF. RANGE
3.3-5.5 g/dI 26-84 u/1
10-47 u/I

AMY 14-97 oil
AST 11-38 u/I
TBIL 0.2-1.6 regldl
GGT 5-65 di
TP 01

t..;...• ...: ...:,.;::.--...::-.1.-`7•:-.:!,.. • - '
...-­
,
.
4NGE
F. TEST RESULT RE
128-145 mmolll

NA''
3.3-4.7 mmoV1

K-
CE 98-108 mmoLl
tCO2 18-33 ramo1/1
DOD-035831
Ware,ection: REQ
LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)
LAST, FIRST, DATE TIME SSN/PSEUDO N.
3N,k At 10\3
(He Urinalysis. • ' .
TEST RESULT REF. RANGE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10 3 Color N/A RPR Negative
RBC 4.7-6.1 x 10 App N/A Mono Negative
Hgb 14-18 (M) 12-16 g/dl (F) Glu Negative Microbiology
Hct 42-52% (M) 37.47% (F) Bili . Negative Source
MCV Pit 130-500 x10 3 verified 80-94 (M) 81-99 fl (F) Ket SG Negative N/A Gram Stain Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(Hematology) Manual Differential pH N/A Micro
Parasites
Segs . Mono Prot Negative Malaria
Bands . Eos Urob 0.2-1.0 O&P
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative
Microscopic Urina
..• • -

RBC HCG Negative
Morph
Spun 42-52% (M)
CSF.--.Blood Bank
Hematocrit 37-47% (F) Sed Rate
Cell
MUST SUBMIT SF 518 WITH
... Count
EVERY UNIT REQUESTED Other Directigen 1 i Negative
ABO/Rh
-Coagulation Studies. ,...-.
Blood. Bank Unit Crossmatch" (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 secs APTT 21-34 secs D dimer . . 20 ug/m1
FDP 10 ug/ml
REMARKS: 1 ,
TYC TIM) "I" T7 TS rrar ,.. . -
DOD-035832

Ward/Seen: REQTrE' -=
LABORATORY RESULT FORM N1(.9) ;--(Subject to the Privacy Act of 1974)LAST, FAT,.1141.
DATE TIME - 9 SSN ,
• UO (0 1 vo G
TEST (Hemat I . :.• -,-; , . , ..:.. ,:i: TEST - Vi.igalYsis , RESULT REF. RANGE TEST I'• RESULT 0 gy • REF RANGE
WBC ,,. =`.::' Color N/A RPR Negative
RBC tigb Hct App , Bib . LIL:atE ._1 .• _ -!... :::..:_. :-. ,:-.J ;•=1..(; '-'-' , -, ,it_ 11,:­J 1 0_ -.-=.
-.-...•.-7 --:--; N/A Negative Negative Mono Source .11•arobiology Negative
MCV -­_.,, .. -,,.; fi.. Di -,.:': ' :.-_,: Ket Negative Gram
Pit r: 7 Plc ¦ , -1.: •-:: ,.-. - ¦ .,;.•:: ., 7, -, L. If.:. 1" ,., -,::•: 1 SG N/A Stain Occ Bid Negative
Lymph % , :-, 1.1_ .1_ :.: Bid Negative H. pylori ' Negative
(Irematidnity Manual Differential.' , pH N/A Micro Parasites
Segs. Mono Prot Negative Malaria • •
Bands . Eos Urob 0.2­1.0 0 & P
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative
ioschpic Urin.'

RBC HCG Negative
Morph ,
-

Spun 4252% (M)
CSF ..• Blood Bank
Hematocrit 37-47% (F) -
: " • .' Sed Rate
Cell
MUST SUBMIT SF 518 WITH
.._ Count
EVERY UNIT REQUESTED
Other Directigen [ Negative
ABO/Rh Coagulation "Studies.
-.. :.Blood Bank Unit Crossmatch• . .
- • -.
:: •... •.': ' ::

(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
REQUESTED)
TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 secs APTT 21-34 secs D dimer . 20 ug/m1
• ...1
FDP 10 ughnl
REMARKS: I REPORTED BY: -DATE: LAB ID NO.:.
'

DOD-035833

CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
Pt Name:

Ha mmol/L
2.4 mmol sL
Ti7n2 29 mmol/L
Hct 22 %PCV
Hb* 7 g/dL
*via Hct

Rt 370
pH 7.331
pe02 52.4 mmHg
PO2 112 mmHg
HCO3 28 mmol/L
BEecf 2 mmoisL

s02*
*calcuIatPd

At Patient Temp

7.339
PCO2 51.1 mmHg
P02 108 mmHq

Pat ient Temp: 97.5F
F102_
.ample Type_ ART

03N0V03 1 12

41, (

oper : ( 5)((a)
Physician:

Jc

°NI )

(P..i.e-COlo),Ckirtii 'st6,, ulg .
RESULT REF. RANGE 128-145 mtno1/1 73-118 mg/d1 7-22 mg/d1 8.0-10.3 nag/dl 0.6-1.2 mg/dl
98-108 mmol/1 18-33 mmolit
BUN AMY TEST RESULT REF. RANGE ALB ALP 3.3-5.5 g/d1 26-84 IA 10-47 IA 14-97 11-381111 0.2-1.6 rng/d.1
NA+ 6.4-8.1 01
LU -tCO2
tCO2 18-33 alino1/1

DOD-035834

Ward/Section-
jrelcItStoh eYprREctTofF1097R11,

uE s-TtRivac8yUAL4 ) I
-1—e.t--¦

-770 I

AT Ff RST. MI. DATE TIME S
S 14-.12 (..b 6
(rigt-olo .

TEST RESULT REF. TEST REST REF. RANGE RANGE
ALB 3.5-5.5 g/dl GLU 73-118 mg/di ri 1.7 mmo 1 /L
ALP 26-84 u/1 BUN 7-22 ilig/d1 cc 2. a mmo 1 IL
ALT 10-47 u/1 cA++ 8.0-10.3 mg/dl TCOZ 29 mmo I /L AMY 14-97 CRE 0.6-1.2 mg/di He
21 ?.PCV AST 11-38 u/I NA+ 128-145 mmol/1Hb* 7 ci/dL TBIL 0.2-1.6 mg/dl IC 3.3-4.7 mrrioul
*via Hct

BUN 7-22 mg/d1 CL 98-108 mmol/I 37C CA++ 8.0-10.3ing/d1 tCO2 18-33 mmo1/1
Dr! .
7. 1'..4
100-200 mg/a1
CHOL
PCO2 4E.2 mmHg

P02 152 mmHg CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE
H003________28 mmol/L

GLU 73-118 mg/d1 ALB 3.3-5.5 g/d1 BEecf 3 mmol/L
TP 6.4-8.1 g/d1. ALP 26-84 u/I
-02* 39%
iccoloj.Metlyte •8 ALT 10-47 u/1
*calcu 1 a t

TEST RESULT REF. AMY 14-97 RANGE
At Pat lent. Temp
GLU 73-118 mg/d/ AST 11-38 &I

pH 7.407 BUN 7-22 mg/d.1 TBIL 0.2-1.6 mg/d1
pi:m2

44.0 mmHg CRE 0.6-1.2 mg/dl GGT 5-65 Lel
pn2

14? mmHg CK 39-380 u/I (M) TP 6.4-8.1 g/dl 30-190 u/1 (F)
Pat lent Temp: '37. OF

NA+ 128-145 mmol/1
F102 : 4. 5

Sample Type_: ART mmol/1
TEST RESULT REF. RANGE
03NOV03 18: 02

98-108 mmoill 128-145 mmol/1
°per:

tCO2 18-33 mmol/1 3.3-4.7 mmol/1
Prigs ic

CL" 98-108 mmol/1
tC0-2 18-33 mmo1/1
.1, 6

REPORTED BY: DATE: LAB ID NO.:
DOD-035835
Ward/Sectio: , . RE Q YSIEI
I LABORATORY RESULT ORM
—
1

(10)(‘) .2--(Subject to the PrivacY Act of ..974
LAST, EIRST, MI.

DATE TIME SSNLPSEUDO S

TbyG) Li-
,
(IL ,.,....ta,.CBC ::

,.. ..Urinalysis : ..Ise:
• .
TEST 1.—

m TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC - '71,77; Color N/A RPR Negative
RBC wi N/A Mono Negative
n --. ,, .•., .

.,.-:-..
Hgb ----' L '' '' Negative :
U Glu :.. Microbiology
Hct z5,3 L 7, :5,i:-.7.0,.:• Biii Negative
Source 7.:;.: ,,.;
MCV .,7, ,-, 3.1.,C; Ket Negative Gram
gi._ Ir.,.6 :7,0

,---;:' 1;31 , -.y...--:: Stain
Pit SG N/A
OCC Bld Negative

'_.-:.
_. j :: --i_ ,.:. i .: .-..,.
Lymph % Bld Negative H. pylori , Negative

I (Heniatakity) Manual Differential ::' pH N/A Micro Parasites Segs. Mono Prot Negative Malaria
Bands. Eos Urob 0.21.0
-
0 & P

Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative
' rDSCOpiC

, • - -, . RBC HCG Negative Morph
Spun 42-52% (M)
Hematocrit 37:47% (F) -• s ' • .

. Sed Rate
Cell

MUST SUBMIT SF 518 WITH . Count EVERY UNIT REQUESTED
Other Directigen Negative
ABO/Rh 'Coagulation Studies.' 1:(-– '.:- •BIoOd:Bank Unit CrOsinatch . .. :::.'
:.•-•.'•.•.-,.

(MUST SUBMIT SF,518.WITI1 EVERY UNIT OF BLOOD : :. -.:::.'.::.;•.:...-.'..-:.-.'':::...:.''''..•.. .'::. :•.' ' : -.
• : •.. ,:.s.- :' REQUESTED)
TEST RESULT REF. RANGE UNIT
TYPE CROSSMITCH
PT 9.8-13.6 secs APTT 21-34 secs D dimer 20 ug/m1
-. FDP 10 ugiml
REMARKS:. (..6 (. .2-REPORTED BY: N-TE: LAB ID. NO.:
DOD-035836

fJ

-s -

Q LJA
" Co
o co
0
co 3 _
CU 0" Li)
(0 Z 0
cn
-13
r-
Aiolwoqei
wJoj ABolomonnAl

DOD-035837

Microbiology Report
IBN SINA - HOSPITAL Laboratory
Name: Specimen: R036 Statijs: F161
Patient ID: Source: Sputum Collected:
Ward/Rm: U1/ Ward of Iso: Attd. Phys:

1 Pseudomonas aeruginosa Status: Final
I.' 2 Klebsiella pneumoniae Status: Final
1 P. aeruginosa 2 K. pneumoniae
Druq MIC Interps Druq MIC Interps
Amox/K Clay (c) 16/8 Amox/K Clay (c) =8/4
Amp/Sulbactam (c) 16/8 Amp/Sulbactam (c) 16/8

Ampicillin 16 Ampicillin
16
Aztreonam =8

S Aztreonam 16 R
Cefazolin

16 Cefazolin 16
Cefepime =8 S

Cefepime =8
Cefotaxime (c) 32

Cefotaxime (c) 32
Cefotetan 32

Cefotetan =16
Cefoxitin 16

Cefoxitin =8
Ceftazidime (a) =8

S Ceftazidime (a) 16
Ceftriaxone (c)

32 Ceftriaxone (c) 32
Cefuroxime (b) 16

Cefuroxime (b) 16
Cephalothin

16 Cephalothin 16
Chloramphenicol 16

Chloramphenicol =8
Ciprofloxacin =1 S

Ciprofloxacin =1
ESBL-a Scrn 4

ESBL-a Scrn 4
ESBL-b Scrn 1

ESBL-b Scrn 1
Gentamicin =4 S

Gatifloxacin =2 S
Imipenem (c) =4

S Gentamicin 8
Levofloxacin =2 S Imipenem (c)

=4 S
Meropenem (c) =4 S

Levofloxacin =2 S
Nitrofurantoin 64 Meropenem (c) =4 S
Norfloxacin =4

Moxifloxacin =2 S
Pip/Tazo (d) =16 S

Nitrofurantoin =32
Piperacillin (a)

=16 S Norfloxacin =4
Tetracycline 8

Pip/Tazo (d) =16 S i.
Ticar/K Clay (a) =16 S

Piperacillin (a) 64 R
Tobramycin =4 S Tetracycline =4 S
Trimeth/Sulfa 2/38

Ticar/K Clay (a) =16 S
Tobramycin 8 R
Trimeth/Sulfa =2/38 S
S = Susceptible N/R = Not Reported
Blank = Data not available, or drug not advisable or tested
1 = Intermediate

= Not Tested

ESBL = Extended spectrum beta-lactamase
= Resistance

TFG = Thymidine-dependent strain
Blac = Bela-lactamase positive
MIC = mcg/ml (mg/L)

R• = Resistant due to extended spectrum beta-lactamases (ESBL)
EBL? = Suspected ESBL. Confirmatory tests needed to differentiate ESBL from other beta-lactamases.
IB
= 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 davutanale or ampicillinisulbactam with enterccocci, refer to the penicillin interpretation.
(a)
For non beta-lactamase producing enterccocci, 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 patients with meningitis. For non-meningitis infections, use 2.S. 2=1, 2=R.

Name: Specimen: R036 Status: Final
Patient ID

Source: Sputum Collected:
Ward/Rm: Warri of Icn•

Req. Phys: MEDCOM - 22262 _ . U9 -2--
DOD-035838
3 3
CD O
O
0 0
CD
sa
Cl)
-n
O
1 3

:slaaqs patioene lo JeciwnN

I

DOD-035839
27 mmoii!

THT, :57u

PH 7.4A7

cf:1r9

PO2 54 mmHg

HCO3 2. mmoliL

sEcf I mmol/L

88 %

rairulated

At Patient Temp

PH

40.9 mmHg
PO2 54 mmHg

Patient Temp: 98.7F
FIn2 : 70
Sample Type_: RR?

04NOV03 00:55

°Per: 11111

Psician:•

_J
Pt Name;

28 mmol/L

At 870
PH 7.249
PCO2 48.7 mmHg
PO2 e5 mmHg

27 rilmoi/L
6Fec4 1 mmol/L
cn2* 91 %
calculaed

Pt Patient Temp
pH 7.:=;4E

49.2 mmHQ
PO2 mmHg

Patient Temp: 99.0F
F102

able RRT
gi4NOV08 02:44

jPer:

Pnusician:

Ser;
Ver:

_J _J

.71 M

•=' E E
11".. tJ U. -0

,7•• •
so, I-

• 1.0

17,1 •
LI

U

6-1 .1. :NJ

L/J

a LL C.1:1

r , -
Pt Name:

28 rANol/L

At 370
PH 7.2.g
mmHg
P02 54 mmHA
hu03 2 mmol/L
5Eec 1 mmol/L
%

*calculated

At Patient Temp
pH
002

47.5 mmHg

P02

55 NMHQ
Patient Temp: 93.4F
FIO2 : ;=;13
Sample Type_: RRT

04N0V03

Of%:25,

°Per:
Pn.4siclan:

a:
.:0C..1 1.0 Cr, CL
1
a
fl
rn
LI LL

Pt r
Pt Name:

:uu2 26 mmol/L
Rt 870
pH 7.2E2
47.1 mmHg
PO2 95 mmHq
-1:03 ze mmol/L
,BEecf ' 1 mmol/L

*calculated

Rt Pauent TeMP
PH

PCO2

49.7 mmHg

P02

102 mmHg

Patient Temp: 100.8F
FIO2

: 100
3amp1e Type_: RRT

04NOV08

05:02

ePer: AIII/I,
pro4sician:

a a
DOD-035840

Rt. 370
Pt1 7.353
IT:n2 47.7 mmHg
P02 12' mmHg
Hr:r13
6FPCf NAW1 1 1_
'Rt 370
002 mmHg

*r a lrulated
sample ype_

04NnV03 09:3C.

OPer:11111.

111111,

111111111P

•lila
, rif. •

7002 27 mmo1,

Pt 37C

pH 7.404
PCO2 41.1 mmHg
P02 mmHg
h003 2.mmol/L
BEecf I mmol/L.

502* 94 %
*rairillated

Sample Type_:

04NOV03

°Per:11111F 006)_2d
P7iysician:

P7_

Pt f.tame : 4
Pt 370

PH
P002 72.1 mmHg

PH 7.397 Rt 370
mmol /L p002

41.0 mmHq P 7.395 BEecf mmo1/L p02
1 03 mmHq P0n2 4111.e mmHg

2=. mmol/ 002 71 mmHg
REerf 0 mmol/L 1003 2s mmoi/L
c02* 8E15& 0 mmol/L

Sample Type_

*calruiateO S02* 94 %
*ralr'ulated

04NOV03 07:47
Sample Type_:

0pr:

Sample Type_:
04NOV03 13:46

Pnysiclan;

04NOV03
OpPr: 0759

Ser4
°Per:1111111r

Phqsiclan:

Ver:

='?r# 4111111111,
60)

_J

rn Cr'
0 M r
E E E

••••••!
ii !:••.1
6.1
C
(1)
U *
cm
W
11) o W
2 iU kr,

_J
rn IT 4_
2 0

a a E

E E E 0 0, f.1
0 0 a *
()(()7,
.1) a) 0 • (..J a
CL

C

•• LI
.13

) I_I fl LI .11ri Li * * a C•• ri CL .71.1
0 N
M L.

11- LL UI U-0_ 0_ 4_ 0 CL

11M (Nk-1

-22265

DOD-035841

Ward/Section:
LABORATORY RESULT FORM

:REQUEST (0 k) 2-
LAST, DA -T1M_E

S

0)(0 Li.' .. nelLOainisn D LI:
uriq. (0) L. emattilogy) CBC— , 1 . TO.gy:
.i'' , .
TEST 11111.11:.:;-,:.--=i-TEST RESULT REF. RANGE TEST RESULT REF RANGE
NBC 1 ,-_-,,it Color N/A RPR Negative
RBC ; --: _ App N/A Mono Negative

Hgb d_ -h CO fl. CO Glu Negative. Microbiology
.. --.7 L ; -'_ 11.0 li1. 1) .. :. .
Hct !!,-t ., -;.,' L 'f. 1:5.0 ::,),::; Bill Negative Source
•
MCV '-.--.. 1 F2 27.0 :1,0 Ket Negative Gram •
3/aL 7.! Y;•=0 Stain
?:.,_. ,.:::::: :=:10'.3.-i- _;:i.,.-.:.,.

Pit SG N/A Occ Bid Negative
Lvt: :i.:.: ,.-4._ .,•". f. 5i.:
Lymph % L. , '.':' :L I '1311 '-: '' 4 Bid Negative H. pylori . Negative

(Hemntokigy) Manual Differeptill ,, pH N/A Micro
': : ' :• : : ,

Parasites
Segs Mono Prot Negative Malaria

• -;,
Bands. Eos Urob 0.24.0 0 & P

Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative - MicioscOpie Urina ' .
RBC }ICG Negative
Morph

Spun 4252% 0.4)
-

CSF , • Blood Bank , • ..-• .
Hematocrit 37:47% (F) ' ' ' • • . -
. ,
Sed Rate

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

Coagulation Studies:: . : : !: - :- .Blood. Bank Unit Crossmatch .
... .. . : .

(MUST SUBMIT SE 518 WITH EVERY UNIT OF BLOOD
REQUESTED)*
TEST RESULT REF. RANGE UNIT TYPE CROSSALiTCH
PT 9.8-13.6 sees
APTT 21-34 secs
D dimer 20 uWim1
FDP .e10 ug/m1
REMARKS: „.......

BY: DATE: LAB ID. NO.:
AN
•
MEDCOM - 22266

DOD-035842
Ward/Se t og: ¦ • ' 71LMISTRY RESULT FORM /VP) —2...— :(Subject to the Privacy Act of 19 .74) DATE TIME S N SE 0 SSN oei(f)4
q't 0/5-3

pt Name: RANGE TEST RESULT :REF.:TEST RESULT REF. RANGE RANGE :
GLU 73-118 mg/di
Na .

mmol/L--

BUN 7-22 rag/d1
mmol/L ------- PICCOLO .

Ina( CA'" 8.0-10.3 nig/d1 TCO2.2a mmoisL 04/11/03.08:30
CRE 0.6-1.2 mg/d1
REFERENCE RANGE: MALE

Hct .*** .

.-128-145 mm01/1
11PATIENT #:

Hh*.

*** gsdL

METLYTE 8

3.3-4.7 mmulil
*via Hct

3151AA4

DISC LOT #:.

98-108 mmo1/1

CL­
OPER#:111..

DR #: 000

At 37C

Tit SERIAL #1 tCO2 18-33 'mmo1/1
pH.7.302

, .

(00021

PCO2.(pfccolo)-Livel: Pane) -
54.c. mmHg

GLU 103 73-118 MG/DL

PO2.F;0 mmHg.4NGE
T-BUN.MG/DL
43* 7-22.
HCO3 27 mmolsL 0.6-1.2 MG/DL

CRE ICT.

zm 11
U/L
NA+.Name:

BEeci .I mmol/L CK 1292* 39-380.

181* 128-145 MMOVL

.94 ;,
di K+.

3.1* 3.3-4.7 MMOVL

*calculated

121% 98-108 MMOVL

CL-.

Crea.

ig/d 2.5 mg/dL
MMOVL

tCO2 19 18-33.

Rt Patient Temp

Sample Type_:

aWa .

PH.7.283 INST CHEM GC: OK
OC: OK.
PCO2.PCIe HEM 0 , LIP 0 , ICT 3+ 04110V03 dl

P02.or mmHg

OPer 1111111 (IDYY)Z-11
Patient Temp: 101.0F .
0

physician:
FIO2.

Sample Type_:

INGE
,
04NOV03.

08:30

11.8-1.43 InM0111
3.3-4.7 mmo1/1

'IP t't ( 6*2.
Physician: .

98-108 mmoLl
18-33 rnmo1/1

REMARKS:
Fq0 6
REPORTED BY: DATE: LA ID NO.:
.

DOD-035843
Ward/f,eiction; IC
CHEMISTRY RESULT FORM
( I Sub'ect to the Privacy of 1974) T SSN/PSEUD
t..5 Q
(Piccolo) Che nistr 12 ic 616):Meibo
Pt f:Narcie: 4

TEST RESULT REF. TEST RESULT REF. RANGE RANGE
No.-170 mmol/L ALB 3.5-5.5 Wdl GLU 73-118 mg/d1
2.6 mmoi/L ALP 26-84 u/1 BUN 7-22 mg/d1
T002 28 mmol/L ALT 10-47 u/1 CA+ 8.0-10.3 mg/di
Hct %Pcv AMY 14-97 u/1 CRE 0.6-1.2 mg/d1
Nb* 7 q/dL

AST 11-38 u/1 NA+ 128-145 MmOlii
via Hct TBIL 0.2-1.6 mg/dl 3.3-4.7 mrnolit
At 37C.BUN 7-22 mg/d1 CL-98-108 mmol/1
pH_.355

CA 8.0-10.303g/di tCO2 18-33 mmo1/1
PCO2 .

.1

CHOL 100-200 mg/d1
PO2.145 mmHg

0.6-1.2 mg/cu1

CRE TEST RESULT REF. .RANGE
HCO3 27 mmol/L

BEerf 1 mmol /L GLU 73-118 mg/d1 ALB 3.3-5.5 g/dl
s02* TP 6.4-8.1 g/d1 ALP 26.84 u/1
*cal ed ." ALT 10471.111
TEST RESULT REF. AMY 14-97 Lill
At Patient Temp

RANGE

PH 7.342 GLU 73-118 rag/di AST 11-38 u/1
.Nrdici

50.1 BUN 7-22 mg/dl TBIL 0.2-1.6 mg/di
150 roi1-19

CRE 0.6-1.2 mg/d1 GGT 5-65 WI
CK 39-380 (M) TP 6.4-8.1 g/dl
..1.t.ient Temp: 100.2F.

30-190 u/1 (F)

Fit2.: 50.NA* 128-145 mmol/1
Type_:
33-4.7 mmol/1

TEST RESULT REF. RANGE
04H0w03.

10:05

98-108 mmo1/1 NA"' 128-145 mmol/1 Op r tC0
111011(0(G) 2--

18-33 mmol/1 3.3-4.7 rnmo1/1
Physician: .

CL: 98-108 mmo111
tCO2 18-33 mmol/1
REMARKS:
136_, F62, 96 7 "re.' J 1 e
REPORTED BY: DATE: LA ID NO.:
MEDCOM - 22268

DOD-035844
Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM

LAST, FIRST, 1A DATE TIME SSN/PSEUDO SSN:'
'r ematOlogy) CBC.. , . .Urinalysiss E: ,, Mis c. Serol?gy:
TEST ..'-...':1:"'":° ""rf7-v____ TEST RESULT REF. RANGE TEST RESULT :REF. RANGE
WBC .;,.1 i- Color N/A RPR Negative
RBC Hgb Hct U01(9) 14 4,..0 :.i.j ri ',41 ,..; _.: -_,.. ral :, I ''•••• ¦ • -L •,;:-.; ., ? ! ::.-:! :Pc ::'7'. 1 L 1 -.-szi '''' _ •-1;...:l1-.3 ,tr) 1 ,:: ­.; i.C1­f 3: ,:l: i :: :., %i. -.5.•.
,..)). ,": App Glu .Bih - N/A Negative Negative Mono ..:. - ,. Source Negative . Microbiology , : •
MCV Pit ;:',. ?"'"_•:'.: , 1.4 _.0 a, S -.. 1 pg '12. -,--. . -.,) :::;:- 7 . J.., .' :7/, Ret Negative N/A . Stain Gram Oce Bld .. Negative
Lymph % L.: 1 : , _ ; -, , ,.: ,., :.,," Bld Negative H. pylori Negative
(Hema tology) Manual Differential ,: . i . pH N/A Micro
Parasites
Segs Mono Prot Negative Malaria
Bands. Eos Urob 0.2-1.0 0 & P

Lymph Baso Nit Negative Other
.

Atyp Imm Leuk Negative
:. kicrscOpit .Urina sis •

RBC HCG Negative Morph
,
.._ ........ ..._

-
pun

". • . -' • • Blood. Bank
'.• . -• •

Hematocrit 37-47% (F)
•.. • •

Sed Rate
Cell

MUST SUBMIT SF 518 WITH. Count EVERY UNIT REQUESTED . Other Directigen Negative ABO/Rh
Coagulation Studies. • - .BloOd. Bank Unit crossmatcli : - " • (MUST,SUBMIT SF 518 WITH EVERY UNTT OF BLOOD . •
. .
•

TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 Seca AFTT 21-34 secs D dimer 20 ug/m1
FDP 10 ug/mi
REMARKS:
REPORTED BY: D 'LAB ID NO.:.

ATE:

E

DOD-035845
Warr CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974)
',111111111t
TIME SS
r •
Pt:
Pt Name:

Na.16-3 mmol/L

.a.2 mmol/L
TCO2.27 mmol/L
Hct .30 %PCV
Hb .10 gsdL

*via Hct
At 37C
pH.
PCO2.

44.8 mmHg
P112.8,f; mmHg

.a mmol/L
6Eecf .1 mmoisL
sO2*.-11; %

*calculatPd

At Patient Temp
PH.7.3“,
PCOZ.

45.2 mmHg
POZ.87 mmHg ,

Patient Temp: ”.0F
FIO2.: 80
Sample Type_:

04NOV03.

12:01

Oper:
•

(LA)
Physician:

e r it

REMARKS:
REPORTED BY:
&Pi&0IO) Chemistry F2 TEST RESULT REF.
ALB ALP ALT AMY
AST TBIL BUN CA CHOL CRE
GLU
TP
TEST

GLU BUN CRE CK.
NA*
_CL­
tCO2
RANGE
3.5-5.5 g/dl
26-84 u/1 10-47 u/I . 14-97 till
11-38 u/1
0.2-1.6 mg/dl 7-22 mg/dI 8.0-10.3mg/d1
00-200 ,oWdI
.6-1.2 mg/di
3-118 mg/d1 .4-8.1 g/dl
sccalgMetlkte.

ALB
ALP
ALT

RESULT REF.:AMY RANGE
73-118 rag/d1 AST
7-22 mg/di TBIL
0.6-1.2 mg/di GGT
39-380 u/I (M) TP 30-190 u/l(F) 128-145 mmol/1

3.34.7 mmol/1 TEST
98-108 mmo1/1 NA
18-33 mmo1/1

CE
t

TEST RESULT REF. RANGE
GLU 73-118 mg/dI BUN 7-22 mg/d1 CA 8.0-10.3 rued' CRE 0.6-1.2 mg/di NA' 128-145 mmol/1
3.3-4.7 mrnol/l

CE 98-108 mmol/1 tCO2 18-33-mm01/1
TEST RESULT REF. RANGE
3.3-5.5 g/d1
26-84 u/I 10-47 u/l
14-97 u/1
11-38 u/I 0.2-1.6 ing/d1 5-65 u/I 6.4-8.1 g/d1
RESULT REF. RANGE
128-145 mmol/I
3.3-4.7 mmol/1 98-108 mmoLl 18-33 ramo1/1

DOD-035846

WarcUSectivn:
1(.11 I
do (0(4 )

:
Pt Name: .

Na.168 mmol/L K 2.7 mmol/L TCO2.27 mmol/L
Hct 21 'PCV
Hb* 7 gidL
*via Hct

Ht 37C
pH 7.413 PCO• 39.2 mmHg P02 121 mmHg HCO3.25 mmol/L Srpcf 1 mmol/L zO2* 155
*ralculatPd

Rt Patient Temp
pH.7.421
PCO2.

35.0 mmHg
P02.120 mmHg

Patient Temp: 58.4F
F102.: 80
Sample Type_:

04N0V03.

1405

Op r:

6)(,(0) 2_

Physician: .

REMARKS:
1b

REPORTED BY: DATE:
r. T
çtlyte
RESULT REF. RANGE
73-118 mg/d1
7-22 mg/.1.1
mg/d1
39-380 u/1 (M) 30-190 u/I (F) 128-145 mmol/1
33-4.7 mmol/I
98-108mmoVI
18-33 mmo1/1
LAB ID NO.:

CHEMISTRY RESULT FORM
Sub'ect to th Act of 1974)

S

10 ( 4+ icco16): •
TEST RESULT REF. RANGE
GLU 73-118 mg!cil BUN 7-22 mg/dl CA" 8.0-10.3 rogidl CRE 0.6-1.2 mg/d1 NA+ 128-145 mmol/1
3.3-4.7 mmo1/1

CL 98-108 mmol/1
tCO2 18-33 mmoV1
Piccolo) Liver Pan el
TEST RESULT REF. RANGE

3.3-5.5 -26-84114 ALT 10-47 &I
AMY 14-97 10
AST 11-38 u/1 TBIL 0.2-1.6 mg/d1 GGT 5-65 uJI TP 6.4-8.1 Oil
TEST RESULT REF. RANGE
128-145 mmol/I
3.3-4.7 mmol/I

CL 98-108 rnmoVl
ECO, 18-33 Guno1/1
(48

ALT AMY AST TBIL BUN CA++
CHOL CRE
GLU TP
TEST

GLU BUN CRE CK
NA+
CL
tCO2
DOD-035847

Wardite rRt.QU-Apllitoyo.
CHEMISTRY RESULT FORM
(Subject to the Privacy Act of 1974)D T INILPSE Se S 1¦/:
111111. (.61.(viL) 0)
Pt Name:

TEST RESULT

ALB
Na.1G8 mmol/L

ALP
.2.7 mmol /L

ALT
T002.2.; mmol/L Hrt .22 %PCV AMY Hb*.7g/'IL AST
*via Hct

TBIL BUN
At 370 pH.7.431 CA P002.
3e.9 mmHg

CHOL
P02.30 mmHg

CRE
HCO3.25 mmol/L

GLU
0 mmol/L.
r.0a* 37 TP
jet01 0?81i'
TEST RESULT
At Patient Temp
pH.7.441 GLU

P002.BUN
35.8 mmHg

.87 mmHg CRE CK
Patient Temp: 37.4F F102.: 75 NA 5ample Type_: ART
14:35

04NOV03.

.CL-
Oper

tCO2
Physician: .

I 02_ 75 1,

DATE:
v .JV )

REF.:TEST RESULT REF. RANGE
RANGE

3.5-5.5 Wdi GLU 73-118 mg/di
26-84 u/1 BUN 7-22 mg/c11

10-47 u/1 . CA+4 8.0-10.3 rag/d1
14-97 u/I CRE 0.6-1.2 mg/d1
11 -38 uit NA' 128-145 mmol/1

0.2-1.6 me& 3.3-4.7 mould
IC

7-22 rog/dI CU 98-108 mmol/1
8.0-10.3mg/d1 tCO 18-33 , mmoUl
100-200 mg/d1
anOTh
J*0)10gx01::1 ­

0.6-1.2 mg/d1 TEST RESULT REF. RANGE
73-118 mg/d1 ALB 3.3-5.5 g/dl
6.4-8.1 g/dl ALP 26-84 oil

ALT 10-47 u/I
REF. AMY 14-97 &I
RANGE

73-118 mg/dl AST 11-38 u./1
7-22 mg/di TBIL 0.2-1.6 rag/d1
0.6-1.2 mg/dl GGT 5-65 u/I
39-380 u/l (M) TP 6.4-8.1 g/dl
30-190 u/I (F)
128-145 mmo3/1

3.34.7 mmol/I TEST RESULT REF. RANGE
98-108 mmol/1 N. 128-145 mmo1/1 t.
18-33 mmol/1 3.34.7 rnmoU1
C 98-108 mmoL'I
tCO2 18-33 mmoUl
.1-
LAB ID NO.

DOD-035848

Ward/Se i :LA REQ '
N: (9) ((i) -2..... LABORATORY RESULT FORM
/ (Sub ect to i • ' Act of 1974 LAST, FIRST,,K. DA z_. ,
Troi . ss
(G b 04,
(H matol ) . . :, : :: : - _Urinalysis :: ., . , 11;1*. -. ' gy
. :. . .
n

TE C."Y7 r _ TEST RESULT REF. RANGE TEST RESULT REF. RANGE
-'.

WBC RBC :.---,-. .._•±.3. 7 LIPJ.T..:7 Color ,, App - N/A N/A RPR Mono -Negative Negative
Hgb Hct ' • 4.6 Wit ,:..E-.-!-,.­.I.: 2. '7,-..-, i_ _--:' -"..:'2,.;.i .:g ._ xift•'.:Sql_ ci.i. — 4,••)1.) ii,:i--` i.i, ..;i.. I IR,:.:--- Glu --Bill Negative. Negative : • • Source Microbiology -.-. ., . . .• , • ' •
MCV .: Pit fk-a Pl. ''. '23. 7 ',-.7. 1? ,3 eN':/ii." L''`'­' '.'27) :',..0 in. Arff.3, Ket SG Negative N/A Gram Stain Oce Bld .--Negative
Lymph % '..'i,•; ; -- 12.;1 ,
wi. :.: :::: , 1, : i. L.2 :., Bld Negative H. pylori , Negative
Menlati*gAM2OuniPifferentiall ',. ,. , ..• , • • •-• pH - N/A Micro Parasites 1
Segs. Mono Prot Negative Malaria
Bands. Eos Urob 0.2-1.0 0 & P -

Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative
MkrascOpiC .Urina ' .
" . . -• . , ... . .

RBC HCG Negative
Morph
'
-

Spun 4252% (M)
.. Blood Bank .•

Hematocrit 37:47% (F)
Sed Rate
Cell
MUST SUBMIT SF 518 WITH

Count EVERY UNIT REQUESTED Other Directigen Negative
'

ABO/Rh .:- Coagulation Studies.: :!; ' , s •
' • --'. -' - •BloOd: Bank Unit Crossmatcli - - ' -•: -
-,-• . . . . • • -
•.. ,, -.. : . .-. -(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD .:
TEST RESULT REF. RANGE UNIT TYPE CROSSA14TCH
PT 9.8-1. 3.6 secs .
APT1' 21-34 secs
D dialer 20 ug/ml .

-FDP 10 tig/m1
REMARKS:
'

REPORTED B DATE: LAB ID NO.: . 41/1)0 (YS
-

DOD-035849

Ward/e" Uon •
RESULT

"(sriZ`!siornM ' 9 I
o lfF1974)

LA5 SS

lAfts rUilbo
lecolo):Chirn-
Pt Mare

"EST RESULT :REF. TEST RESULT REF. RANGE RANGE
Na Na ,B 3.5-5.5 z/d1 (3LU 73-118 mg/d1
15 mmol/L

UN 7-22 mg/d1
2.8 mmoisL

CI.

TCO2 28 mmoi/L 8.0-10.3 mg/di
PICCOLO

..

PH Hct 22 .PCV D4/11/03 16:04 RE 0.6-1.2 mz/d1
PC Hb* 7 cisdi. REFERENCE RANGE:.128-145 mmo1/1
MALE

POl RATIEN1 #: 1111111, %.(9)
hid
3.3-4.7 mmolit
1ETLYTE 8

.

-.,

DISC LOT # 98-108 mmol/1
3151AA4

.
HC! 7. 4 DPER #: DR #: 000 :02 18-33 mmoL/l
RI AL

saj. mmHg
(Piccolo) Liver Panel Plus.
34 mmHg

BEI 3LU.
133* 73-118 MG/DL TEST RESULT REF. R4JVGE
------a7 iriio 1/L

47* 7-22.

3UN.MG/DL

An .
LB 3.3-5.5 g/dI
mmol /L :RE.ICT 0.6-1.2 MG/DL
Ca
LP 26-84 u/I
2K 1293* 39-380 U/L BU NA+ 164* 128-145 MMUt LT 10-47 u/I
0 3.5 3.3-4.7 MMOi/LGL 2L-.121* 98-108 MM0f/L MY 14-97 till
Pt Pal Terqp

tCO2 22 18-33.

MOM_

Cre PH ST 11-38 u/I
Het PCO2 40.2 mmHg INST QC: OK.0.2-1.6 rpg/cll
CHEM 00: OK BEL
HEM 0 , LIP 0 , ICT 3+

Hg] ISO mmHg GT 5-65 u/I
P 6.4-8.1 Wdl
7at lent Temp: 37.4F

Ti (Piccolo) Electrolyte
•ample Type_:Doi
rEST RESULT REF. RANGE
04HOVQ. 16:0

Drc
128-145 mmol/1

Abi (
o P er:1101 ic)(6) 2-

3.3-4.7 mmo1/1
PhysiLian:

98-108 mmo111

:02 18-33 mmo1/1
REMARKS:
ckc

F! :'75/'
REPO TED BIT DATE: 1 •
I LAB ID NO.:

riC 4M 3
DOD-035850

Watielir: REQ IAN: (b b \
LABORATORY RESULT FORM
) ( (1) 2.-
(Subject to the Privacy Act of 1974)

LAS, .- - ---'1 SS N:
ZUVE 'TM) WO ) 4
.. ii. . . o ) CBC :: Urinalysis . ' wpsc seroigys
TEST -,. :n--:n ':`71. TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC -''' (6)(6) 1
Color
N/A RPR Negative RBC App N/A Mono Negative
1;:
..

Hgb ,---Negative.
Microbiology
-. -.:,::.
. • • -

Hct .:t _...::: : .-: -— — Bili Negative
Source MCV Ket Negative
._ Grain
21+ :ss:77.:;-al. ci
Pit 7- N/A Stain OCC Bld Negative
:_,-; 1, -:; -,.1:-­:;,.._ z,2 -,Lymph % eR1031°ItY). Nimbus] Differential Segs Mono Bid pH • Prot Negative N/A Negative -II. pylori Micro Parasites Malaria . Negative '
Bands. Eos Urob 0.2-1.0 0 & P
Lymph Baso Nit Negative Other

Atyp Imm Leuk Negative
:.MicipscOpic NFU'

RBC HCG Negative
Morph
Spun 42.52%(M)
. . Blood Bank ...- . .

hem atocrit 37-47% (F)
Sed Rate
Cell

MUST SUBMIT SF 518 WITH. . ..... Count EVERY UNIT REQUESTED Other Di rectigen Negative ABO/Rh
4
. .., Coagulation Studies.'

' ; -' ' . '.: - .Blooltl Bank Unit Crossmatch
• . . , -(MUST,SUBMIT SF 518 WITH EVERY LINT1r OF BLOOD :
TEST RESULT REF. RANGE UNIT TYPE
CROSSILL4TCH

PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
• FDP 10 ug,/m1
REMARKS: [ REPORTED
LAB ID NO.: ' 1/1/Uti°3
2-
MEDCOM - 22275

DOD-035851
Ward/Section:
LABORATORY RESULT FORM

(Subject to the Privacy __ of ,
LAST, FIRST, Mt DA p.MESSN EUD

qktue. 0 nt) (13)1,V4
emat logy) CBC _Urinalysis
a

TEST — :°" ' °:'sf'-TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC .1:7f:.::-Color N/A RPR Negative
_ .-_

, ..._,

RBC -App N/A Mono Negative
Hgb Negative'
Glu hfirrobiology
. •

Hct .-I-. :I•' Bili Negative Source
.S .f. _.,.
MCV Ket Negative Gram

-.7_; :1.0_,
Stain
.: : S1,7, L ,

Pit , . .-.:: SG N/A OCC BId Negative
Lymph % ., . . , Bid Negative H. pylori ' Negative
. _ . -. _ . _ ,
—

ematOlogy) Manual Differential - -pH N/A Micro
Parasites
Segs Mono Prot Negative Malaria

-

Bands Eos Urob 0.21.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative . roscopic [Irina '
:. ..

RBC HCG Negative Morph ,
Spun 42-52%(M)
CSF • Blood.Bank , Hematocrit 37-47% (F) . •
Sed Rate Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen Negative I ABO/Rh
.. Coagulation Studies. :-: -- .Blood: Bank Unit Crossmatch - -
.

(MUST SUBMIT SF.518 WITH EVERY UNIT OF BLOOD
.

TEST RESULT REF. RANGE UNIT TYPE CROSSMATCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1 •
FDP 10 ug/ml
REMARKS:
REPORTEDBY: DATE: LAB ID NO.:
DOD-035852
cD
CD

CD C) 3 3
CD cp.
t-k

CCD c
C

0
•
0

cr C.
0 5
0
0
0.

0 .0 CD
CD
r+
m
0
3

Numberof attached sheets:
DOD-035853

a)r— Cl)) w
rn

Z Z
0.1
3 3
9). rn
3
0

co
CD .C2
CO
CD
O

O

3
0
6

Do

DOD-035854

•
O

0:
5
O 0
‘. 7J
CD
.0
C

CD
O

1
2

DOD-035855

Ward/Section: ‘ R UE
LABORATORY RESULT FORM 1
7--

fb)((9) (Subject to the Privacy Act of 1974)
LAST, FIRST,/vll. I DATE
TIME SS h. J )I SSN":6
.

51 -0\10-5 0 r) ()C 's emato , i4, . BC Urinalysis
Wise: Serotol. . ,..

) 0°
L T .:-:r' '17:17-TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC iL: '',-:--Color N/A RPR Negative
,,,,
RBC App N/A Mono Negative

Hgb Glu Negative .
Microbiology
.... . ,. .. . •-• -.

.: ;1 _ , iL ,., ,..7:‘, Bin
Hct Negative
'ri:: :. -:: --:;..-Source
MCV Ket Negative
Gram
Stain
Pit F': 27i. ;:f)':: i . 1F ,: z':, SG N/A Occ Bid Negative

Lymph % , ::.i 1,7 , -,.fl-: -:. i i,: ; Bid Negative H. pylori ,Negative.
(Hemattilcigy) Ma•nual Differential : : pH N/A Micro
...

Parasites
Segs. Mono Prot Negative Malaria

Bands . Eos Urob 0.2-1.0
0 & P 4 Lymph Baso Nit Negative Other
•

Atyp Imm Leuk Negative • ' '• -• •
TonOpIC UM'S
. . ..•
RBC ECG Negative •
Morph

Spun 42-52% (M)
, Blood.Bank .
_ % • .

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

MUST SUBMIT SF 518 WITH
Count EVERY UNIT REQUESTED
Other Directigen Negative

ABO/Rh

-:' Coagulation Stu•diO. -' -•: , - Blood BaOkUilit:rossniatch -
:: : •'::• ':.: :' --: . : e
-(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD • : :I.
. . _ . . -
. . .:: ,.. . . . .

• : ' : : -, .:i :• REQUESTED)
TEST RESULT REF. RANGE UNIT
TYPE CROSSMITCH
PT 9.8-13.6 secs -
APTT 21 -34 secs
. D dimer 20 uWm1
.

FDP 10 ug/ml
REPORTED BY:
DATE: LAB ID NO.:
DOD-035856

Wan:I/Section: CHEMISTRY RESULT FORM ) (Subject to the Privacy Act of 1974) DATE TIME SSN/PSEUDO
--777-7744g4W

( ,ieOlol:QhiinAtt¦! triecatiywtatioriePaliel--"..
P:

:)i(.6 4
.

Pt Haute: TEST RE • T.TEST
REF. RESULT REF. RANGE
RANGE
GLU 73-118 mg'd1
Ha .mmol/L PICCOLO ------- BUN 7-22 mg/d1

3.Mmol/L
8.0-10.3 rag/d1

10:55 . CA".
TCO2 27 mmoisL 05/11/03.REFERENCE. RANGE: MALE CRE 0.6-1.2 mg/d1
Hrt_____

PATIENT #: 111111,610 NA+ 128-145 mmol/1
Hb* 7 q/dL

GENERAL CHEMISTRY 12

3.3-4.7 mmol/1

3204AA4 DR #: 000 CU 98-108 mmol/1
DISC LOT #:.

OPER #41111,.

It
MON

SERIAL.tCO2 18-33 mmoIJl
) G/DL icolo)Livea Panel Plus:..
1.4* 3.3-5.5.
26-84.•

40.3 mmHg ALE.
P02 7 mmHg ALP 61.
U/L TEST RESULT REF. RANGE ALT.U/L
56*, 10-47.

•e mmoI/L

ALB 3.3-5.5 g/dI
AMY.U/L

95 14-97.

BEecf 1 mmol/L

AST.U/L ALP 26-84 u/I
185* 11-38.55 % TBIL 14.5* 0.2-1.6 MG/DL ALT 10-47 u/1 *calrulateH BUN.MO/DL
61 * 7-22.8.0-10.3 MG/DL AMY
CA++ 8.7.14-97 u/I CHOL 89* 100-200 MG/DL
At Patient Tlp

11-38 u/I

ICT.

CRE 0.6-1.2 MG/DL AST
PH.7.410

146* 73-118 MG/DL TBIL
GLU. 0.271.6 g/d1
PCO2.

TP ICT.
G/DL

6.4-8.1.

GGT 5-65 Lill P03 74 mmHci 6.4-8.1 01
INST QC: OK.

CHEM QC: OK

Patient Temp:

HEM 1+, LIP 0 , ICT 3+

F102, .: E0

3ample Type_:

05MOV03 10:52 128-145 mmcilil

-Tir5

REPORTED BY: DATE: . LAB ID NO.:
I

DOD-035857
Ward/Sect. REQUESTING
04))(2 )A L
_
BORATORY RESULT FORM
C....1/1
(Subject to the Privacy Act of 1974)

LAST, FIR T,MI.
TIME SSN/PSEUDO SS1110 c (e
0034 i 0 .c-•

Unna lysis • :: . ... , Misc. Soogy
TEST :.,-,_--;.: TEST RESULT REF. RANGE TEST RESULT

REF RANGE

_ ,:
-
WBC
N/A RPR Negative

App N/A Mono Negative
. .., : -, -: .::
Hgb --_ i :--',. i Glu Negative' -

Microbiology

. :. . • ' • •
Hct -: , -. Bili Negative

_..... _ : Source --:-._
MCV Ket Negative
Gram Stain

Pit :--:7. :I:': ' i7. -:. SG N/A
Occ Bid Negative

Lymph % ,•.' , 1-::-:i_ ..:: ':, ' Bid Negative H. pylori Negative
clieniatO1901 Manual Differential : N/A

pH Micro
Parasites
Segs Mono Prot Negative

Malaria

Bands Eos Urob 0.2-1.0
0 & P

Lymph Baso Nit Negative Other
Atyp Imm Leuk 'Negative
:iCioscapicT.Trifitilyiis:

RBC HCG Negative
Morph

.. -......

Spun 42-52% (M)
. CSF • . . Blood Bank . • '
.

Hematocrit 37L47% (F) .
— , • • . ' .
Sed Rate

Cell

MUST SUBMIT SF 518 WITH . Count
EVERY UNIT REQUESTED -Other Directigen Negati ve
I ABO/Rh ,
r.7 Coagulation Studies : -

! '' ' :': : -: Blood Bank Unit -ercissmatch . , . (MUSTSUBMIT SF:518.VVITHEVERy UNIT OF BLOOD REQUESTED)
TEST RESULT REF. RANGE UNIT
TYPE CROSSILL4TCH
PT 9.8-13.6 sees
APTT 21-34 sees
D dimer 20 ug/m1
•
,

FDI 10 ughni
-

REMARKS:
REPORTED BY: DATE: LAB ID NO.:
•

DOD-035858

Ward/ Section'
LAST, FI
Pt Name:

TEST :

Na
Ma: ig;e mmol/L
mmol/L

Cl.T002.ae mmol/L

PH.

Hrt .22 7,.PCV

PCO2 Hb* 7 g/dL
P02 *via Hot
TCO2
Fit 370

HCO3
pH.7.381

s02 P002.
41.3 mmHg

P02.84 mmHg

BEecf
HCO3.24 mmol/L

AnGap
BEerf .-1 mmol/L

Ca
BUN

*calculated

GLU

t Patient Temp

Creat
7.386

Hot.

PCU2.

40.7 mmHg
14gb.

P02.82 mmHg

.Patient Temp: 8. OF

TEST
FIO2.: ;3 0
•.ample Type_:

Troponin
05NOV03.

12:55

Drug of.

Abuse v..,.....

Oiler
)((0)

Physician: Of3

.../

5erit

111/

REMARKS:
REPORTED BY: DATE:
TIME
6.4-8.1 g/d1
REF.
RANGE

73-118 mg/d/ 7-22 mg/d1 0.6-L2 mg/di
3.34.7 mrno1/1
98-108 ramo1/1 18-33 mmol/1
LAB ID NO.:

CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974) SSN/PSEUDO SSN:
ici:o10)*Metab O I , •
i-sih,.

OD)y(6) 44

Pt

111111

Pt Ware: .

Glu.162 mg/dL
BUN.40 mg/dL
Na.1.:;5 mmol/L

.3.5 mmol/L
11 .130 mmO1/L
TCO2.24 mmoi/L
AnGaP.15 mmol/L'
Hot .21 %PCV
Hb*.7 Q/dL

*via Hot
pH.7.375
PCO2-.

39.3 mmHg

.23 mmol/L
BEecf .-2 mmoisL

5ample Type_

12:46

05N0w03.

opera"

phqL1clan, .

98-108 mmoL'l
18-33 mmo1/1

DOD-035859
•

Ward/Section: REQUESTING PHYSICIAN:
LABQRA.TORY RESULT FORM

LAST, FIRST,Ivit
DATE TIME SSN/PSEUDO SSN:
.( exitatOlogy) cpc :: : : Uri,' ilysis .i Misc: Ser.?!• gy.
,TEST -:I: :;TT.. TEST RESULT REF. RANGE TEST RESULT REF. RANGE
-...:._
.,.;

--, ColOr N/A , RPR Negative
,.._ RBC H_f_ __ App N/A Mono Negative
Hgb ::::-;" '.._:•:- Glu Negative -. -Microbiology
Hct _.. _ . .. Bili Negative Source '
MCV , Ket Negative Gram •-
•:-..1. -_.1.:_; •,_ , :._ --.,., ; 7_ :i Stain
Pit :7:-. : :,-i' -.. !-:-', =:;•, SG N/A Occ BEd Negative .
Lymph % :.- ..,:....L Bld Negative H. pylori ' Negative
(lionatalOgY) Manual Differential -.. :'' pH N/A Micro Parasites _. ../
Segs. Mono Prot Negative Malaria '
Bands. Eos Urob 0.2-1.0 0 & P , .
Lymph Baso Nit Negative Other .4,

Atyp Imm Leuk Negative :4171.1ciosceipie Uriaa ' . . :::: ' RBC HCG Negative . Morph
-• '

Spun 42-52% (M)
CSF ., -' : i' ,i, Blood Bank ::,, •
Hematocrit 37:47% (F) . , . . . • ... . •
Sed Rate
Cell MUST SUBMIT SF 518 WITH . :. Count EVERY UNIT REQUESTED Other Directigen Negative ABO/Rh
V.

.., Coagulation Stu:dies:: ' : :' - • • ' .' ..: -: Blood Bank Unit Crossmatch -.: - . :
::: (MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD REQUESTED)
TEST RESULT REF. RANGE UNIT TYPE CROSSALITCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 0 ughnl .. -
FDP 10 ug/mi .
REMARI(S:
All

PORTED BY: • DATE: LAB ID NO.:
DOD-035860

Wardi$5...tion:
7(6)(,(0 7, .

LA , FIRST, Iv DATE T.11\
TEST
Na
K
Cl
pH PCO2
P02
TCO2 HCO3
s02
BEecf
AriCrap Ca
BUN
GLU
Creat
Hut
Hgb
,-. --.7
TEST
(D

2:2....-.....: Nzl.v._,. i ;:r..z. i;. TAT) ft7711..(Pic-rolo),-CliirUislri .:1
-.,.....--,:-.--::..:
RESULT REF RANGE 1 TEST ' RESULT -,:. --- 'I/INGE
138-146 umnol/L ALB -3.5-5.5 Wdl
3.54.9 mmoL/L• ALP 26-84 till
98-109 mroold. ALT 10-47 till
7.31-7.45 AMY 14-97 &I
3545 mmHg (art) AST 1 1 -38 till 41-51 rrunl-1 Fr (yea) 80-105 mmHg (art) 0.2-1.6 mg/d1
TBIL,
WA (veal 23-27 mrnol7L (In) 7-22 mg/di
BUN
24-29 mmol/L. (yea)
22-26 mmol,L (art) 8.0-10.3rag/d1

CA
23-28 mruoUL (yen)
95-98% -CHOL 100-200 mg/d1

/

(-2) -(+3)
f
=nun, 10-20 mmol/L
1.12-1.32 mmol/L
8-26 mg/dl
70-105 mg/d1
0.7-1.5 mg/di 36-51% PCV 12-17 gh2
U-Misc;Ictieliiitt
RESULT REF RANGE

Troponin-1

Drug of Abuse
REMARKS: REPORTED BY:
CRE
GLU TP
Pt : Pt
0.6-1.2 mg/di
73-118 mg/di 6.4-8.1 g/dl
,..!t
1111/( 31) (G)1 Harie:
or ea 2 . 9 ifi9..."dL 5amp I e Type_:

ChrAvIISTRY RESULT FORM
(Subject to the Privacy Act of 1974) SSN C)S 610.
TEST RESULT REF. RANG.E
GLU 73-118 mg/di BUN 7-22 mg/dl CA++
8.0-10.3 mg/dl CRE 0.6-1.2 mg/d1 NA' 128 -145 mmol/1
3.3-4.7 mmu1/1
K:

CL: 98-108 mmol/1 18-33 ,mmoUl
1002
" :.(pitolo) Lis.tt Panel fis:,;,,?,;.,

TEST :RESULT
ALB ALP ALT
AMY
AST TBIL GOT TP
REF. RANGE
3.3-5.5 g/d1 . 26-84 u/1 1047 IA
-
14-97 WI
11-38 WI
0.27 1.6 mWdl 5-65 till • -. ... dl
IIIIIIIIIIIIIIII!

',35140.....03: -4 ..:. :.e610.--glittOlte:-".
14:11.' .

open ON ,------ TEST RESULT REF RANGE
Pnysici an: _ 161 ) 1' _ __ NA+ 128-145 mmo1/1 t
2 -- 3.3-1.7 mrnot/1
WE . CI: 98-108 mmolll

18-33 mmoUl

tCO2
1 .
i

DATE: LAB ID NO.:
DOD-035861

H
0 73
C1.2 cD
3 0 cp.
%-".-CD
C2_
-
C_
a

0 cs-0
CD C/) o
o

3 a
uuoj ;senbej Af3olomongAl

Imherof attachedsheets:
DOD-035862

Microbiology Report

IBN SINA - HOSPITAL Laboratory Name: Specimen: W109 Status: Final Patient ID: Source: Wound/Sterile site Collected: Ward/Rm: U1/ Ward of Iso: Attd. Phys:
1 Pseudomonas aeruginosa Status: Final 2 Stenotrophomonas (X.) maltophilia Status Final
1 P. aeruginosa 2 S. maltophilia
Druq MIC Interps Druq MIC Interps
Amox/K Clay (c) 16/8 Amox/K Clay (c) 16/8
Amp/Sulbactam (c) 16/8 Amp/Sulbactam (c) 16/8
Ampicillin 16 Ampicillin 16 Aztreonam =8 Aztreonam 4, 16 Cefazolin 16 Cefazolin 16 Cefepime =8 S Cefepime 16 Cefotaxime (c) 32 Cefotaxime (c) 32 Cefotetan 32 Cefotetan 32 Cefoxitin 16 Cefoxitin 16 Ceftazidime (a) =8 Ceftazidime (a) 16 Ceftriaxone (c) 32 Ceftriaxone (c) 32 Cefuroxime (b) 16 Cefuroxime (b) 16 Cephalothin 16 Cephalothin 16 Chloramphenicol 16 Chloramphenicol 16 Ciprofloxacin =1 Ciprofloxacin 2 ESBL-a Scrn 4 ESBL-a Scrn 4 ESBL-b Scrn 1 ESBL-b Scrn 1
Gentamicin =4 Gatifloxacin =2 Imipenem (c) =4 Gentamicin 8 Levofloxacin =2 Imipenem (c) 8
Meropenem (c) =4 Levofloxacin =2
Nitrofurantoin 64 Meropenem (c) 8 R
Norfloxacin =4 Moxifloxacin =2
Pip/Tazo (d) =16 Nitrofurantoin 64
Piperacillin (a) =16 Norfloxacin 8
Tetracycline 8 Tetracycline 8
Ticar/K Clay (a) 64 Ticar/K Clay (a) 64
Tobramycin =4 Tobramycin 8
Trimeth/Sulfa 2/38 Trimeth/Sulfa =2/38
S = Susceptible NUR = Not Reportea Blank = Data not available or Drug not advisable b.' tested = Intermediate Not Tested ESEtt. = E.:e,cec spectrum beta.;aciamase R = Resistance T Po = Thymidine-dependent strain Blac = Beta- actamase posy -i MIC = mcg/m1(mg/L)
R' = Resistant due to extenaea spectrum beta-lactamases (ESBL i EBL/ = Suspected ESBI. Confirmatory rests needed to differentiate ESBL from other beta-lactamases IB = Inducible Beta-lactamase Appears in place of Sensitive with species known to possess inducible hexa-lactamases potentially tney may become resistant to ail oeia-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 amoxicitlin/K clavulanate or ampicillin/sulbactam with enterococci. refer to the penicillin .nterprelation
(d) For non beta-Lactamase producing enterococci, refer to the penicillin interpretation Footnote (a) also adblies to this drug
Interpretive breakpoints are based on NCCLS M100-S12 Jan 2002 Soarfloxacin (for Gram Negative isolates ant mo.ulto..ac.n are oases on FDA -;bb/ovec breakpoints For S pneumoniae. cefotaxime and cefiriasone breakpoints are base° on isolates from patients witn menung :.s F rn infect,ons use ••2=5 ,2=R
Name: Specimen . W109 Status: Final Patient ID: Source: Wound/Sterile site Collected:

QD10-
Ward/Rm: Ward of !so: Req. Phys:
111111111111
Printed 11/6/2003 933.1414 AM Page 1 of 1 Tech:
1.0

DOD-035863
Ward/Section: REQUESTING PHYSICIAN: LABORATORY RESULT FORM Sub ect to the Privacy Act of 1974 LAST, FIRST, DA TIME SSN/PSEUDO SSN:
Elva b)(62)+ 1 1 TE tACO
1 cf,

•:•:(Heniato ogy . • Urinalysis Isc,'Sero
TEST 1 . TEST RESULT REF. RANGE TEST RESULT REF. RANGE
-,-.; --
7,rsc -Color N/A RPR Negative
RBC -: App N/A T• Mono Negative
Hgb Glu Negative - . lyfiCrobio.ogy -.
.. . • ,-
Hct 1,. L Bili Negative Source
-'— --

MCV Ket Negative Gram Stain Pit . :: :, •: SG N/A Occ Bld Negative .
Lymph % -Bld Negative H. pylori . Negative
1
. . (Ren:!atiology)•Manua1 Differential .,,- pH -N/A Micro

•, ...-• . .-., • : .. , ...
Parasites
Segs • Mono Prot Negative Malaria
..... '° .

Bands . Eos ' 0 & P
Ly mph o Baso aKIAL IRA-1540D ii/uu/vJ Uu.•. Other
Patient IDANNI(,I0)GA

Atyp Imm mkoasoipit.Vrixiilysis
Test Name :PT ' :•-:: -:-,:.•:•:;• --:,.• ... .

Test Result:. 23.9 sec,

RBC
***RESULT OUT OF RANGE***

Morph
Ratio . 2.0 Calculated INR = 2.97 Sample Type:citrated wh. blood.
Spun ,t.-52% (M) • Blood.Bank ',•-.
, ..

Test Date :11/06/03 . . : ....
Hematocrit 37247%(F)
Test Time :06:00

Sed Rate MUST SUBMIT SF 518 WITH
Card ((AA :060206

...,.. EVERY UNIT REQUESTED .
OperatorUM
Other IABO/Rh
(b)R0) 2—.
-Coagulation'Studies.- -RAPIDPOINT COAD -ANALYZER V4.54 it Crossmatch': - - • . •• ... :-. .. .

-. .

._ ,.-. SERIAL #005485-- 11/06/03 06:05 ,EVERY .UNIT OF. BLOOD.
.. , .. -. . . . ..., -,... . .... -
. i - . . STEDY •-•:, .•-• :-.-....-.. , .: . • . -••F
TEST RESULT REF. RANGE Patient ID: ) )k..(..)1 CROSSE4TCH
CDTest Name :APT

Fr 9.8-13.6 secs
: Test Result . 87.0 sec. 1071-r 21-34 secs ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood' D dimer 20 ug/m1 Test Date :11/06/03 •
----..

FDP 10 ueml
REMARKS: Cta,
1)7 IPTT
.

REPORTED BY: DATE: LAB IR NO.:.
DOD-035864

NIlard/Section: REQUESTING:i H CH EMISTRY RESULT FORM
pep___

(Subject to the Privacy Act of 1974) LAST, FIRST, MI. DATE TIME SRWPSEUDOSSN:
tlIc0
481*

TEST RESULT REF. RANGE TEST RESULT
73-118mga

Na :PICCOLO . K -- 06/11/03.05:17 7-22m011
-- REFERENCE RANGE: , MALE

Cl Pt. "Haute: 8.0-10.3 mg/dl
-PATIENT #:.

pH WL1 0.6-1.2 mg/d1
BASIC METABOLIC

1e4 mmol/L

311202 Ha.DISC LOT.128-145mmdA
3325AA4

K .4.3 mmol/L -- OPER #1111,

DR #: 000 3.3-4.7 mrnalil TCO2.29 mmol/L ERIAL
P02
TCO2 98-108 mmol/1
Hct.21 %PCV

HCO3 GLU.18-33 mmo1/1
154* 73-118 MG/DL

.g/dL

BUN 53* 7-22 MG/DL

503.

*vi a Hct

CA++ 7.9* 8.0-10.3 MG/DL

BEecf -. RESULT
CRE ICT 0.6-1.2 MG/DL

Rt 37C

NA+ 167* 128-145 MOM_

Antap! pH.7.381 3.3-5.5 g/dI
K+ 5.2* 3.3-4.7 MMOVL

Ca 26-84 u/I
pffia 4.S. ,S mmHg

CL- 120* 98-108 MMOVL

BUN Pira 111 mmHg 10-47 u/I
tCO2 23 18-33 MMOVL

HCO3 23 mmol/L

GLU 14-97 al
INST QC: OK.

nerf.3 MM01/L CHEM QC: OK

— HEM 0 , LIP 0 , ICT 3+

Creat ' '-FIE:* 95 % 11-38 6/1
Het *ralrulated 0.2-1.6 mg/d1
Hgb 5-65
5amp1e Type_: 6.4-8.1 g'dl
..-

TEST :9tal0V03 L53:55
Troponin-. gper: RESULT
Drug of Physician: 128-145 mmo1/1 Abuse
3.3-4.7 mmoUl
98-108 mmoLl
18-33 mmo1/1

REMARKS:
IQ
C C_Sr\ek^n,

REPORTED BY: DATE: LAB ID NO.:
Ward/Sectio REQUESTING PHYSICIAN:
CHEMISTRY RESULT FORM
'Vs. \

(Subject to the Privacy Act of 1974)
DA,TE TIME
k
•(PiccoI)).ClJtmistr 12

„: 11111111L (,)(0i N fele Pt TEST
ALB
N 164 mmoi/L

ALP
4.4 mmo1/1._

ALT
TCO2 2 9 mmol/L

AMY
•

Hct. .21 .PCV.

Hb*.7 ct/dL
*Via Hct
At 37C
pH 7.370
Pr.02 47. 1 mmHg
25' mmHg

HCO:';.2:7 mmol/L
sEPcf.mmol/L
.97 %
*calruiated

Rt Patient Temp

7.371

PH.
pr:n2 47.0 mmHg
P02.59 mmHg

patient Temp: 58.5F
F102.: 45
Sample Type_:

06:53

Og.H0V03.

op er:

AST TBIL BUN CA . CHOL
CRE
GLU
TP
TEST
GLU BUN CRE CK
NA+
LU
tCO2
Physician: .

KT: MARKS:
REPORTED BY: DATE:
RESULT REF. RANGE
3.5-5.5 g/dl
26-84 u/1 10-47 u/1
14-97 u/I
11-38 u/I
0.2-1.6 mg/d1 7-22 ng/d1
8.0-10.3mg/d1
100-200 mg/d)
0.6-1.2 mg/di
73-118 mg/di 6.4-8.1 g/dl
RESULT RANGE
73-1I8 &d1 7-22 mg/til 0.6-1.2 mg/di 39-380 u/I (M)
30-190 WI (F) 1'8-145 canon
18-33 mroolil
LAB ID NO.:

GLU BUN CK" CRE NA+
CL

tCO2
TEST
ALB ALP ALT
AMY
AST TBIL GGT TP
CL

tCO2 SSN/PSEUDO SSN:
73-118 mg/dl
7-22 mg/di
8.0-10.3 mg/di
0.6-1.2 mg/dI 128-145 mmol/1
3.3-4.7 mmoIrt
98-108 mmol/1
18-33'mmo1/1
RESULT REF. RANGE
3.3-5.5 g/d1 26-84 u/I
10-47 u/l
14-97 till
11-38 u/1 0.2-1.6 med,
5-65 u./1 6.4-8.1 Wdl
RESULT REF. RANGE
128-145 mmo1/1
3.3-4.7 mmo1/1
98-108 naaolll
18-33 mmol/1

Ward/Section: REQUESTING PHYSIC •
' CHEMISTRY RESULT FORM
g,....„,....A, i

b ((. 2— Sub'ect to the Privacy Act of 1974) LAST FIRST MI. DATE TIME S •P EUDO : (0 L' fit4 ' • _i-STAT) :.,;:-;;.;,:: .-7(Piccolo) -r-;
I:I ::;;-..::!--:fi(PieCoilo),CliiiiiistIT,::::'-7 .....,. . ' (rjc...010).:Met41i(CII
..:::;: f.:'''. .-:: i.:', -....r.:: '.1:. : ,,...: .,!.. r .- ,,,.;.,:.:,',."..,;•. ;:-:,'..:::;.'i'."'...;.; .i..';:::
TEST RESULT REF. RANGE TEST RESULT REF. TEST RESULT REF. RANGE RANGE
Na i6 c_f 138-146 mmol/L ALB 3.5-5.5 Wdl GLU 73-118 mg/c11
4fr'
K 3.5-4.9 mmoUL ALP 26-84 IA BUN 7-22 mg/dlr 98-109 mmol/L ALT
Cl 1047 u/1 • CA+4 8.0-10.3 mg/d1
pH -7. 3;7 7.31-7.45 AMY 14-97 ull CRE 0.6-1.2 mg/d1
34 5:4m t) 11-38 u/I
PCO2 ifs , i 1 5,5 mmF:t,(c'arAST NA' 128-145 mmo1/1
6 0 „4,v80iAlosemK 3.3-4.7 mrno1(1
P02 mnilig on) TBIL 0.2-1.6 mg/di
TCO2 .g. 7 7 mmol/1-7-22 mg/di CL.-98-108 mmo1/1 ;.34:2/L ren))
29 BUN
-

HCO3 ,),G 223 26 CA+' 8.0-10.3mg/d1 tCO2 18-33 mmo1/1
:L/L en).)
95-98%

2 -28 mm IIL ayrr

s02 CHOL 100-200 (Piccolo)Liver Pi-Lit'PIis'
9.0 ...::J..-•--,--:; .;,...,...,:,.:.i:: ;-.::..;:. :..-=.;,: ::' i..;•::::-..!:-.....: BEecf 1 1 (-2) -(+3) CRE 0.6-1.2 nIctl TEST RESULT REF. RANGE
nunol/L AnGap 10-20 mmol/L GLU 73-118 mg/d1 ALB 3.3-5.5 g/dl '
Ca 1.12-1.32 nunon TP 6.44.1 g/dl ALP 26-84 u/1
BUN 8-26 mg/d1 ;?,...,..,; : '- .., (PiecOlOY-Metlkte 8 -.. ,: .--_.,...: , ALT 10-47 u/1
GLU 70-105 mg/d1 TEST RESULT REF. AMY 14-97 till RANGE
Creat 0.7-1.5 mg/di GLU 73-118 mg/di AST 11-38 u/I Het . d 1 38-51% PCV BUN 7-22 mg/dl TBIL 0.2-1.6 mg/d1
Hgb 12-17 g/di CRE 0.6-1.2 mg/di GGT 5-65 u/I
-7 4fisc tlittiiisti-y --".::::''.:;-4":;:: CK 39-380 u/I (M) TP 6.4-8.1 g/dl :.-. ..'-..-'.':-g::-. 1-.:'..-:;":-;: .'. :'. 30-19010 (F) TEST RESULT REF RANGE NA 128-145 mmolfl ...- ':,:-. '....-: :(Pie6016).EltiObii..;":4;'-';.'s•-'
Troponin-1 K4 33-1.7 mmol/I TEST RESULT REF. RANGE
Drug of _CU 98-108 mmolll NA+ 128-145 mmol/I Abuse tCO2 18-33 mmol/1 } 3.3-4.7 mmol/1
-CU 98-108 mmoLl
tCO2 18-33 mmo1/1
REMARKS: .
fieD z... 4/ S— ti T&' 9,i/
',L..

REPORTED BY: ' DATE: I LAB ID NO.:
I

DOD-035867

Ward/Seca: REQUESTING P . a
LABORATORY RESULT FORM I
. be' (6 —1---Suliect to the P ivac Act of 1974)
LAST; FIRST, Ml. DA TIME SSN/PSEUDO SSN ce
- -ems ogy) CBC Urinalysis , Misc. &rol gy .• . • ' -
TEST _i__-:: TEST RESULT REF. RANGE TEST RESULT REF RANGE
WBC (6) RIY4,..__, . '..- Color N/A RPR Negative
RBC . App N/A Mono Negative
Hgb - , _ : -. - . ,.,.: . -- Glu Negative• Microbiology . . .
Hct . But Negative Source
MCV -: •_- ---_7: : 2 --_',... ¦ -:' n — -' -- --:. Ket Negative Gram Stain
Pit - ,..-. .• .5- ,-;,. SG N/A Occ Bid Negative
Lymph % :.: :, : .,_ ! :,. Bld Negative H. pylori . Negative
•ematal°gY)Nlinual Pifferentiii . ' pH N/A Micro
Parasites
Segs Mono Prot Negative Malaria '
Bands . Eos Urob 0.24.0 0 & P
Lymph Baso Nit Negative Other

Negative

Atyp Imm Leuk • roscopic IJriiialysis'
RBC HCG Negative
Morph ,

Spun 42-52% (M) ' '•' Blood Bank
...

Hematocrit 37-47% (F) : . • • •
Sed Rate Cell
MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED Other Directigen Negative I ABO/Rh
-

-Coagulation Studies. . : ' '.' . : . - Blood Bank Unit Crossmatch
- • (MUST SUBMIT SF,518 WITH EVERY UNIT OF BLOOD . . .
TEST RESULT REF. RANGE UNIT TYPE CROSSILL4TCH
PT 9.8-13.6 sees
APTT 21-34 secs
D dime:: 20 ug/ml
FDP 10 ug/ml u • -•
REMARKS:
'

REPORTED BY: DATE: LAB ID NO.:
MEDCOM - 22292

DOD-035868
REQUESTING PHYSIC
CHEMISTRY RESULT FORM
Pt Name: .

Na 1e3 mmol/L

4.4 mmol/L
TCO2 25 mmol/L
Hct *** %PnV
Hb* *** q/dL

*via Hrt

Rt 37C
PH 7.41
PCO2.

43.7 mmHg
PO2 84 mmHg
HCO3 25 mmolsL
BEecf 4 mmoliL
s02* 5G %

*ralculAted

Rt Patient Temp
PH 7.41G
PCO2.

48.7 mmHg
Pn2 84 mmHg

Patient Temp: 58.6F
FIO2 : 40

REPORTED BY:
ATE 6 A/44

TEST REF. RANGE
ALB 3.5-5.5 g/dl
ALP 26-84 u/1
t Name:

111. mgsdL

-.
.

5 mq/dL

Sub'ect to the Privacy Act of 1974)
.
RESULT REF. RANGE
73-118 mg/di 7-22 mg/di 8.0-10.3 mg/dl 0.6-1.2 mg/d1

NA+ 128-145 mmo1/1 r K
3.3-4.7 mrnoIil CL" 98-108 mmol/1 18-33 mmol/1
h; .

mmol/L

4.4 mmolsL
Cl 180 mmolsL
T002 2A curuol/L
RnGap 11 mmol/L
Hct 21 .PCV
Hb* 7 g/dL

*via Hct
pH.
PCO2.

42.7 mmHg
HCO3 25 mmol/L
EEecf U mmol/L

Sample Type_:

OGNOV03 09:23

Oper: 7

Phqsician:

6'6 171:17 DATE: E LAB ID NO..
RESULT

ALB 3.3-5.5 g/d1

agg NyOk-1

Pt

Crea 3.0 mqsdL

TEST RESULT REF. RANGE
128-145 mmol/1

3.3-4.7 mmo1/1 CL" 98-108 mmoLl tCO2 18-33 mmo1/1
NA'

efr-C Crect
Ward/Section: REQUEST PHYSICIAV:
CHEMISTRY RESULT FORM
-,....,..,

4_
(.)( (e) 2--(Sulice to the Privacy Act of 1974)

LAST, FIRST ;
TIME /PSEUDO LI ZI&LL 1-ZAJ
Cb) (62 ) i,s,,T.V::-g: (Piccolo) .0h6SPrit:e);..1:, ..., 43q .4
i...,. ' ; : .. icc.c0 .!?- ,V t4t,z-,
TEST RESULT REF. RANGE TEST RESULT REF. TEST RESULT
f

REF. RANGE RANGE Na 138-146 mmo1/1... ALB 3.5-5.5 Yd1 73-118 mg/d1
GLU
/ 63

K . i 3.5-1.9 mmoUL ALP 26-84 u/1
BUN 7-22 mg/dl 98-109 mmol/L ALT .
10-47 u/1 ' CA*' 8.0-10.3 mg/di
PH 7.31-7.45 AMY 14-97 ull CRE 0.6-1.2 mg/d1
7kr7O PCO2 , .1 43 15:4515 mml-ef
AST 11-38 &I NA' 128-145 mmol/1
f (veal P02 7 2-14/A(veul 813-105 mmHg (art) • TBIL 0.2-1.6 mg/d1 K' 3.3-4.7 mmol/1
TCO2 23 -27 mmol/ (art) BUN 7-22 mg/d1
CU 98-108 mmol/1
3-C 24 -29 rnmo1/1..(vco HCO3 22-26 mmoVL (art) CA 8.0-10.3mg/d1 tCO2 18-33 Thmo1/1d-'''C 23 -28 mruol/L. (von) s02 95-98% 100-200 ro g/d1
9S-' CHOL picetilo) ,Lly t Pan el . pl u -...:::: .
'.:,....: .:11,-,..-:-,,..:: .,.:BEecf (-2)-(+3) CRE 0.6-1.2 mg/dl TEST RESULT REF. RANGE=Ion. AnGap 10-20 mmol/L GLU 73-118 mg/d1 ALB 3.3-5.5 g/d1
' Ca L12-1.32 mmol/L TP 6.4-8.1 g/dl 26-84 u/1
ALP
BUN 8-26 mg/d1 ',.'(Piccolo} .i8te 1M-8 ALT 10-47 u/1
GLU 70-105 mg/di
TEST RESULT REF. AMY 14-97 ull RANGE
Creat 0.7-1.5 mg/di GLU 73-118 mg/dl AST 11-38 ufi
Hut 38-51% PCV 7-22 mg/d1 TBIL
BUN 0.271.6 ©g/d1
? I Hgb / L2-17 g/d1 CRE 0.6-1.2 mg/di GGT 5-63 WI
-lyrist:cheliiiStry CK 39-380 u/l(M) TP 6.4-8.1 g/d1
30-190 u/l(F)
TEST RESULT REF. RANGE NA* 128-145 mmol/1 ..

PkcP1614160iol3tc'

Troponin-1 334.7 mmol/I
,,, TEST RESULT REF. RANGE
Drug of _CL -98-108 mmol/1 NA' 128-145 mmol/1 Abuse tCO2 18-33 mmol/1 r 3.3-4.7 mrno1/1
-CU 98-108 mmoV1
tCO2 18-33 rnmo1/1
REMARKS: • -.L1 -1... cr T. 1 '74 r REPORTED BY: DATE: LAB ID NO..
DOD-035870
Ward/Section:
CHEMISTRY RESULT FORM A 1 ) (6) 2— (Subject to ipsE cyA
thePrivaossct of 1974) LAST, FIRST, MI. ATE TIME
AkS0 1 t Z-— (.(1)Lf 43.S.INT) -(P 61o)',P10iaii : ic colo) Metabohc riaif.,--'..1,-;:
TEST RESULT REF. RANGE TEST RESULT REF. TEST RESULT REF. RANGE
RANGE

Na 144 138-146 mmol/L ALB 3.5-5.5 gidl GLU 73-118 mg/d1
K ,i 3.5-4.9 'ninon: ALP 26-84 u/1 BUN 7-22 mg/dl
Cl 98-109 mmol/L ALT 10-47 u/1 CA.+4 8.0-10.3 rng/d1
pll -7-7.31-7.45 AMY 14-97 u/1 CRE 0.6-1.2 mg/d1
-w 3

35-45 mmHg 11-38 u/1
PCO2 Ltd__ 1..., r AST NA* 128-145 mmol/1
41-51 mmHg P02 80 -4) TBIL 0.2-1.6 mg/d1 K 3.3-4.7 mmolit
'-) —2-NA(v

TCO2 23-27 mmol/L (art) BUNT 7-22 mg/dl C-1: 98-108 mmol/124-29 mmol/L (yen) HCO3 9....1.,.— 22-26 mmoVL (an) CA++ 8.0-10.3mg/d1 tCO2 18-33 mmoUl 23-28 mruoUL (yen)
. . „

?i.( 95-98% too-200 mg/d1
s02 CHOL ''..::]Z `.'(1.1.i .c ole.•) Liyet Pan el Plus:.
(-2)— (+3)

BEecf CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE.
mmol/L AnGap 10-20 mmol/L GLU 73-118 mg/di ALB 3.3-5.5 g/d1
Ca i .12-1.32 mmol/L TP 6.4-8.1 g/d1 ALP 26-84 u/1
BUN 8-26 mg/d1 10-47 u/1
,(Piccolo).Mgil • i ALT

GLU 70-105 mg/d1 1 TEST RESULT REF. AMY 14-97 Lill RANGE
Creat 0.7-1.5 mg/di 73-118 rag/di t 1-38 u/1
GLU AST
Hot P• 38-51% PCV BUN 7-22 mg/dl TBIL 0.2-1.6 mg/dl
Hgb c-,, 12-17 gidt CRE 0.6-1.2 mg/d1 GGT 5-65 utill
. CK 39-380 u/1 (M) TP 6.4-8:1 g/d1
W4s:c::46niM

. ', !.-,:'.:,Z1 .:•!.: ,'::-.F::. ".::.-...-:-.-:.. . v 30-190 u/l(F)
128-145 mmo1/1 .

TEST RESULT REF RANGE NA + (lieolo)„,petzily.I,..-..„.1_;,-,-.::
Troponin-1 K+ 33-4.7 mmol/1
TEST RESULT REF. RANGE
Drug of _CL” 98-108 mmolfl NA-'• 128-145 mmol/1 Abuse tCO2 18-33 mmol/1 3.3-4.7 mmol/1
CL" 98-108 mmol/1
tCO2 18-33 nuno1/1
REMARKS:
REPORTED BY: DATE: LAB ID NO.:
DOD-035871

•

Ward/Sect -• -REQ ' ((o ) .a..., (sBt tohRpYaE
00 LAubORATtOrivRc RESULT FORM
C...4.4 -
•

y Act of 1974)
LAST, FIRST PATE

TIME I. ..
' SN: (, (,(0
b arl

Urinalysis its '", .16gy.
TEST TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 7 -Color N/A RPR Negative
_.:_ .

RBC App N/A Mono Negative
Hgb — --:-. _ -J. -. -: --Glu Negative . Microbiology
Hct 5: ,:: _-.: 7 . . -E.' But Negative Source
----_
-

MCV -.:1 ::-.=:-_,1 Ket Negative Gram
Stain

.: . __ _ .: --

Pit SG N/A OCC Bld Negative
-

Lymph % -= -----' Bld Negative H. pylori . Negative
(Heins tiok,gy) Manual Differential : '• pH N/A Micro
Parasites
Segs Mono Prot Negative Malaria

-

Bands Eos Urob 0.21.0 0 & P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative Mkroscopic [Irma
RBC HCG Negative
Morph

Spun 42;52% (M)
CSF -' -. Blood Bank . .
. .

31-47% (F)
Sed Rate Cell MUST suBlynT SF 518 WITH
Count EVERY UNIT REQUESTED -
Other Directigen Negative ABO/Rh

Hematocrit
Coagulation Studies.. •. : . .. • Blocid. Bank Unit CrOssmatch' : - , ::•.. - -'::-...- '.• ' . '.
--•.
.• (MUST,SUBMIT SF 518 WITH EVERY UNIT OL BLOOD
TEST RESULT REF. RANGE UNIT TYPE CROSSAL4TCH
PT 9.8-13.6 secs
•

APTT .. 21-34 secs
D dimer _ 20 ug/ml
FDP IC ug/tni
REMARKS:
I REPORTED BY: DATE: LAB ID NO.:
DOD-035872

CN:(

CHEMISTRY RESULT FORM (Subject to the Privacy Act of 1974) TIME SSN/PSEUDO SSO4.0
• . "nInI:Chernjstrv12

TEST RESULT REF. RANGE PICCOLO = = 7 17 TEST
06/11/03.

15: 3 : All

REFERENCE R GE :.

/ MALE 3LU
PATIENT #:.

(boV01(4 3UN
GENERAL CV­
IEMIS1RY 12

:3A+ 4
DISC LOT #:.

Pt Name: 3204AA1 .

OPER #:

DR #. 000

SERIAL

Ma 162 mmolsL

•• Uo ).(;
..............

ALB.

4.0 mmolsL 1.4* 3.3-5.5.

13/DL

ALP CZ'
TCO2 27 mmol/L 66 26-84.

U/L

ALT.

58* 10-47.

Hct 25 .PCV U/L tCO2

AMY.

56 14-97.

Hb* 5 gSdL U/L

AST •4• 11-38 U/L

*via Hct

TBIL 13.4* 0.2-1.6 MG/DL TEST RESULT BUN 52*
7-22

At 37C MG/DL ALB

CA++ 8.1.

8.0-10.3 MG/DL

pH 7.350 ALP
CHOL 99* 100-200 MG/DL

CRE

42.0 mmHg

PCO2 ICT.

0.6-1.2 MG/DL ALT
GLU

113.

P02 7. mmHg 73-118 MG/DL

TP.

4.4* 6.1-8.1 AMY
HCO3 25 mmoliL G/DL
necf mmol/L

INST QC: OK AST
CHEM QC: OK

s02* 95 %

HEM 1+, LIP 0 , ICT 3+ TBIL
*ralculated

GGT TP
F102 55

Sample Type_: RRT

oemovo3 16:42 TEST RESULT
NA

1st (06)7, I (;[
oPer:
Phqsician.7. .

900
CL-
0-2

REPORTED BY:
73-118 mg/di
7-22 mg/di
8.0-10.3 mg/dl
0.6-1.2 mg/d1
128-145 mmol/1
3.3-4.7 mmolil
98-108 mmol/I
18-33 mmo1/1
•
REF. RANGE
3.3-5.5 g/dl
26-84 ul
10-47 u11
14-97 till
11-38 till 0.2-1.6 mg/d1
5-65 6.4-8.1 g/dl
REF. RANGE
128-145 mmol/1
3.3-4.7 mmo1/1
98-108 mmol/1
18-33 mmo1/1

DOD-035873
Ward/Section:
r .

LASh'IRSTC:t I. 1
(.6 6
-- '

CHEMISTRY RESULT FORM
„ bp.) z_ (Suliect to the Privacy At of 1974) pATE . TIME SSN/PSEUDO Sstoyc)
6 4 /74D
__ ' ...,!,:.(Piecolo) (liitalitii'.,:i.t:'$";,'-.=:',". -.;;;I.::-(piC)j o .*: etaboliC„Piiier::::::

., .,.... ­
TEST RESULT RESULT REF. RANGE
TEST RA .FERANGE
ALB 3.5-5.5 edi GLU 73 -118 mg/di ALP 26-84W! BUN 7-22 mg/di ALT 10-47 u/1 " CA++ 8.0-10.3 mg/dl AMY 14-97u/1 ORE 0.6-1.2 mg/d1 AST 11-38 un NA 128-145 mmo1/1
TBIL 0.2-1.6 mg/d1 K 3.3-4.7 mmolil BUN 7-22 ing/d1 CI;.98-108 mmo1/1 CA++ 8.0-10.3medl tC O2 18-33 ThmoUl
CHOL 100-200 n3Wdi 2'..,-:,":" . (PiCCCilo).Lii, i. Panel. Phigf;,--
..--,;-.'....: ,-.....;':::-F--, :-::'..-

27.l...:5 -..:..:.i;.:::-.. ;:-;.CRE 0.6-1.2 mg/di TEST RESULT REF. RANGE GLU 73-118 mg/d1 ALB 3.3-5.5 g/dl TP 6.4-8.1 edl ALP 26-84 u/1 ..1;-,-.. ---ALT 10-47 u/1
.-(1",icCOIP):Meible13::T.:' .± ..: ::!.:-:-i'.:i. ..'. ....7,•'. ,. :::.::::::'........: .... '!..:.:.:":.-:-:....':..::'-.'......:.:;..;::: TEST RESULT REF. AMY 14-97 ull RANGE
GLU 73-118 mg/d1 AST 11-38 u/1 BUN 7-22 mg/d1 TBIL 0.2-1.6 mg/dl CRE 0.6-1.2 mg/d] GGT 5-65 WI CT( 39-380 ull (M) TP 6.4-8.1 g/d1
30-190 u/1 (F)
-_ -..... .

N A 128-145 mmol/1 :t:-. ..;.:,.::-:...:(pilecOlo):',Peetrolyte,•;
K+ 33-4.7 trimo1/1 TEST RESULT REF. RANGE
.CL - 98-108 ramolll NA+ 128-145 mmol/l t
tCO2 18-33 mmo1/1 IC 3.3-4.7 mmo1/1
-CI: 98-108 InmoLl
18-33 mrnoUl

1002
(....,al, t.....--.. 1 -
DATE: LAB ID NO.:
i, -:---. ,::-. :­
TEST

Na K C1
pH
PCO2
P02
TCO2
HCO3 s02
BEecf
AnGap
Ca BUN
GLU
Creat
Hct
Hgb
--c.:-..ciiS:. AT) -'I.::. ' ''''
RESULT REF. RANGE
16 4 138-146 mmol/L 3.5-1.9 rnmol/L
4-0
7....."712.
I/ i
i

,(0
.. ii
F1/4/
•-- i

2..„,./
Y
98-109 mmol/L
7.31 -7.45
35-45 mmHg (art) 41-51 mmHg (yen)
80-1°5 mmli g (an)N/A (yen) • 23-27 mrnal/L (art) 24-29 mmol/L (vcn)
22-26 mmol/L (arr) 23-28 mmol/L (yen) 95-98%
(-2) -(+3) nunol/L
10-20 mmol/L
1.12-1.32 mrnol/L
8-26 mg/di
70-105 mg/d1
0.7-1.5 medl 38-51% PCV
12-17 g/dl
.....7S:n.st:clhetiiiti-yr::' :::.

::',.;:y:;.. ;.-:::.:,;.::;,-.;.,;. -..,_:;;;......:' .!,-'...1••:-..:::--,:::',.-r.: -:::"•!..,
TEST RESULT REF. RANGE

Troponin-[
Drug of
Abuse

REMARKS: REPORTED B'
¦•••¦•••

DOD-035874

Ward/Section: EQUESTING PHYSICIAN:
LABORATORY RESULT FORM

LAST, FIAST.,,MI.

[EST

WBC
RBC
Hgb Hct MCV
Plt Lymph %
(Hematology

06-11-03
ID111.

1727 Patient
Limits UDC 15.4 H 1109/uL 4.5 10.5pC 3.141 x101.6/01. 4.04 6.04Pob 9.1 L g/di 11..0 18.0fict 2B.9L z 35.0 60.0
ttL'J 92.0 ft 90.0 99.9 NM 28.9 pg 27.0 31.0 DC 31.5 I. g/di..33.0 37.0 Plt 267. x101/UL 150. 450.LYX 12.3 *L Z 20.5 51.1 LYN 1.9 * x101/ol. 1.2 3.4
(Ilemattilpgy). Mantial Differential

Segs Mono Bands Eos Lymph Baso Atyp RBC Morph
Spun 42-52% (M) Hematocrit 37-47% (F)
Sed Rate
Other
Coagulation Studies
TEST RESULT REF. RANGE

PT • 9.8-13.6 secs APTT 21-34 secs D dimer 20 ug/nil
FDP 10 ughni
REMARKS:
-T.
DATE TIME
I 6 (3
•
Urine
TEST RESULT
Color App Glu Bili Ket
SG Bld PH
Prot sis
REF. RANGE
N/A N/A . Negative
Negative Negative
N/A Negative N/A
Negative
, 54
Patient ID: 1,6104t
les I Ndli16 : PT
Test Result := 25.0 sec9rbf.fj-

! ,

***RESULT OUT titRAlik-k ",-1.(1?_, Ratio , 2.0• Calculated?INR-, 320 Sample Type:citrated wh. blood Test Date :11/06/03 Test Time :19:29 Card Lot :060208 Operator ammo
RANDPOINT COAG ANALUER N4,54 SERIAL 4005485 11/06/03 19:35
Patient ID:11111/ Test Name :APTT Test Result:= 93.6 sec. ***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test Date :11/06/03 Test Time :19:31
TA

REPORTED BY: DATE: LAB ID NO.:.
kef\A-AAD
(Sub.eet to the Privacy Act of 1974) SSN/PSEUDO SSN:
0
TEST
RPR
Mono
Source
Gram Stain Occ Bld
H. pylori Micro Parasites Malaria
O&P 'ther
Misc. Serology ,
RESULT REF RANGE
Negative Negative
Microbiology
Negative
Negative
Microscopic Urinalysis
Blood Bank
BMT SF 518 WITH TNIT REQUESTED
I
itch' :
j. UNIT OF BLOOD .
CROSSM4TCH

DOD-035875

Ward/Section: REQUESTING PHYSICIAN-
CHEMISTRY RESULT FORM
I MEW (Subject to the Privacy Act of 1974)
I • n r-r
DATE 14le SSN/PSEUDO SSN:
COO
PiCeoloiCliitilii.tri,.1.-2:,,.:

Pt Name: .

EF. RANGE TEST I RESLTLT REF.
TEST RESULT REF. RANGE
-146 rnmoUL

di I GLU 73-118 mg/d1
i ea mmo 1 4L..

'-.9 mmo1/1;

BUN 7-22 mg/dl
4.0 mmo1/L
-

9 mrmo - -- :•= 7 - - - PICCOLO - - - - - -
8.0-10.3 mg/d1

TCO2 2 MOPL
7 M 00:29 AM
06/12/03 ,--t 2,S. %Pc.,,, .45 REVERENCE RAN: MALE CRE 0.6-1.2 mg/d1 ITITTI:
:, PATIENT if: (04i
rlo* •c, /dL runs NA' 128-145 mmol/1
__.

mm METLYTE 8
/d1 3.3-4.7 mrno1/1
3152AA4

en) DISC LOT #:.
runo

# : 0 00 CL" 98-108 mmol/1
Ht 370 =0, OPER #: MI.
PH 7.437 /di tCO 18-33 mmoU1
(1.0 103 73-118 MG/DL •:ict610);I:jitt
........ .

BUN 44* 7-22 MG/DL TEST
RESULT REF. RANGE
ICI 0.6-1.2 MG/DL
mmo CRE
ii

ALB 3.3-5.5 g/dl
E.Ee c i F,Ani/L 3670* 39-380 U/L
32 in CK -.7n::
NA+ 147* 128-145 ALP 26-84 u/1
'7!7 %

3g/d1 K+ 4.8*. 3.3-4.7 MMOt'L 10-47 u/I
+calculated ALT 5 mgid CL-119* 98-108 MMOVL tCO2 19 18-33 MMOVL AMY 14-97 Lill Rt Patient Temp , 5 mg/d1
PH 7.4 1 -5, CHEM DC: OK AST 11-38 u/I '7'013—
LIP 0 , ICT 3+

PCO2 3'51 .2 mHgm CV ITISMTOGIC: ()KU TBIL 0.2-1.6 mg/di
P02 gicil
E;;11 mmHg GGT 5-65
TP g/dl
Patient Temp: : :•:::.:i..::.‘•`..:?' _
97.1F.

.
.
.
R4NC

F1 0 2 : F.5 Piccolo) Electrolyte.
-5a ple Type_: m
TEST RESULT REF. RAIsiGE
NO 0 3 19:27 NA 128-145 mmol/1
Op
e r : oft (b)(4
3.3-4.7 mmol/1

Physician: .

CI; 98-108 rnmolll
tCO2 18-33 mmo1/1
REMARKS:
ocKrhe)

PPlo

REPORTED BY: DATE:
LAB ID NO.:
1

DOD-035876

Ward/Section: knQUEST1NG PHYSICIAN:
1 utA,---k ' LAST, FIRST, MI. DATE TIME
t.
)

-ir.:-'1‘.-:.-;.7.;f , ,a,.iioloichilpit-ry 12
TEST RESULT REF. RANGE TEST RESULT REF.
RANGE

Na 138-I46 mmol/L ALB 3.5-5.5 g/d1 K q. i 3.5-4.9 mmol/L ALP 26-84 u/1 Cl 98-109 mmol/L ALT 10-47 u/1
7.31-7.45 14-97 ull
PH ) il II AMY PCO2 4 1::5 mmHg (art) AST
351 rn-11-38 uii
P02 0.2-1.6 mg/cit
ri r "2N N TB/4'•
/-°5:11milg (art) TCO2 -0.4.0 ,:ciiL.cn)) BN . 7-22 mg/d1
234-.4.79 mrnoa. (6art

. HCO3 3 2268 mmo
ucri)) CA÷1-8.0-10.3mg/d1
232:2lt avrt

s02 95-98% CHOL 100 200 rngicu
Cit 5-9 BEecf (-2)-(43) CRE 0.6-1.2 mg/d10 mmol/L AnCrap 10-20 mmol/L GLU 73-118 mg/di
Ca E12-1.32 mmol/L TP 6.4-8.1 wcu.
8-26 mg/d1

BUN I -icole_siTAIe Ikte.8::.z. .." .' . '' ''':...:1 ,-...,1.,-. .:: ::::_,•.:.:.: . ",'::;.5. GLU 70-105 mg/d1 ! TEST RESULT REF. RANGE
Creat 0.7-1.5 mg/di GLU 73-118 rag/d1 net ,:a ...) 38-51% PCV BUN 7-22 mg/d1
Hgb 12-17 g/dl ; CRE 0.6-1.2 mg/d1
. -:.' '''' ' " ftkiiiiit " '''...'• :-.F'_.•--CK 39-380 u/l(M) 30-190 u/I (F) TEST RESULT REF. RANGE NK-128-145 camo1/1
Troponin-1 K+ 3.3-4.7 nunolii
Drug of _CL-98-108 mmo1/1 Abuse tCO2 18-33 mmol/1
•

REMARKS:
N956 I

a 5c;,-,
-

REPORTED BY: DATE: LAB ID NO.:
CHEivIISTRY RESULT FORM Sub ect to the Privacy Act of 1974) SSN/PSEUDO SSN: ---.1
' '' cpjgoloylg_ct4boliop 4o-.
,;:..,---::,
TEST RESULT REF. RANGE
GLU 73-118 mg/di
BUN 7-22 mWdl
cA+1 8.0-10.3 mg/d1

CRE 0.6-1.2 mg/di
NA-128-145 mmo1/1

3.3-4.7 mmolit
IC

CU 98-108 mmol/I
tCO2 18-33.mmoUl
-(pi6-40) -j-ii*o: ran Plus
o...: •:
:,.., -:-,.,:;.::-...,, f.! ,. !,: ,,7:1, : :::-...;,:.`.-. .•; .z ::,;-: '

TEST RESULT REF. RANGE
ALB 3.3-5.5 g/d1 -
ALP 26-84 10

ALT 10-47 u/1
AMY 14-97 u/1
AST 11-38 u/1
TB]1 0.2-1.6 mg/dl
GGT 5-65 uil
TP 6.4-8.1 g/dl

.ti ::-1. -.C61011ittiOti6---. ----: ';:.:.' ...".-'.,',.'.1v.-..,--'''.--.::::::::,L:!-:.:':.,.'!,--::7.-- •=1::,:7::::- . --..--..:;
TEST RESULT REF. RANGE
NA+ 128-145 mmol/1
K-3.3-4.7 mmo1/1
CE 98-108 mmolll
tCO2 18-33 ramo1/1
-

DOD-035877

Ward/Section: 0 REQUESTING PHY
LABORATORY RESULT FORM
(Subject to the Privacy Act of 1974)

LAST, FIRST.,.M1.
DATE TINIE SSN/PSEUDO S N:
gol.(t) "7,..)00 ot-loe b
(Hematology CBC

Urinalysis Misc. Serology
TEST
Ala
p ANT:r

ID: TEST RESULT REF. RANGE TEST RESULT REF. RA NGE
07-11-03
WBC 04:13
Color N/A RPR Negative
Patient

RBC
Liaits App N/A Mono Negative {MC 15.8 H 110"3/uL 4.5 10.5
Hgb Glu Negative
RBC 3.50 L x10"6/al. 4.00 1).00 • . MiCrobiology 11gb 10.1 L 9/d1 11.0 18.0
Hct Bili Negative Source
/Id 32.2 L Z 35.0 60.0
91.8 fL . 80.0 99.9
MCV Ket Negative
Gram

MN 28.9 pg 27.0 31.0
DC 31.4 I. 94 Stain

33.0 37.0
Plt Pit 262, x109/td. 150. 450. SG 'N/A Occ Bld Negative

LYZ 11.7 *I Z

20.5 51.1
Bld Negative

Lymph % LYD 1.8 I d0"3/a. 1.2 3.4 H. pylori Negative
(Hematology} Manual Differential pH N/A Micro
Parasites
Segs Mono Prot Negative

Malaria

Bands Eos n 1_1 n
Ti O&P
Lymph Baso
n Other
Atyp I m m Patient 10:4111110(01
• • --:Microscopic Uriai

Test Name :PT
RBC Test Resull:= 20.4 sec.

TuRi.

Morph aiT UI- RANGE*** Rd! 6 , • . IMP = 2.30 Spun 42-52% (M) Type:citrated oh. blood l
Blood.Bank

Hematocrit 37-47% (F) Test Date :11/01/03 Test Time :04:09
Sed Rate
MUST SUBMIT SF 518 WITH

Card.

Lot.

:060206

(6/..) EVERY UNIT REQREQUESTED
Operator 411111111r.

LP

Other
ABO/Rh

CoagulitioirStudies:-RANDPOINr COAG ANALYZER V4 . 54 it Crasmatcli;
•, SERIAL 14005485 11/07/03 04:15 1EVERY .UNIT OF BLOOD .:
TEST RESULT REF. RANGE Pat i ant ID: f OoMi STEM CROSSM4TCH
Test Name . TiI

PT 9.8-13.6 seta
Test Result:= 90.3 sec. APTT 21-34 secs ***RESULT OUT OF RANGE*** Sample Type:citrated oh. blood
D dimer 20 ug/ml Test Date :11/07/03
Tpqt TiMP
1114:11

FDP 10 ug/ml
REMARKS;
-r

REPORTED BY: DATE: LAB ID NO.:

DOD-035878

Ward/Section: REQUESTING PHYSICIAN:
CHEMISTRY RESULT FORM
LAST, FIRST, MI.
11111
Pt Name:

•

1.1 a 158 mmo I /_1

3.9 mmol/L
TCOZ 2e mmoisL
Hct 29 %PCV
Hb* 1i ./dL

*via Hct

At 370
PH
P.02.

42. 4 mmHg P02 85 mMHg Hri18 25 mmo 1 /L BEecf mmo 1 /L
s02.9
*Ca. 1 cu ed

At Patient Temp
pH 7.85
PCO2.

41.f. mmHg

P02 .

mmHg

N

Patient Temp: 97.8F

F102 SF,
Sample Type_:
07NOV03.

03: 50

U per :
Physician:

REPORTED BY:
C

DATE TIME
e . . . olo):,Che ruts . „
TEST 4ULT REF.
RANGE

ALB 3.5-5.5 ea) ALP 26-84 u/1 ALT 10-47 u/I AMY 14-97 &I AST 11-38 u/I
TBIL 0.2-1.6 mg/di B1
C

(Subject to the Privacy Act of 104) SSN/PSEUDO SSN:
Metabolic Fauel TEST RESULT REF. RANGE
GLU 73-118 mg/dl BUN 7-22 mg/dl CA++ 8.0-10.3 mg/di
CRE 0.6-1.2 roggl NA+ 128-145 mmol/1
3.3-4.7 mmo1/1
"."
98-108 mmol/1
18-33 mmol/1
)2

PICCOLO .
03:51

07/11/03.

RESULT REF. RANGE

REFERENCE RANGE:.

MALE 757
1(22 PATIENT #: 11111,4a0N

3 3.3-5.5 g/d1
.

METLYTE 8

26-84 u/1
DISC LOT #: 3151AA4

10-47 &I

OPER #: .

DR #: 000 r

SERIAL

'//e. 1111111111111

B
c:

6)(602.-

1

GLU 91 73-118 MG/DL

BUN 4 4 * 7-22 Mail_
CRE ICT 0.6-1.2 MG/DL
CK 3349* 39-380 U/L
NA+ 153* 128-145 MMOVL
K+ 1.7. 3.3-4.7 MMOVL
CL-115* 98-108 MMOVL
tCO2 21 18-33 MMOVL

.

Y 14-97 u."1
11-38 u/I L 0.2-1.6 rag/d1 T 5-65 ult
ST RESULT

INST OC: OK.

CHEM DC: OK

128-145 mmol/1
HEM 0 , LIP 0 , 'ICT 34

3.3-4.7 mmol/I 98-108 mmoLl
18-33 mmol/1

)2
Warcl/Sectt REQUESTIN
I
LABORATORY RESULT FORM

A b z,
Subject to the Priv

LAST, FIRST,.M1.
TEST

WBC RBC
Hob
Fizt MCV
Plt Lymph %
ematology) CBC:, : am 001, 07-11-03
PatientQ9'59
Limits

WBC 16.8 Hx1V3/uL 4.5 10.5 RBC 3.58 1 x101/uL 4.00 6.03 11gb 10.3 L g/dL 11.0 18.0 Hct 33.1 1 % 35.0 60.0 to 92.5 fL . 80..0 94 9 HCH 21 7.
pg - 27.0 31.0 IVIG 31.1 L ght. 33.0 37.0 Plt 265. x10"3/11 150. 450.
LYX 10.4 il. I 20.5 51.1
LI 1.7 * a10"3/uL 1.2 3.4

(Efeinatology).Manual .

DBTerentiil ..:
• -•

. . .. . Segs . „.... . Mono .
Bands . Eos

Lymph Baso
Atyp Imm
RBC
Morph
Spun 42-52%(NO Hematocrit
37-47% (F) Sed Rate
Other
go 00:St ear
TEST RESULT REF. RANGE

PT 9.8-13.6 sees APTT 21-34 sees D dimer 20 ug/m1
FDP 10 ughnt
REMARKS: p.--

.
TIN '
•.Vrioa •
TEST RESULT REF. RANGE
Color N/A App N/A
Gl, Negative
u
Negative

}Ili , Negative
r'et
SG N/A •
Bld Negative
pH N/A
Prot Negative
Urob 0.2-1.0
bUtlIAL 1JUD40:i.

ii i I/ UI; Iv.,,

Patient ID: 00)(6 ) kf
T est Name :P lest Result:- 28.0 sec. ***RESULT OUT OF RANGE*** Ratio = 2.3
Calculated INR = 3.84

H. pylori Negative Micro Parasites Malaria
0 & P Other
• -•MicroscOpie Urinn
..., :..- •• • ..
:. . r.. ...
SSN/PSEUDO S$N:
TEST
RPR Mono
Source
Gram Stain Occ Bld
‘
.
, .Mic.. Serology
RESULT REF. RANGE
Negative Negative
•. Microbiology
-Negative
• Blood.Bank

Sample Type:citrated Nh. ..
blood.-.

..

. • •
Date.
Test Time.

Test :11/07/03.

:10:115 MUST SUBMIT SF 518 WITH
Card Lot EVERY UNIT REQUESTED

:060206.
Operator.

ABO/Rh •

iliflir-

• t•Crossinatch . - : - ..
RAPIOPOINI WAG ANAL'/'ER.

V4.54 [EVERY UM
_ T or BLOOD.
4005485.

SERIAL 11/07!03 10 : 1 I 4iDy ::-. -• .
CROSSILL4TCH

Patient ID: INF (KO 't .
lest. Name.

:APTI
Test Result:=121.5 sec.
***RESULT OUT OF RANGE***
Sample Type:citrated wh. blood

T,,i-.

1-1.+0.

.11/A7/n2

REPORTED BY: DATE: LABID NO.:
•

"

DOD-035880

1,Var S ecti

EMIS TR Y RESULT FORM

(Subject to the Privacy Act of 1974)

.

6 —6 to)(()kf
wiR 00)M4
Pt Name:

TEST RESULT REF. TEST RESULT REF. RANGE RANGE
A iLU 73-1.18 mg/dl
NA

mmol/L

4.3 mmol/L
Tr:oz ze mmol/L = PICCOLO -----------...--

PICCOLO

07/11/03 10:23 AM

Hrt 28 %PCV

10:39

07/11/03

REFERENCE RANGE: („AALE
Hb* 10 gSdL MALE

REFERENCE RANGE:

PATIENT #: 111111,V494q

*via Hot PATIENT #: 11111,0*(0

METLYTE 8

LIVER PANEL PLUS

DISC LOT #:

3152AA4

At 37C 3154AA7

DISC LOT #:

OPER #11111

DR #: 000

pH 7.309 DR #: 000

OPER #4111

S RIAL

11111111111,

SEPAAL #: z__4111111111,

49.0 mmHQ

yis.)
GLU • ...v4a,) .

PO2 95 mmHg 92 73-118 MG/DL

1.5* 3.3-5.5

ALB

43* 7-22

Hi O5 25 mmol/L BUN MG/DL U/DL

74 26-84

CRE ALP U/L

ICT

0.6-1.2 MG/DL

mmol/L

BEecf 58* 10-47

ALT U/L

CK 3281* 39-380

39 14-97

NA+ U/L AMY U/L

4.#

128-145 MMOVL

124* 11-38

*calculated K+ AST U/L

5.1* 3.3-4.7 MMOVL

TBIL 11.9* 0.2-1.6 MG/DL

CL-

117* 98-108 MMOL

14 5-65

GGT U/L

MMOVL

At Patient Temp tCO2 19 18733

TP G/DL

4.8* 6.4-8.1

pH 7.318

INST DC: OK

CHEM OC: OK

CHEM DC: OK

PC 02 47.7 mmHg INST DC: OK

HEM 0 , LIP 0 , ICT 3+

PO2 90 mmHg HEM 1+, LIP 0 , ICT 3+
Patient Temp: 97.5F

A/ „.._ (Co

FIDE Ff
: 55

ism 00)(1.0 ) kt
Pt Name:

_ample Type_: ART

10:12

Crea

2.5 mg/dL
(I2)(6) -& Sample Type_:

07H0V03

10:51

oper war 4)(6)
Physician:

REMARKS:
mweill

REP I • TED BY: DATE: LAB NO.:
DOD-035881
Ward/Section: REQUESTING PHYSICIANTI al\
LABORATORY RESULT FORM(C).1 111111111111r (Subject to the Privacy Act of 1974)
LAST, FIRST., MI.
ATE TIME SSN/PSEUDO SN:
_o 130\103 g_83c,6
ma, o ogy) CBC Misc. Serology
TEST
TEST I RESULT I REF. RAATr;P:
TEST RESULT REF. RANGE
111111

09:07 '
Patient

WBC
RBC
Limits
PICCOLO

WBC 13.6 H x10"3/u1 4.5 10.5

Hgb ------- PICCOLO ==1:77-7
RBC 3.17 L x101/ul 4.00 6.00 08/11/03 , 0?:08 AM HO 9.2 L g/dL 11.0 18.0 08/11/03 . 09:07
REFERENCE RANGE: MALE

Het
Hct 29.2 I. Z 35.0 60.0
REFERENCE RANGE: ALE

PATIENT #: 1110401

PO 92.1 H. 80.0 99.9
ti M

MCV PATIENT #: 411111,W104
1031 28.8 pg 27.0 31.0 LIVER PANEL PL ICRC 31.3 L g/d1. 33.0 37.0 BASIC METABOLIC
DISC LOT #: 3154AA7

Plt Pit 246. x10"3/u1 150. 450. DISC LOT #: 3325AA4
OPER AIM DR #: 000

LYZ 10.8 *I. Z 20.5 51.1 .
OPER #:4111" DR #: 000

SERIAL #:

Lymph % LI 1.5 * 1101/ul. 1.2 3.4
LAL # jinn."
(Hematology} .Manual Differential
)
ALB 1.4* 3.3-5.5 G/DL

GLU 84 73-118 MG/DL

Segs ALP 82 26-84 U/L
Mono
BUN 45* 7-22 MG/DL

ALT 67* 10-47 U/L

Bands. Eos CA++ 8.5 8.0-10.3 MG/DL
AMY 33 14-97 U/L

CRE ICT 0.6-1.2 MG/DL

AST 136* 11-38 U/L

Lymph Baso
NA+ *4. 128-145 MMOVL
TBIL 11.9* 0.2-1.6 MG/DL

K+ 4.8* 3.3-4.7 MMOVL

Atyp Imm (,GT 18 5-65 U/L
CL- 120* 98-108 MMUL

TP 4.8* 6.4-8.1 G/DL

tCO2 21 18-33 MMOVL

RBC Morph INST QC: OK CHEM QC: OK INST QC: OK CHEM QC: OK
HEM 1+, LIP 0 , ICT 3+

HEM 0 , LIP 0 , ICT 3+

Spun 42752% (M)
Hematocrit 37-47% (F)
Sed Rate

Other
Coagulation Studies

TEST RESULT REF. RANGE
PT 9.8-13.6 secs APTT 21-34 secs D dimer 20 ug/m1
FDP 10 ug/ml
REMARKS:
REPORTED BY:

DATE: LAB ID NO.:
'-ex)
(10z-

)
MEDCOM - 22306

DOD-035882
¦,\'arcUSection:40u.
)RE11111161-Al;:: 00 ((p) -?.....: CHEMISTRY RESULT FORM I C(A (Subject to the Privacy Act of 1974)
. LAST, FIRS ¦
DATE T1M6-30 SSN/PSEUDO SSN:
/
_ (.0 (i
. .

ki..51'1!.., -.:iic•joi... :c.tiiFni-§t-612::.,.., Metabolic
TEST RESULT REF. RANGE
Na 138-146 Damon K 3.5-4.9 mmol/1; Cl 98-109 mmol/L pH 7.31-7.45
PCO2 3545 mmHg (irt)
41-51 mmHg (yen) P02 80-105 mmHg (an) N/A. (yell) TCO2 23-27 mrnoUL (art) 24 -29 nunoUL (yen) HCO3 22-26 mmol/L (art) 23 -28 mruoUL (Yen) s02 95-98%
BEecf (-2) -- (+3) nunol/L AnGap 10-20 mmol/L
Ca 1.12 -1.32 mmol/L
BUN 8-26 mg/d1
GLU 70-105 mg./d1
Creat 0.7-1.5 mg/d1 Het 38-51% PCV Hgb 12-17g/dl
. . . ,.
'.'..ITis....

c;',Vieiciisitiy: : :: • -:.
TEST RESULT REF RANGE
Troponin-1
Drug of Abuse
REMARKS:
REPORTED BY:
TEST RESULT REF. TEST RESULT REF. RANGE RANGE
ALB 3.5-5.5 Wdl GLU 73-118 mg/d1 ALP 26-84 u/1 BUN 7-22 mg/dl ALT 10-47 IA CA++ 8.0-10.3 rug/di AMY 14-97 &I CRE 0.6-1.2 mg/d1 AST 11 -38 uil NA+ 128-145 mmol/1
TBIL 0.2-1.6 mg/d1 IC' 3.3-4.7 mmo1/1 BUN 7-22 mg/d1 CL." 98-108 mmo1/1 CA++ 8.0-10.3mg/d1 tCO3 18-33 mmo1/1
CHOL 100-200 mg/al . :(PIC '• ' is.,0-, Panel PO.: Orb 0.6-1.2 mg/ill TEST RESULT REF. RANGE
GLU 73-118 mg/di ALB 3.3-5.5 g/d1
TP 6.4-8.1 g/dl ALP 26-84 ufl

ii :":7': :':. C....t.-, (1!ke010MetliIe C;:-''''''. ALT 10-47 &I ' -.
'1:Z;.'..•'''.:'. 7.,:...., '''.;:.*:•:'...--:'::;:-........,.';';:_. TEST RESULT REF. AMY 14-97 Lill RANGE •
GLU 73-118 mg/ill AST 11-38 u/1 BUN 7-2_2 mg/dl TBIL 0.27 1.6 rng/c11 CRE 0.6-1.2 mg/d1 GGT 5-65 ail CK 39-380u11(M) TP 6.4-8.1 01
30-190 u/1 (F)
NA+ 128-145 uuno1/1 .::: :..', : (picCPIo.)',E1ct-067t.

e:: -:::..,

......
3.3-4.7 mmol/l

TEST RESULT REF. RANGE
.CL" 98-108 mmol/1 NA + 128-145 mmol/1
ICO2 18-33 mmol/1 K-3.3-4.7 mmoV1
• CL-. 98-108 mmolll
tCO2 18-33 mmoL/I
a , C.,„ E-4-7--/ C F7--
DATE: LAB ID NO.:
WarcUS /int 11.-AtST

p t : OOP 5t

'

Na
4.3 mmol/L
Tea 24 mmol/L
31 7f.P0V
11 q•dL
hrt

At 370
pH 7.315
P002 4 , rimHQ

HCO3 2:3 mmol/L
-3 MMOI/L

4t Patient Temp

PH Pt7n7 • NM119 P02 112 mmHg
Patient Temp! 98.3F
FIO2 ; 80
Sample Type_;

08NOV03 1 ¦;:50
: i a n:
425
A41:

/11-73G,

z_
Ch. LSTP1 RESULT FORM
(StiLect to the Privacy At of 1974) TIME SSN/PSEUDO SSN:
1
icCi

TEST RES LILT RE RESULT REF. RANGE

BUN 7-22 mg/di
104
ruga

11 2
-
inuMW

0.2- REFERENCE RANGE: f iviVA4E PATIENT #: bAW METLYTE 8 mmoi
8.0- DISC LOT #:

3151AA4

OPER #:

DR #: 000

SERIAL / 4#)( RANGE
73- GLU 96 73-118 MG/DL ed
e

6.4- BUN 39* 7-22 MG/DLCRE ICT
0.6-1.2 MG/DLiccolP),-MetlYte CK 1959* 39-380
U/L

NA+

••# 128-145 MMOVL
K+

5.2* 3.3-4.7 MMOVL
CL-

115* 98-108 MMOVL
tCO2 20 18-33

MMOVL

7-2

0.6

INST OC: OK

CHEM OC: OK

39. HEM 0 , LIP 0 , ICT 34
30-

12: -01f1"
Cfr Y5

133

98
18
Cita

17,0 2 30
REPORTED BY: DATE: LAB ID NO.:
L

MEDCOM - 22308

0

.

img/d1
it
Won

RANGE
15 mruoI/1 rrirno1/1 mmoV1 mrao111

DOD-035884

Ward/Stan*/ REQ SIC N.
LABORATORY RESULT FORM I (Subject to the Privacy Act of 1974)

LASI, FIRSk.,ttLi

DATE TIME SSN/PSEUDO SSN:

2At4? J(0 2-0
(HeinatOlogy .CBC
Urinalysis
Misc. Serology

TEST RESULT REF. RANGE TEST RESULT REF. RANGE I TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A I RPR Negative
RBC 4.7-6.1 x 10' App N/A I Mono Negative
Hgb 14-18 g/d1(1v1) 12-16 g/d1(F) Glu Negative Microbiology
Hct 42-52% (M) 37-47% (F) Bili Negative Source
MCV Plt 80-94 tI (M) 81-99 fl (F) 1300 .500 x 103 verified Ket SG Negative N/A Gram Stain Occ Bld Negative
Lymph % 20.5-51.1% Bld Negative H. pylori Negative
(Hematology) Manual Differential pH N/A Micro
Parasites
Segs Mono Prot Negative Malaria
Bands . Eos Urob 0.2-1.0 O&P
Lymph Baso Nit Negative Other
Atyp Imm Leuk Negative • Microscopic Uri/a• . • .
RBC HCG Negative
Morph

Spun 42-52% (M)
CSF Blood. Bank

Hematocrit 37-47% (F)

Sed Rate
Cell
MUST SUBMIT SF 518 WITH
Count

EVERY UNIT REQUESTED Other Directigen Negative
ABO/Rh
Coagulation Studies

Blood Bank Unit CrOssmatch
(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD
REQUESTED)

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

D dimr 20 ug/m1
FDP 10 ug.'ml
nritA A TAT.,0_ ft

REPORTED BY: DATE: LAB ID NO.:
DOD-035885

War d/ :

(6) to -2-
I

LAST, FIRST, MI. E
O) chinistTy ; :

TEST RE ESULT REF.
P
t
(i))((k)t..1 RANGE
Na 3.5-5.5 g/dl
Na 15"3 mmoi/L 26-84 u/1
Cl 3.9 mmol/L 10-47 uil
pH T002 2e mmol/L 14-97
PCO2 Hct 2 %PCV 11-38 till
P02 Hb* 9 g/dL 0.2-1.6 mg/di
TCO2 *Yid Hct 7-22 mg/d1
HCO3 At 370 8.0-10.3m0
s02 pH 7.325 100-200 rogki/
BEecf P002 44.7 mmHg 0.6-1.2 mg/dl
AnGap Ca P02 H003 6Eecf 82 mmHg 24 mmol/L -2 mmol/L 73-118 mg/d1 6.4-8.1 Wd1
BUN 2* 35 % :610-Metlyte
GLU *calculated 'ESUL T REF.
RANGE
Creat At Patient Temp 73-118 mg/d1
Hct PH 7.330 7-22 mg/dl
Hgb P002 44.0 mmHg 0.6-1.2 rag/d1
P02 81 mmHg 39-380 u/l (M)
30-190 u/1 (F)
TEST RE Patient Temp: 98.0F 128-145 mmol/1
FIn2 : 90
Troponin­1 Sample Type_: ART 33-4.7 mmol/1
Drug of Abuse 09NOV03 08:47 98-108 mroalll
Oper' 18-33 mmol/1
Physician: e0 A4)?,

REMARKS: ,

bG n62 96,

REPORTED Y: DATE: LAB j NO.:
CHEMISTRY RESULT FORM (Sub'ect to the ct of 1974)
ieCo o *tabOliOrlkt..

TEST RESULT REF. RANGE
GLU 73-118 mg/di
1211 ...."/,41

BUN CA++ CRE _____== PICCOLO 09/11/03
NA+
REFERENCE RANGE : ri

\i, \I f
KT

PATIENT #: ilimpub)owt
CL METLYTE 8 DISC LOT #:
tC O2 3151AA4
OPER
Allip DR #: 000

SERLeiL #: __11111111111
O

TES,
GLU 113 73-118 113/DLALB BUN 38* 7-22 MG/DLALP CRE ICT 0.6-1.2 MG/PL
CK 2196* 39-380 U,

ALT MMOR.. AM'S K+ 4.8* 3.3-4.7 MOM_ CL-114* 98-108 MGM_ AST tCO2 20 18-33 MMOtt.. TBII
INST QC: OK CHEM QC: OK

GGT
HEM 1+, LIP 0 , ICT 3+

TP

TE!
CAE"-2r:S

tCO2
DOD-035886

Ward/ ti REQUESTLNG PHYSICIAN:
LABORATORYRE1SULT FORM

LAST, FIRST,.MI;
DATE TIME • : SSN/PSEUDO SSN:
00 (,(0-
.. (Hethatology).CBC -
.
--• . _,--

. RANGE TEST ID 09-11-03
NBC Wil Color
(.2:44
RBC ratiert

App

Lis Hgb a 16.8 H x10"3/aL 4.5 10.5 Glu RPZ 3.31 L x106/tiL 4.00 6.00 Hct E 9.5 L gAL 11.0 18.0 Bili Hct 30.7 L Z 35.0 60.0 . • - . MCV l'0.1 92.8 ft 80.0 99.? Ket itH 28.6 pg 27.0 31.0 Pit MX ,)0.8 L g/dL 33.0 37.0
SG

Flt 262. x10"3/UL 150. 450. Lymph % DI 10.4 *I. Z 20.5 51.1
Bid
-LI 1.8 * K10"3/IL 1.2 3.4

(HetnatidOgy).Manual Differential : ipH
Segs. Mono Prot
Bands . Eos Tirob
Lymph Baso Nit
Atyp Imm Leuk
RBC HCG Morph
r._.._ --c,n A. r• s¦= 1=--
Hematocrit 37-47% (F) Sed Rate
Other
Coagulation Studies..

TEST RESULT REF. RANGE
PT 9.8-13.6 secs APTT 21-34 secs D dimer -e2t) ug/ml
; FDP 10 ug/ml REMARKS:
•
Cell Count
Directigen

• Urinalysis . .• .. ... , ...Misc..Serology : . ,. .
RESULT

, L14 -I 11,1.., /IAA 01E7/4)

REF. RANGE TEST RESULT REF. RANGE
N/A RPR Negative
N/A Mono Negative
Negative -. MiCrobiology
Negative Source
Negative Gram
Stain
'N/A Occ Bid Negative
Negative H. pylori Negative
N/A . Micro
Parasites
Negative Malaria
0.2-1.0 0 & P
Negative Other
Negative : •MI rOSCOpiCUalyS
Negative
•,

Blood Bank
MUST SUBMIT SF 518 WITH
EVERY UNIT REQUESTED

Negative
ABO/Rh

-BloOd. Bank Unit CrOssmatch . : '
(MUST SUBMIT SF 518 WITH EVERY UNIT OF BLOOD . - REQUESTED) :
UNIT TYPE CROSSM4TCH

REPORTED BY:
DATE: LAB ID NO.: .
DOD-035887

Pt Name=

TCC!2

52.3 mmHg
POE 75 mmH9
HCO3 mmoi/L
8Eecf -1 mmol/L

at pd

Sample Type_l

OPer:
PhLps ici an

Ver:
P02 90
Rol gess
-
Pt 370
P'7! 7.3e3

53.0 mmHg
POE 70 f4mi.ig

mmol/L

-

-LaJCULat e d
7ype_:
C?DNOV03 17:54

C per
ci

5er*

',ler: was

AWN:RN., qci
)

(U0z
____ ____ ff:M0j /L
37c

ph

7.La
53.E; mm-Si

P02
7moi/L

4.7 F(01H9

. _

C:c5,NOVI?

oper ,

MINI/

physician:

Pt.
TCO2 mmoi/L A 37C
qg-W.

PO2 52.1 mmV. P02 22 mmHg HCO3 24 mmnisL
REecf -2
mmoisL s02* 88 %
*calculated
sample Type_:

0•77qi0V03 10:27 Oper:
5er#
VPr:

Sr

F Oz 80 7. toy
1 -STRT G3+
Pt :

P+ NemP:
Tulz ZE NIM01/L

Rt 37C

..y. pi:hE . 5 f1L mmHg' raf,-mmHg
=-_-.­
L
ultAniri!=leare
4=K 03
_, . • ...

V..:15.c -f:i m D.1 0 ! ,-1

--•,
fir;f*

*rairulat ed
03H0V03 12:14
-.3 1s

0r4 er:ae-Hco
•iat.Or -e-

P =isiciar4 ovei4S-ricde4
Acidit4MV

.De r#

Ordev 3S rhal-.1'
0,100

q7
F-102_9 0 1
(G)

TCn2 27 mmol/L
37C
pH 7.220
PCO2 53.3 mmHg
PO2 73 mmHg
H003 25 mmoisL
BFprf

*ralrulAted
Semple

09NOV03 14 03 Oper:11111, Physlrian:
-Terve q7
Roz

u\o (4"7-
RLIIIINVAN:09)(64-i-' CHtivIISTRY RESULT FORM
war°
(Sub'ect to the Privacy Act of 1974)

LAST, FIRST, 1s,
TEST 'SI RESULT
Na K Cl pH PCO2
P02
TCO2 HCO3
s02
BEec f
AnGap Ca BUN
GLU
Creat Hct Hgb

REF. RANGE
138-146 mmol/L
3.5-4.9 trunol/L
98-109 mmol/L
7.31-7.45
3545 mmHg (art)
41-51 rnmHR (von) 80-105 cnotHg (art) N/A (veal . 23 -27 mmol/L (art) 24 -29 mmol/L (von)
22-26 mmoUL (an) 23-28 mmoUL (von) 95-98%
(-2) - (+3) nunol/L 10-20 mmol/L
1.12-1.32 mmol/L
8-26 mg/d1
70-105 mg/dl.
0.7-1.5 mg/di 38-51% PCV
12-17 g/d1

C:Clieiti40.,A':.-...E.:., , ::.
TEST RESULT REF. RANGE
Troponin-1
Drug of
Abuse

REMARKS:
h 6

REPORTED BY:
(3311‘
... _
.
...-,.......-,

! (PiedoloYcliirni -st-T027:' , 4 ;-...7
TEST

ALB ALP
ALT AMY AST
TBIL BUN
CA CHOL CRE
GLU
TP
TEST

GLU BUN CRE ,CK
NA'
,+
.CI;
tCO2
RESULT REF. RANGE
3.5-5.5 0:11 26-84 WI 1Q-47u/1
14-97u11
11-38 ull 0.2-1.6 mg/di 7-22 rug/d1
8.0 -10.3mg/d1 100-200 mg/dl
0.6-1.2 mg/di
73-118 mg/d1 6.4-8.1 g/dl
(PiCcolii):Metlyte f3";::-;::_:.;:'-,._.,
RESULT REF. RANGE
73-118 mg/di 7-22 mg/di 0.6-1.2 mg/dl 39-380 u/l(M)
30-190 u/1 (F) 128-145 mmot/1
33-4.7 mmol/1
98-108 mmo1/1
18-33 mmol/1
-

SSNIP
AT EGe+

111111
•aM e
Na 1R3 mmol/L

K. .3.8 mmol/L TCO2 2g. mmol/L
Hct. Le %PCV
• 9 gsdL
*v i a Hct

At 37C
pH
PCO2
P02
Hr:03
necf
-702*

7.293

50.9 mmHg
e9 mmHg
25 mmo 1 /L
-2 mmol/L
31 %

*ca 1 cu 1 at ed Rt Pat ient Temp
pH 7.293
pr:02 50.9 mmHg
P02 63 mmHg

Patient Temp: 98.6F
FIO2 : 80
3ample Type_: ART

09N0V03 10:2?

7-e_ii--10 qP)6

1-102_Fin4
DATE: LAB ID NO.:
DOD-035890

Ward/Section: REQUESTING PHYSICIAN: )
CHLoilSTRY RESULT FORM (Subject to the Privacy Act of 1474)LAST, P1RST, ATE
11.1111.111FTIME SSN/PSEUDO SSN: te)ANit53.— or? o
TEST REF. TEST RESULT REF. T RESULT REF. RANGE RANG
FAT EGG+

'FIT CREA

Pf:
Pt Name: Pt IA arge:

Pt: 11111,

Na 150 mmol/L Glu le0 mg/dL -Crea 2.5 mgdL

RUN

5.3 mmol/L 52 mgsdL

7
Sample Type_:

T:02 28 mmol/L Na 151 mmol/L

22 %PCv 5.2 mmol/L 10NOV03 07:42

HO* 7 g'sdL -CI 120 mmol/L
Oper: 7

-TCO2

*via Hct mmol/L

-AnGap

10 mmol/L Physician:

At 37C

Hct

27 PCV
PH 7.044 -# 42011

Hb*

p g/dL
PCO2______31.e mmHg JRM504GA

-*via Hct
CLEW A93
P02 mmHg

pH 7.oe2
HCO3 25 mmol/L

PCO2 5'2.0 mmHq
BEecf -e mmol/L HCO3 (SW

2g. mmol/L
E-02* 74 % TP 6.4-8.1 ell

BEecf ­
4 MMOI/L
*calculated

5ample Type_:

izit Patient Temp

TEST RESULT REF. RANGE
10NOV03

07:36
pH 7.027

NA: 1/8-145 mrno1/1
POO2 mmHg

°per: an

P02 g.4 mmHg 3.3-4.7 mmo1/1
Physician/

Patient Temp: 101.0F

CL' 98-108 ramoLl
FIO2 : 100

ECG.: 18-33 minol/l
le Type_: ART

NOUO3 07:35

/6/
REPORTE-D BY: DATE: LAB ID NO.:
DOD-035891

Ward/Section: REQUESTING PHYSICIAN:
LABORATORY RESULT FORM1
(Subject to the Privacy Act of 1974)

LAST, FIRST.,,MI.
DATE ThME SSN/PSEUDO SSN:
TEST
WBC
RBC
Hgb WIC 19,3 H .g10'3/uL
Hct RK 2.99 L x10'&111L
Hgb S. 6 ght 11.0
MCV itt 213.0 L 35.0
NV 95.4 IL 60,0
Plt GC 28,8 30.9 L pg g/dL 27.0
Lymph % Plt 1217. 54. r10'3AL 1 7.5.41. 15", r,

(HematOkLYK.3.4* xirt3lut. 1.2
• -3. ,.•..

Segs Mono
Bands Eos
Lymph Baso
Atyp Imm
RBC
Morph
Spun 42-52% (M) Hematocrit 3747% (F)
Sed Rate
Other
Coagulation Studies

TEST RESULT REF. RANGE
PT.Isp„ 0 9.8-13.6 secs APTT Wi 21-34 secs D dimer 20 ug/m)
FDP.I ugirn1
REMARKS:
REPORTED BY:

.Urinal•sis. Mist: Serology :
TEST RESULT REF. RANGE TEST RESULT REF. RANGE
Color N/A. RPR. Negative N/A.
App Mono Glu Negative 10,5 Bili Negative
18.0 07:38
Ket 10/11/03.
60.0 Negative
MALE

REFERENCE RANGE:.

C9.9

31.0 PATIENT #:.
SG N/A (kolG)4
7,0
METLYTE 8

450,

Bld Negative 3151AA4
DISC LOT #:.

r, I.I
DR #: 000

pH N/A OPER #: .S RIAL
Prot Negative
)0Y1'

X165* 73-118 MG/DL

GLU.

Urob 0.2-1.0 BUN 41* 7-22 MG/DL
Nit Negative CRE CK .ICT 1202* 0.6-1.2 39-380 MG/DL U/L
Leuk Negative NA+ 142 128-145 MMOVL
K+ 6.0* 3.3-4.7 MMOVL
HCG Negative CL- 114* 98-108 MMOVL
tCO2 20 18-33 MMOVL

CHEM DC: OK

INST OC: OK.

CSF
HEM 1+, LIP 0 , TCT 3+

Cell
Count

Directigen Negative

.Blood. Bank Unit (MUST SUBMIT SF 518:WITH .. REQUEST
UNIT . TYPE
DATE:.j LAB ID NO.: .
DOD-035892

TANH.74

se
_cp.,eve3

.7!ffiHq

FIoa

-

ipe_: pR7

Pn YSLC:a: .
"am
0\141 40+
1263505 1263525.I soc) ck-s---
-

.\3'1
4363225

1645474 \.T5
MEDICAL RECORD - ANESTHESIA
For use of thi's`•form, see AR 40-66; the proponent agency is the OTSG
-, TOTALS
D z K"\-.01/4 VV.(.) 3
(-0 I ce)
0 0 -(.
0
,9 2

I- Z
LI k-

4-
...
a• yi

-I zoo
n2 z ...
0 VOLikr, -r.% del LA 0 (4:

6.19

• L./ bids
Z AGENT .% e.t. O CRYSTALL ID.
AIR.L/Min
ot r
o Z L("3

N20 L/Min LiSpO
02.L/Min .2_ SINGLE DOSE DRUGS-MARK ON GRID.„,0 (D 0 WITH NUMBERS L ENTER IN REMARKS BLOOD-LINE site.)
0 Warmed
=114.
IINMINII
c SC c.0 Warmed i—R
i=10:71=-

.110ZeMiEf . ¦
Code drugs with numbers,
0 Warmed

U
=IMIEVINIMAPI:g=
events with tatters
Lic M..1111•1101:S ini-
Ii Warmed L.

Mq:11.63M 0 MAIM MU'
EST BLOOD LOSS

IMEMONIIIIIWZ, alliiiiMI.wry-
URINE -

IlleMaliiIIIME11111.
PHYS STATUS-MIMEO
15-..---3 D
1 airzak. TIME
SYMBOLS

BODY WEI. Imolowelownsil
220
4210 BP by cuff

—
7 200 .-MIGNifill. 1=1:111
HEMATO CRIT: A V a= Me:
180
WEIN

Heart r te
INIRAkakrka:.•
BP-.Resp rate 140 MN

immommom

-2_ 71111111111=2 MUM
MIMeuriumi
120 -..pumwas2wilre—
HR-viu) BR ...ammuncarawarimemir
(transduced) 100 NW _
MINia liNIMI
R-Iii1
80
212

OK?- IMP
TOURNIQUET 60 an
T _.ErWomisrainiwymm-_
manomormag
40 MR II IIMMINIIMINIEMBILIMMUILIEtiill
OK for
PROCEDURE?

ANES- x-x

20
TIME-

PROC-
III
.

VT - ml c
--150 15-0

161.1.1 110¦117=.131121.n'U¦ (a-TO
I breaths/min
co \Co.\LI
Peak MI pres / PEEP

HININIK11111111
3 33

E - SI on). A(ssist). Clan) '3 2"
c C C

P/Auto Cuff hi T 02 (torrl -REC
o

111.11111a9MVIMW11111MILVIIEVII C
0 Frac or %I PACU ICU Spicily)
smEarsurp-02 1:1011111111111a1MENIIILTO.ILIVINN1 • 1
ISteth- PC/ES.1%) iiii1111701110111LTRILIMILUillIrialliel/1 %e)

OTHER

CG. C St
MEMO c-c-CONDITION:
Gas analyzer.MP-site
30— 353 •
w ESEIENILIEBRILIEMIMIMIM
RESP-.

N-M Block (TM) 'fr. Mil
4 1111111ININI LPSp02-1Ce
BY..R-L
U)
0
Ut Start Room End 0
Warmln, blkt
Cony warmer \-?at %39c
Merk with letters & symbols, EVENTS_._ 0 Ready
Begin End
explain unite, REMARXS.
Position --"" 0
0() 0

i
a. 4)2C,

PROCEDURES and CPttsidek_.....D ..k.
ANESTHETIC TECHNIQUES:

1_-.c-PA6N Describe block technique under Remarks -1/47 'a t_.:'.((ç\ ecx-s-cltitc) ev-N .(k-) I:7" Pc PATIENT IDENTIFICATION:
Typed or written enu; s: Alarnet"trade/Rate „...-
AIRWAY MANAGEMENT:

intubation route, blade, technique, comments
Medical facility.' 5 S-:.A.
-D &A fe e-R
SURGE
PROCEDURE

u 'IrNit
E „---...,E,- cele3y--,A--cck,s-e / pe r "-tole' LOCATION: \.
DATE:
iNESTH

-'%--- 2-5 strcs-.I '.VD /7-77 /03
MEDCOM -22318.T_SITi\
rs.r-•-.11,. •.el. PAGE.OF it
OS

DOD-035894
CONTINUOU S/REPE ATEDDRUGS SPECIFY UNITS -MG/MCG/ML. "I' -CONSTANT INFUSION
MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
oFitio:::::::::,::::::::::::.,:,•:•:::::10-iiiw:: TOTALS TOTAL, EBL Vt-Z..( ,2,.) j 1,- int X.I ....,.I 14,1-.( J._ ) 'I I I.
i (Ill 7 C itootooti(.) hik-K-g.,--.(.) b-0
e,-,.-, i00 *i.j(ICW: re-r( % del Y•L —.1 ''''' il -i (w"----r 4 X FthIS . 0M1'10.0
AGVITT:::: % el. CRYSTALLOID-
AIR Zo-J A-330 02.L/Min I.—2-..--------
EST HETWAGTS:ANW.DAVGS
SINGLE.
•-/b. f--1
WITH NUMBERS & ENTER IN REMARKS i3.
LINE site L?T
REMARKSagnagg:-.:::
..0)
Warmed

rk.7 P Code diugs with numbers, ey-aL.:.D Warmed air! ----......'""
events with hatters
5 ,,
111 "
11 i 4363204°f'

' EST BLOOD LC:E ,_ /15-13
1:0444: '..-'-1263512 '- lx: 41
: UR NE
un 11 c -

.'11P13
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g TIME + .//If -3-, Y•.
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HEMA
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4.04.,••• ¦¦ L,Ai I.
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TI ..,
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f -breaths/min 4g.)12.(.L7

!
431' )31
Peak int pres / PEEP 3
3 I.-s-.12
MODE - Slpon), A(ssist). Clan)

0-.c„.c.C 0.0** *.t: / a .LID
K BP/Auto Cuff 'ET CO2 (torn yo.3".ra
PACU VU iti_Isp.mv)
BP/oth $ F102 (Frac or %) r g.. 8.I b.-t3
ART line ) Sp02.(%l /DO.laO.)O0./CIO
OTHER

Steth- PC/ES yECG .g.r.ST.T COVX.:
Gas analyzer TEMP-site

PESPJ ° ).Sp02' X N-M Block 11/41 , 0.° • , BP / 1/1/73 HR.
fi1411-.,,,,

9.
------6.t:tF4WSTFF:7T—
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Warming blkt z
Arc(' et'''. felt. Cony warmer
ES Ready Begin End
Mark with letters & symbols, EVENTS__,
o
172-P

n. 1?3-19/D
...pub, under REMARKS.Position.
-

PROCEDURES and CPT cocip54, a, . ANESTHETIC TECHNIQUES: Describe block technique under Remarks
g...r L. L40

t.O . Weritsit t CMItY "-- '.' PATIENT IDENTIFICATION:.Typed or written entries: Name, Grade/Rafe,
AIRWAY MANAGEMENT: Intubation route, blade, technique, comments
Medical facility

411111 N(G)9 SURGEONS: 111111111M1-- (1D) (4) 2" PROCEDURE LOCATION: OW) c7 The(
ANEST,HVISTp: .ik/Tr---
MEDCOM - 22319 Int 6+04-¦ PAGE.1.OF
DOD-035895

s ¦.4.1.3-0 - I SS-72.9 ••¦
'OLOGIC CONSULTATION REQL, PORT
Plucl2ar Al.,71.iiciaejUltraiound/Caciputed Tcrnagr, :31711.1¦ J(1.00
REQUESTEO ..CE SEX I SSN iSpon:o REGISTER NO

PR EGNAN 7
I 1 vEs
1 n

TELEPHON E/PAGE
of R..EQu=7,TEC jr(1.5) 5i R. PO R REQUEST. 1:ns'inrs)
(buct.J1).
b-R'3.\P.t:ht.,
E:...A.MiNA ION (..Wort:.1. day. yr) DATE OF REPORT. yrc,) CTE or TRANSCR!?71 N.
.
;•,•'OICG:C. REPO AT'
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-
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11111.
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.
1.
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MEDCOM - 22320

DOD-035896
11 PI AFF ART=114/881991. TIFF T2AFF eT41J F
SPO2=921 NI PFAFF .........
•.•.• • • •

.... ........... . .... . .. .. : • ¦.• ¦.•......
:.......•."
...... :." 7 " ..•
POR DISPLAY.OR
p. .140
''
68
1111
9-0.7 PI 41FF ART=143/1311(1 ) RR--20 Sp1)2!--947 NIBP-AFF TIAFf T2--OFF A14FF
:.: :.: : : .. :.•
f. I

DISPLAY ON
...

140
". .\ 1\
\,1

68
4x
Ldl

4:81_ FR=IO2 PI AFF ART=142/130(108) RR--29 SP02=927 NIBP-AFF.aTAFF
PL4IFF _61.=-1910_9(99)_W4. . SP022124 . 111BPAFT„
ii.14F_ 1241FF at4FF

0. 60X6Y1-
.
MEDCOM - 22321

DOD-035897

...
-77,-----37.:.

-977-8P4IFT14/: -F—T• :::..
7,777- 111-41........

-7-7-75142

----)--F4°8..::.
1 --1194F2 Pi 4IFT0111'147-83-(99::::.
:.:.. . ..:::::::::::.:.
•....
::.• :::

:.: :.: ::::: ....•. .:..1-:.
..

?RCEOliiisPIA OH.
•
__NI0114FF__11.4FF T24IFF eT4)F.f

APT-1421 4109113974Sio.R.,•
'D:42:51_ }1_t-.97.r-rIFY _: :
PACER DISPLAY ON
140
API
_
4x

Ldl
4IFF ARI=136/64,187)_ t 2_ $01243Efi 140P4iF T1 FF 12FIFF:
rit

PACER DISPLAY ON
140
• / \
\ ART.\

621
4x
Ldi
-
DOD-035898
. NSN 440-00434-4158
MEDICAL RECORD
BLOOD. OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

COMP NENT REQUESTED (Check one)
TYPE OF REQUEST ICheck ONLY if Red Blood Cell REQUESTING
Products are requested.)
RED BLOOD CELLS
kI ((1)
' FRESH FROZEN PLASMA . TYPE AND SCREEN DIAGNOSIS OR 0.ATIVE PROCEDURE LI.PLATELETS (Pool of units) CROSSMATGH
CRYOPRECIPITATE (Pool of units)
DATE REQUESTED I.have collected.a blood.specimen.on.the belowRh IMMUNE GLOBULIN .0j._,_.
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED,..,--patient and verifiedthe : specimen tube label to be
4-A....lt ;

OTHER (Specify) correct. - • • .- -,, VOLUME REQUESTED (If applicable)
KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATUR REACTION (Specify)
ML

REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY
-OF: DATE VERIFIED RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING
UNIT NO. TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHV: ANTIBODY SCREEN CROSSMATCH
0 RECORD.NO RECORD PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST

DONOR RECIPIENT
ABO O ABO 0 CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED REMARKS: DATE ..,„„
Rh Rh .rp_S A-,go

SECTION III -RECORD OF TRANSFUSION
POST-TRANS51,08101TDAM•N AMOU T GIVEN TIME/D -COMPLETED/INT RUPTED
1-.57.7V.577
ON • TEMPERATURE u .'.PULSE.
B10011eRpsuRE DNE EI SUSPECTED
31C77
.

IDENTIFICATION-.
f reaction is suspected—IMMEDIATELY: I haVe examined the Blood Component,ppntainer . label and this form and I find all 1.
'scontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the conta ii • .' ed' recipient matches item by item. 2. r, tify Physician and Transfusion Service.The recipient is the s. ••. nt Transfusion Form and 3. Fol w Transfusion Reaction Procedures.
on the pati.'
4. Do or discard unit. Return Blood Bag, Filter Set, and I.V.:Solutions to the Blood Bank. 1St VERI
DESCRIP ON OF REACTION .[1, -URTIC RIA.fCkIJ,LL 0 FEVER 0 PAIN
echy).
(G)

OTHER DIFFICULTIES (Equipment; clots, etc.) NO•;1,. YES TEMP. SIGN ..
.

DATE OF,TRANS SION TIME STARIED5t3
0

PATIENT IDENT CATION—USE EMBOSSER (For typed or written entries give: Name—Las rate; hospital or medical facility) •
NIL AR
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record

IMP (4(01

STANDARD FORM 518 (REV. 9-92)

Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1
MEDCOM - 22323

DOD-035899

Lar

MEDICAL RECORD-
HENT REQUESTED (Check one)
-iED BLOOD CELLS
FRESH FROZEN PLASMA •
PLATELETS (Pool of.units)

.L1
CRYOPRECIPITATE (Pool of .units)
. Rh IMMUNE GLOBULIN
OTHER (Specify) . VOLUME REQUESTED (If applicable)
.
. MI:
REMARKS:
UNIT NO. TRANSFUSION NO.
PATIENT NO.

/.5Y
DONOR RECIPIENT
ABO ABO
Rh Rh
PRE-TRANSFUSION DATA INSPECT D ISSUED BY (Signature)
. CROSSMATCH NOT REQUIRED FOR THE COMPONENT'REQUESTED DATE 1-90e,f3=3
REMARKS:
SECTION III - RECORD OF TRANSFUSION
POST-TRAN
•
TIME/DATE MPLETED/I TERRUPTED

NSN 754-00-6,34,-4158
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

TYPE OF REQUEST (Check ONLY if Red Blood Cell Prodi cts are requested.)
TYPE AND SCREEN CROSSMATCH DATE REQUESTED
DATE ANEYHOUR REQUIRED
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF: RhIG TREATMENT? DATE GIVEN: . HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING

TEST INTERPRETATION ANTIBODY SCREEN CROSSMATCH
C
REQUESTING
DIAGNOSIS OR OPERATIVE PROCEDURE

I have collected a blood specimen on the below named patient, verified the -me and ID No. of the patient and verified the men tube label to be
correct.
SIGNATURE OF VERIF1
TIME VERIFIED
PREVIOUS RECORD CHECK: .
El RECORD
0 ECORD SIGNATURE OF PERSON PERFOR MING TEST
TETERAT E PUL1

BLOOD PRESSURE AT (Hour) ON (Date) )ictiol E I I SUSPECTED
1 28-

IDENTIFICATION
If reaction is suspected—IMMEDIATELY: I have examined the Blood Component container label and this form and I find all
Discontinue transfusion, treat shock if present, keep intravenous line open. .
,
information identifying the container•with the intended recipient matches item by item.
2. otify Physician and Transfusion Service. The recipient is the same person omponent Transfusion Form and 3.
ow Transfusion Reaction Procedures. on the patient identificatio
4. Do T discard unit. Return Blood Bag, Filter Set, and I.V. Solutions to the Blood Bank. 1st VERIF R
DESCRIPTIO F REACTION URTICARIA

CHILL.LI FEVER.ill PAIN
OTHER (Specify)
(
b)

OTHER DIFFICULTIES (Equipment, clots, etc.) PRE-TR
NO . YES TEMP.
PU SE DATE OF TRAN USION
TIME STARTED )0 7-71 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—L rate; hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION
11111 (6Y0
Medical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR. F1RMR (41 CFR) 201-9.202-1

MEDCOM - 22324

DOD-035900
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 RE VESTING P.ICIAN P .
Products are requested.)

RED BLOOD CELLS
•
FRESH FROZEN PLASMA . TYPE AND SCREEN
DI.
URE.

. PLATELETS (Pool of.units) CROSSMATCH
Caprei waind5
CRYOPRECIPITATE (Pool of.units)
. DATE F2•
QSTE6 +

I.have collIcted a blood specimen on the below
. Rh IMMUNE GLOBULIN e..../
named patient, verified the name and ID No. of th DrDeUR RE patient and verified the specimen tube label to
REQUIRED

. OTHER (Specify) correct.. 4
VOLUME REQUE1TEDvvi(If apaable).KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF VERIF17,_
REACTION (Specify)

. ,...._
ML

010 ---1.a...6)( ).

REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERIFIED
.

RhIG TREATMENT? DATE GIVEN: TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN?
s'\
SECTION II - PRE-TRANSFUSION TESTING

UNIT NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH
RECORD.. NO RECORD
PATIENT NO.
SIGNA
fr Cci737/9

DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTEI.
DATE c LAO
ABO ABO REMARKS:
Rh Rh edi
la O5
°

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

INSPECTED AND ISSUED BY S' natu AMOUNT GIVEN TIME/DATE COMPLETED/INTE URTED
•

4o ML +0 if))7-,'
REACTION TEMPERATURE PULSE
BLOOD PRESSURE ON (Date) R".? NONE . SUSPECTED A-C41.
-41

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 i m. 2. Notify Physician and Transfusion Service.

The recipient is the same person named on this Blood Component Transfusion For 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.
let VERIFIER (Signature)

DESCRIPTION OF REACTION

. URTICARIA . CHILL
. FEVER . PAIN
. OTHER (Specify)

OTHER DIFFICULTIES (Equipment, clots, etc.) PRE-TRANSFUSION . NO.
YES (Specify)
.

TEMP.'.71 I PULSE Oa.IBP t SIGNA
DATE OF TRANSFUSION TIME STARTED..,
2:7 or:-E- 21 SCD
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first,4niddle; grade; rank;
SEX
rate; hospital or medical facility)
wArCa

BLOOD OR BLOOD COMPONENT TRANSFUSION
111141 111,
Medical Record

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

MEDCOM - 22325 a 11 Medical Record Copy
DOD-035901

51;123
NSN 7540-00-634-4158
'MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

COMPONENT REQUESTED (Ch ck one) TYPE OF REQUEST (Check ONLY if Red Blood Cell RE
Products are requested.)

• RED BLOOD CELLS
..g"FRESH FROZEN PLASMA D TYPE AND SCREEN
DIAL/IIIIIIIP
E . i

PLATELETS (Pool of.units) • CROSSMATCH
• CRYOPRECIPITATE (Pool .units)
.
DATE REQUESTED I have collected a blood specimen on the below
,157.03

Rh IMMUNE GLOBULIN
named patient, verified the name and ID No. of the DATE AND HOUR R patient and v he specimen tube label to be OTHER (Specify) co
s
VOLUME REQUESTED (If applicable) . KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)

ML.

(b)(6) -z_
REMARKS: IF PATIENT IS'FEMALE, IS THERE HISTORY OF: TE VERIFIED
:LEI Ov 0 5
RhIG TREATMENT? DATE GIVEN: .
Cia-) TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN?

cp

SECTION II -PRE-TRANSFUSION TESTING
.

UNIT NO. TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
RECORD.

0 NO RECORD PATIENT NO..
NATURE OF PERSON P

DONOR RECIPIENT
CROSSMATCH NOT REQ UIRED FOR THE COMPONENT R
ABO ABO

REMARKS:
281 OL-teS

Rh? 1, Rh Fek-5
5
SECTION - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

INSP AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUP ED
ML

oa\S-ticsV?

REACTION TEMPERATURE i PULSE 13LeMESSU
AT (Hour) b. ON (Date) pm °crab NONE fl SUSPECTED
IDENTIFICATION

If reaction is suspected—IMMEDIATELY:
I have examined the B od Component container label and this, form and I .find a
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
Follow Transfusion, Reaction Procedures.
on the patient identificati

4. o NOT discard Unit. Return Blood Bag, Alter Set, and I.V. Solutions to the Blood Bank. 1st VERIFIER Si atur
DES IPTION:OF REACTION

UR ARIA 0 CHILL . FEVER 0 PAIN
2nd VE
4,1 OTHER DIFFICULTIES (Equipment, clots, etc.)
PRE-TRANSFUSION

NO.0 YES (Specify)
°

TEMP. I PULSE SIGNATU RE
HI.

DATE OF TRANSFUSION TIME STARTED
-2.0 OA-€53 Oils
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; ran

RD
rate; hospital or medical facility)

2X...it-Us— 1
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 - 22326

DOD-035902

518-123
MEDICAL RECORD
COMPONENT REQUESTED (Check one) RED BLOOD CELLS
.
FRESH FROZEN PLASMA PLATELETS (Pool of.units)

.
CRYOPRECIPITATE (Pool of.units)

.
Rh IMMUNE GLOBULIN

. OTHER (Specify) .
(If applicable)
ML
REMARKS: . "JP
UNIT NO.

TRANSFUSION NO.
PATIENT NO.

DONOR RECIPIENT
ABO 0 ABO
Rh Rh
PRE-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature)
AT (Hour) IDENTIFICATION
I have examined the Blood Component , container- rebel ,and this form and I fin
information identifying the container with the Intended recipient matches item by item.
The r- ' • nt is the same person named on this Blood Component Transfusion Form and
on t.ent identification tag.
ignature)

PRE-TRANSFUSION-.
TEMP....
P-1/R I PULSE.C(.I BP DATE QF TRANSFUSION.
TIME STARTED
°Grp? 1.31fro
NSN 75(

-4158
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

TYPE OF REQUEST
(Check ONLY if Red Blood Cell Products are requested.)
DATE
REQUESTED2'7 00,fiS

DATE AND HOUR REQUIRED
KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)

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

I have collected a blood specimen on the .elow
named patient, verified the name and ID No. of the
patient and verified. the spe imen tube labe to be
dorfect.;
DATE
TIME VERIFIED ,
PREVIOUS RECORD CHECK:
. RECORD.
IiimM NO RECORD ._.. Sl4NATU.P.
F.EST i

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUEST. DATE REMARKS:
SECTION III -RECORD OF TRANSFUSION
POST-TRANSFUSION DATA
AMOUNT GIVEN

TIME/DATE COMPLETED/INTERRUPTED ML /0/z.77'
3rz".
R CTION
TEMPERATURE..PULSE

at.000pe5suRE
NONE .E SUSPECTED
:I IV

If reaction is suspected—IMMEDIATELY: .
•

1. Discontinue transfusion, treat shock if present, keep intravenous line open.
Notify Physician and Transfusion Service.

3..ow Transfusion Reaction Procedures.

4. Do.discard unit. Return Blood Bag, Filter Set,and .

Solutions to the. Blood Bank.:':: DESCRIPTION.EACTION
. URTICARIA.

ILL.. FEVER.. PAIN:.,
°.
(0) 7.¦

OTHER DIFFICULTIES (Equipment, clots, etc.) YES (Specify)
OVE

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

BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record MEDCOM - 22327
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

DOD-035903
,rte

518-123 Ngtb4.154Qzp0-634-41.58
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I — REQUISITION

COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTIN
Products are requested.)

RED BLOOD CELLS
FRESH FROZEN PLASMA TYPE AND SCREEN
. DIAGNOSIS
RE
11111111111

PLATELETS (Pool of units) SMATCH
'0 CRYOPRECIPITATE (Pool of .units)
DATE REQUESTED
.
I have collected a blood specimen ' on the low Rh IMMUNE GLOBULIN
named patient, verified the name and ID No. f the DATE AND HOUR REQUIRED patient and verified the specimen tube lobe to be
. OTHER (Specify) 'correct.
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION
REACTION (Specify)

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

TEST INTER PRETATION PREVIOUS RECORD CHECK:
ANTIBODY SCREEN CROSSMATCH
0 RECORD 1ENT NO.
SIGNATUR
C Q2.-A .7/,' 1 .

DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
ABO ABO REMARKS:
p - 0 cid—c:23

Rh Rh -
SECTION III — RECORD OF TRANSFUSION
PRE TRANSFUSION-DATA POST TRA

INSPECTED AND ISSUED BY (Signature
REACTION TEMPERATURE BLOOD PR SSURE
AT (Hour) ON (Date).NE SUSPECTED

7-;

IDENTIFICATION
reaction is suspected—IMMEDIATELY:
I have examined the Blood Component . container label and this form and I find all 1.
ontinue transfusion, treat shock if present, keep intravenous line -open.
Information identifying the container with the intended recipient matches item by item.
2. Noti ysician and Transfusion Service. The recipient is the same person named on this Blood Component Transfusion Form and
3. Follow Tr fusion Reaction Procedures.
on the patient identification tag.
4. Do NOT disc

unit. Return Blood Bag, Filter Set, and I.V. Solutions to the Blood Bank.
is

DESCRIPTION OF R.ION
URTICARIA. FEVER.PAIN
•.Specify)

2nd VERIF1E
b,)61) 2IR

0 HER DIFFICULTIES (Equipment, clots, etc.)
PRE-TRA
ri YES (Spe

TEMP. 8-1 ) 2-SIGNATU OF PERS DATE OF TR
PATIENT IDENTIF1CATION—USE EMBOSSER (For typed or written entries give: Name—L
Apo:
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

DOD-035904
.
518-124
NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIA (Print)
Products are requested.)
RED BLOOD CELLS
FRESH FROZEN PLASMA TYPE AND SCREEN
DIAGNOSIS OR OP RA IVE PR EDURE 111 PLATELETS (Pool of .units) CROSSMATCH CRYOPRECIPITATE (Pool of.units) I have collected a blood specimen on the belo
. Rh IMMUNE GLOBULIN
name patient, verified the name and ID No. of th DATE AND HOUR REQUIRED pa d verified the specimen tube label to OTHER (Specify) .
VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION:E REACTION (Specify)
.ML

REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: RhIG TREATMENT? DATE GIVEN: . TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN? .
SECTION II -PRE-TRANSFUSION TESTING

UNIT NO. TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
RECORD.PATIENT NO.
kr-0-NO RECORD
SIGNATURE OF PER

DONOR RECIPIENT eb
CROSSMATCH NOT REQUIRED FOR THE COMPONENT DATE •
ABO ABO REMARKS:

Rh Rh
Pa

SECTION III - RECORD OF TRANSFUSION
PRE TRANSFUSION DATA

POST-TRANSFUSION DATA .INSPE nature) AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
e•LaCir) ML
O1 5-0

REACTION TEMPERATURE.PULSE.BLOOD PRESSURE AT (Hour).OS ON (Date) 27 ea.° NONE. . SUSPECTED .).kry
lea n...

IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all
. Discontinue transfusion, treat shock if present, keep intravenous line open. information identifying the container with the intended recipient matches item by item. otify Physician and Transfusion Service. The recipient is th- me person named on this Blood Component Transfusion Form and 3.
ow Transfusion Reaction Procedures. on the ation tag. 4. Do IT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. 1st V
DESCRIP OF REACTION
URTICARI CHILL . FEVER . PAIN
.
VO

t LT-ig3t0 OTHER DIFFICULTIES (Equipment, clots, etc.) PRE-
YES (Specify)
TEMP.
NO) 3 1.4
DATE OF TRANSFUSION TIME STARTED Df-O b ((0 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first,
WARD
rate; hospital or medical facility)
ZCLL

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 - 22329
Medical Record Copy

DOD-035905
518-124
NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

COMPONENT REQUESTED (Check one)
TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN Print)

2&\
Products are requested.)
RED BLOOD CELLS
E FRESH FROZEN PLASMA
Ei
TYPE AND SCREEN DIAGNOSIS OR OPERATIVE PROCEDURE
El PLATELETS (Pool of .units) CROSSMATCH
CRYOPRECIPITATE (Pool of .units)
DATE REQUESTED

I have .collected a blood specimen on t

• Rh IMMUNE GLOBULIN below
named patient, verified the name and ID N

. of the DATE AND HOUR REQUIRED patient and verified the specimen tube lab I to be
• OTHER (Specify) .
correct.

VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION
RE OF VERI REACTION (Specify)
A .ML

REMARKS:
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
PA"­
lD

RhIG TREATMENT? DATE GIVEN: TIME VERIFIED
HEMOLYTIC DISEASE OF NEWBORN? 1 C)0
SECTION II - PRE-TRANSFUSION TESTING

UNIT
TRANSFUSION NO.
TEST INTERPRETATION

PREVIOUS RECORD CHECK: ANTIBODY SCREEN
RECORD.

0 NO RECORD PATIENT NO.
DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
ABO

CD
ABO REMARKS:

Rh

tg-kr 3G cDe.._.-to
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA

POST-TRANSFUSION DATA AMOUNT GIVEN
TIME/ ATE COMPLETED/INTERRUPTED3 co ML j0/1-1./ Si;
.
REACTION

TEMPERATURE PULSE
AT (Hour) ON (Date) NONE.SUSPECTED 37

. .BLOOD PRESSURE
$ y. / 2 0/70
IDENTIFICATIO
If r.ion is suspected—IMMEDIATELY:

I have examined the Blood Component container label and this form and I find all
1. Disco

ue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item.
2. Notify Ph "clan and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Tran sion Reaction Procedures.
on the patient identification to 4. Do NOT disca
unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION OF R TION
ILL FEVER.fl PAIN
Ej OTHER (Specify

OTHER DIFFICULTIES (Equipment, clots, etc.).PR NO.. YES (Specify)
TEMP. 37.
PULSE.

./ LI ti SIGH.
TING ABOVE DATE OF TIANSFUSION
TIME STARTED
r

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; rate; hospital or medical facility) WARD
) C IA 1

,10 1(\/1111, (6)(GA
BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/1CMR. F1RMR 141 CFR) 201-9.202-1

MEDCOM - 22330
Medical Record Copy

DOD-035906
MEDICAL RECORD
OMPONENT REQUESTED (Check one)
D BLOOD CELLS

.
FRESH FROZEN PLASMA
PLATELETS (Pool of units)

.
CRYOPRECIPITATE (Pool of units)

.
Rh IMMUNE GLOBULIN

.
OTHER (Specify)

VOLUME REQUESTED (If apqlicable) / (/7 '' "*. ML
1 '

REMARKS:
TRANSFUSION NO.
PATIENT NO.
RECIPIENT

ABO ABO
Rh Rh
POS
PRE-TRANSFUSION DATA

INSPECTED AND ISSUED BY (Signature)
A.3...ON (Date).CI.
I DENTIFICATION.
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION

TYPE OF REQUEST (Check ONLY if Red Blood Cell Products are requested.)
. TYPE AND SCREEN
.25kieftSSMATCH
DATE REQUESTED
•

DATE AND HOUR REQUIRED
KNOWN ANTIBODY FORMATION/TRANSFUSION REACTION (Specify)
IF PATIENT IS FEMALE, IS THERE HISTORY OF:
RhIG TREATMENT? DATE GIVEN:
HEMOLYTIC DISEASE OF NEWBORN?
SECTION II - PRE-TRANSFUSION TESTING

TEST INTERPRETATION
ANTIBODY SCREEN CROSSMATCH

Cio A-N-143
REQUESTING

01& DIAGNOSIS OR OPERATIVE PROCEDUR . *-,4 -5(/.47 qZ-41 &
6

I.have.collected.a blood.specimen.on.the bel named patient, verified the name and ID No. of .e patient and verified the specimen tube label to be
correct.
.
VERI. 3D 4,110 3 TIME VERIFIED /. ) .

I
PREVIOUS RECORD CHECK:
RECORD.. NO RECORD SIGNATURE OF PERSON PERFORMING TEST

CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED. I DATE
267c2cro,..3
REMARKS:
‘30
SECTION III - RECORD OF TRANSFUSION
POST-TRANSFU.TA

AMOUNT GIVEN TIME/DATE .MPLETE.ERRUPTED
—

3s-t).ML /1/ es) ac, 01/1::_zi3
REACTION. TEMPERATURE.PULSE BLOO PRESSURE
DONE . SUSPECTED '''7 C .
- -

52 GPYtal
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all .Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. .'.otify Physician and Transfusion Service.
The reci ' nt is the same person named on this Blood Component Transfusion Form and ..w Transfusion Reaction Procedures.

on the •.identification tag.. 1st VE.
PRE-
TEMP DATE OF TRANS. TIME STARTED
2,C1 aTel 7
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last. rate; hospital or medical facility) •
60)((e)z
4. Do c discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
REACTION CHILL . FEVER . PAIN
0TH R DIFFICULTIES (Equipment, clots, etc.) 0.. YES (Specify
WARD
/CU

BLOOD OR BLOOD COMPONENT TRANSFUSION
Medical Record

STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR 141 CFR) 201-9.202-1

PA, MEDCOM - 22331 A Medical Record Copy
DOD-035907

518-124
MEDICAL RECORD
NSN 7540-00-634-4159
BLOOD OR BLOOD COMPONENT TRANSFUSION
COMPONENT REQUESTED (Check one) RED BLOOD CELLS SECTION I - REQUISITION TYPE OF REQUEST (Check ONLY if Red Blood CellProducts are requested.)
. FRESH FROZEN PLASMA
. TYPE AND SCREEN
. PLATELETS (Pool of.units) CROSSMATCH D URE

.
CRYOPRECIPITATE (Pool of.units)
DATE REQUESTED Rh IMMUNE GLOBULIN
. r tr
I have collected a blood specimen on th

below
. OTHER (Specify) D • AND HOUR REQUIRED named patient, verified the name and ID N . of the
patient and verified the specimen tube la VOLUME REQUESTED (If app 'cable) • Jr
correct. el to be
•

KNOWN ANTIBODY FORMATION/TRANSFUSIONREACTION (Specify) SI NATIJ OF
ML

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

UNIT NO_ SECTION II - PRE-TRANSFUSION TESTING
TRANSFUSION NO. TEST INTERPRETATION ANTIBODY SCREEN
PREVIOUS RECORD CHECK: CROSSMATCHPATIENT NO.
RECORD.
. NO RECORD SIGNATURE OF PERSON PERFORMING TEST

DONOR
RECIPIENT
6.10
.

ABO 0
CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQ P E ED
ABO REMARKS:

Rh Rh Yr at- 03
44,04 3 /Uvu

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA INSPECTED AMP ISSUED BY (Signature)
POST TRANSFUSION DATA AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
. ML 00-sz5r,
our) O • REACTION Q
ON (Date) / TEMPERATURE.PULSEIDENTIFICATION 111 NONE . SUSPECTED lir PRESSURE
/CO
If r tion is suspected—IMMEDIATELY:

I have examined the Blood Component container label and this form and I find all
information identifying the 1. Disco
container with the intended recipient matches item by item. The recipient is the same person named on this Blood Component Transfusion Form 2. Notify Ph
ue transfusion, treat shock if present, keep intravenous line open. on the patient identification tag. an and Transfusion Service.
and
3. Follow Trans

'on Reaction Procedures.
1st VERIFIER (Signature) 4.
Do NOT discard

t. Return Blood Bag. Filter Set, and I.V. solutions to the Blood Bank.DESCRIPTION OF REAC • N
. URTICARIA.CHIL..FEVER.PAIN
2nd
131rEriarM,•
OTHER

)L1-A (6/
PRE-TRANSFUSION OTHER DIFFICULTIES
(Equipment, clots, etc.)
TEMP../ /07 0..
PULSE YES (Specify) DATE BP•
F TRA SFUSION
SIGNATURE OF PERSON NOTING ABOVE t 3t TIME STARTED
O`er
--NOSs
e.,

PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle;
Li-•a
rate; hospital or medical facility)
grade; rank:
SEX
WARD
(
)
1.064N

BLOOD OR BLOOD COMPONENT TRANSFUSION Medical Record
MEDCOM - 22332
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR19n1 _0

DOD-035908

518-124 NSN 7540-00-634-4159
MEDICAL RECORD BLOOD OR BLOOD COMPONENT TRANSFUSION
r SECTION I - REQUISITION
ONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print).\
Products are requested.)

' RED BLOOD CELLS
FRESH FROZEN PLASMA Ind I •E AND SCREEN DIAGNOSIS OR OPERATIVE PROCEDURE
x.i
PLATELETS (Pool of.units) P2 CROSSMATCH

S7,-CP4'.i

I. CRYOPRECIPITATE (Pool of.units) DATE REQUESTED
I.have collected.a.blood.specimen on t e.below
Rh IMMUNE GLOBULIN 6 4104 0 S named patient, verified the name and IDN . of the
patient and verified the specimen tube lab I to be
DATE AND HOUR REQUIRED
correct.

OTHER (Specify)
6/16=4 07 A-91re

VOLUME RE UESTED (If
REACTION (Specify)

RE .plicable) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF
(.4•1/til,f3. . ML

6)1ap i
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: D.I
•
.

RhIG TREATMENT? DATE GIVEN: 6 Ai‘i TIME VERIFIE)
HEMOLYTIC DISEASE OF NEWBORN?
zal el)
SECTION II - PRE-TRANSFUSION TESTING

UNI TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH RECORD.0 NO RECORD
PATIENT NO..1 1-}, SIGNATURE OF PERSON PERFORMING TEST

J
CAA-194

DONOR RECIPIENT CROSSMATCH NOT REQ UIRED FOR THE COMPONENT REQUESTED. /0
ABO ABO REMARKS:
0

0

.
eo
Rh Rh
104)5

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST-TRANSFUSION DATA

INSP.ND ISSUED BY (Signature) AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED
M L

REACTION SUSPECTED TEMPqT,u3k) PULSE.BLOOD PRESSURE
At (Hour).0 (Date) Ce.g40.4.) NONE 0

11F 8.0:4r)1
IDENTIFICATION
If reaction is suspected—IMMEDIATELY: .
.4r
I have examined the Blood Component container label and this form and I find al
1. Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. Notify Physician and Transfusion Service.

The recipient is the same person named on this Blood Component Transfusion Form and 3. ow Transfusion Reaction Procedures.
on the patient identification tag.

4. Do.discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank.
1st VERIFIER (Signature)

DESCRIPTIO I F REACTION
URTICARIA

CHILL 0 FEVER 0 PAIN
OTHER DIFFICULTIES (Equipment, clots, etc.) .•
E-TRANSFUSION
NO.0 YES (Specify)
9 Pi.
TEMP..PULSE SIG I TORE OF PERSON NOTING ABOVE
DATE OF TRANSFUSION. TIME STARTED
tf`G 1\43,-1.-ra‘ SSk) \ LT/ IN1¦A
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, firs ml.. e; a.e; ran ;
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 - 22333.
Medical Record Copy

DOD-035909

.

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

COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)
Products are requested.)

ED BLOOD CELLS
F
RESH FROZEN PLASMA TYPE AND SCREEN DIAL OPERATIVE PROCEDURE
. PLATELETS (Pool of units) /CROSSMATCH
. CRYOPRECIPITATE (Pool of units)
DATE REQUESTED I have collected a blood specimen on the.below
AL6-4 01

. Rh IMMUNE GLOBULIN
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRED patient and verified the specimen tube abel to be
. OTHER (Specify) correct.
C ptL4 a '3.AT A­
,

VOLUME REQUESTED (If applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION S.F VERIFIER REACTIO,N1 (Specify)
/ (4 /413-

. Ns (0) .YZ..—
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: DATE VERfF1ED
•

RhIG TREATMENT? DATE GIVEN: L NAI al TIME VERIFI ED
HEMOLYTIC DISEASE OF NEWBORN? atto
SECTION II - PRE-TRANSFUSION TESTING

UNIT NO. TRANSFUSION NO.
TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN.CROSSMATCH
13,„ZECORD.

. NO RECORD PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST

DONOR RECIPIENT
CROSSMATCH NOT REQUIRED FOR T E COMPONE ABO
REMARKS:
13\3,5
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA POST TRANSF

INSPECTED AND ISSUED BY (Signature) AMOUNT GIVEN.TIME/DATE OMPLET • TERRUPTED
/ 124••41-ML Pio1/4i.6A4)4 ez. 7 RE CTION TEMPERATURE.PULSE BLOOD PRES URE AT (Hour) ON (Date) NONE . SUSPECTED 7/
Pr 65
IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all
Discontinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2.

tify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Fol.Transfusion Reaction Procedures.
on the patient identification tag.
4. Do NO.

scard unit. Return Blood Bag, .Filter Set, and I.V. solutions to the Blood Bank. DESCRIPTION•EACTION
. URTICARIA.HILL . FEVER . PAIN
THER (Specify)
(0)

THER DIFFICULTIES (Equipment, clots, etc.) P
NO EI YES (Specify) TEMP. PULSE • 2, BP (Ye-) SIV
"N •TURE OF P RSON NOTING ABOVE DATE OF TRANSFU•. TIME STARTED
11)1. 413‹)
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, firs 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 - 22334
Medical Record Copy

DOD-035910

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

..„CO
.ONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell REQUESTING PHYSICIAN (Print)Products are requested.)
RED BLOOD CELLS
FRESH FROZEN PLASMA TYPE AND SCREEN DIAG.I8 • • •.• •TINE PROCEDURE
PLATELETS (Pool of units) 4. CROSSMATCH
Cry)

CRYOPRECIPITATE (Pool of units) DATE REQUESTED
I.have collected.a blood.specimen.on the.below Rh IMMUNE GLOBULIN named patient, verified the name and ID N•. of the
DATE AND HOUR REQUIRED
6, th.q co

and verified the specimen tube la el to be OTHER (Speci
i
correct.
(Specify)

6h16-4 os,.
i.

VOLUME REQUESTED q qpplicable) KNOWN ANTIBODY FO TION/TRANSFUSION SIGNATURE OF VERIFIER
i UkIr . ML REACTION (Specify)
1111111.111111., 00)(G)
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: RhIG TREATMENT? DATE GIVEN: DATE VERIFIED 4 ivov 03
HEMOLYTIC DISEASE OF NEWBORN? TIME VERIFIED 09to. 1

SECTION II – PRE-TRANSFUSION TESTING

UN TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
0 RECORD.

NO RECORD PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST
RECIPIENT

CROSSMATCH NOT REQ UIRED FOR THE COMPONENT' REQUESTED ABO ABO REMARKS:
area

Rh 05
Rh ?GS

SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA

POST-TRA ATA AMOUNT GIVEN TIME/DATE I MPLETED.INTERRUPTED
ML
At-tzti
n

XTION TEMPERATURE.PULSE.BLOOD PRESSURE AT (Hour) N. N (Date) GrittithicAS 'ONE 0 SUSPECTED t Psh_x,
Tr.

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. otify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. ow Transfusion Reaction Procedures.
on the patient identification tag.

4. Do •T discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. 1st VERIFIER (Signature) DESCRIPTIO OF REACTION
URTICARIA.El CHILL.El FEVER.
Ej PAIN
OTHER (Specify

2nd VER
0TH • DIFFICULTIES (Equipment, clots, etc.) PRE-TRANSFUSION . 0.YES (Spec
TEMP. ?,)-- S
DATE OF TRANSFUSION TIME STARTED
6 IN•bbq 3
06-C4 PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, mi
SEX
rate; hospital or medical facility)

BLOOD OR BLOOD COMPONENT TRANSFUSION
11111 (cow
Medical Record

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

MEDCOM - 22335.
Medical Record Copy

DOD-035911
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDIAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER.TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS SIGN

c }if).
.—sit . 1.0-AteA)
111 Mmq
1C4c-a,e.

NURSING UNIT ROOM NO. BED NO.
ts? f
CI) t
PATIENT IDENTIFICATION DATE OF ORDER.TIME OF ORDER

. HOURS

k---5-1(7 /QS dick-pi-0 c jt
.

1^3 .
cfm C-7_1
NURSING UNIT ROOM NO. BED NO.
t(.e/ka.J1--Fti.—Q1%- 57tA_,c_JL
/1/1-FID7

PATIENT IDENTIFICATION' D ATE OF ORDER.TIME OF ORDER
Art(e-f-f..c? g/-C HOURS
3 /1250.T /L- fl/-, 14 ALLI-6.1./6"- ChA&Ai h
ebra..
cx,,e

A-(6-at.-( Wee A Cii:o
. NURSING UNIT ROOM NO. BED NO.
11
;;.

PATIENT IDENTIFICATION DATDATE OF ORDERCAC( PfA-)
TIMI0FafR
. HOURS
CACI 6 Lair ,146-- cV
clAA„ .
&Rif •?-1

ry .
L9j1 LSI rC /1
.

NURSING UNIT OOM NO..BED NO.
REPLACES EDITION OF 1 JUL 77 WHICH MAY
DA 4256
FORM
1 APR 79
MEDCOM - 22336

DOD-035912
CLINICAL RECORD • DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS.
IF PROBLEM ORIENTED MEDIAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF ORDER.TIME OF ORDER LIST TIME ORDER TED AND
b HOURS
SIGN
URSING UNIT
PATIENT IDENTIFICATION

NURSING UNIT
N URSING UNIT
ATIENT IDENTIFICATION

NURSING UNIT ROOM NO..
BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
1 FAOP FIR M79
MEDCOM - 22337

DOD-035913

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDIAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER.TIME OF ORDER LIST TIME ORDER NOTED AND
C./ HOURS
SIGN
.jitvi‘e

/T1-44
.11/T

1151&--
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION
DATE OF ORDER.TIME OF ORDER
n''
.HOURS
254 OCT

U hAs-rzb Yt niAU ,
.

NURSING UNIT ROOM NO. ED NO.
PATIENT IDENTIFICATION'
DATE OF ORDER TIME OF ORDER
(291.7DC2( t

\\ \
NURSING UNIT ROOM NO.
BED NO.
PATIENT IDENTIFICATION DATE OF ORDER.
TIME OF ORDER
NURSING UNIT.ROOM NO..
BED NO. fri
REPLACE"'. "".MAY BE USED.
DA 4256
1 FAOPR
M79
MEDCOM -22338

DOD-035914