Medical Report: Non-Iraqi Male, Detainee, Baghdad Iraq re: Shrapnel Fragments to Chest and Bilateral Lower Lobe Pneumonia

Medical report of "Foreign National-POW/INTERN" of an unknown age or nationality. The file is of the detainee's lab results. Medical conditions included, shrapnel to the Left Upper Quadrant (LUQ)abdomen and pneumonia. X-ray images are included. The medical records do not state how the detainee received his injuries and does not give any personal information on the detainee.

Doc_type: 
Medical
Doc_date: 
Friday, April 18, 2003
Doc_rel_date: 
Wednesday, June 15, 2005
Doc_text: 

b)(3)-1@
24 Apr 2@;@0823 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
PAT ENT LAB WI'
For: 24 Jan 03 - 24 Apr 03
Report requested by: r)(6)-2

UM-4 NnA. MM-4
M/6d Reg #: Ph: Military Unit: 1141s.CIAN
24 Apr 03 @ 0350 (Coll) BLOOD V1EC 21.1 (4.8-10.8) K/UL RBC 3.6 (4.7-6.1) 1X10 6/UL Fl2B 11.3 (14.0-18.0) g/dL HCT 32.6 (42-52) MCV 91 2 (80- 94) fL
MCH 31.6 (27-32) P9 MCHC 34.6 (31-37) g/dL R3N 14.0 (12-14) PLT CNT 942.0 (150-450) lx10 3/UL
Result Comment:
Critical result verified by repeat analysis
Notified CER Stevens-Roth on 4FP of result @ 0425 ---jsf

MPV 7.8 (7.4-10.4) FL NEUT/100 \AEC 79.2 NEUT% 16.7 lx10 3/UL LYMPHS/100 VeC. • 12.9 LY# 2.7 lx10 3/UL MONO/100 V\EC 7.9 fVCN:Y/0 1.7 1X10 3/UL
L=Lo H=1-li *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed []=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
b)(3)-1@
24 Apr 2 3@0823 Page 1
Personal' Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY @For: 24 Jan 03 - 24 Apr 03
b)(6)-2
Report requested by: A
:b)(6)-4
W(6)4 M/6d@Reg #:r)(6)-4
Ph: Military Unit: 1slNICW¦1
24 Apr 03 @ 0350 (Coll) SEFCM NA+ 144 (137-145) mmol/L K 4 2 (3.6-5 .0) mmol /L CL-109 H (97-107) mmol/L CO2 23 (22-31) mmol/L BUN 43 H (9-21) mg/dL GLUCOSE 199 H (76-110) mg/dL CREAT 1.8 H (0.8-1.5) mg/dL
L=Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed []=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
-
2@1
LABORATORY 1-71-0 24 Apr 2003@2356

Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)

Lab Certified Result Notification
Drt requested by: System Generated

(b)(6)-4 (b)(6)-4
M/6d 2391 ph#
Mil. Unit: UNKNOWN

Acc#: b)(6)-2
Ordered by: rx6)-2 Col: 24 Apr 2003@2227 Specimen: CS1, (CEREBRO) Pri: ROUTINE Ord# 1(b)(6)-4 Res Lab: LAB Req Loc: 1C2 Test name ResultHNormal range
Units
WBC .56HMM3
RBC 11.1HMM3
COLOR COLORLESS

APPEARANCE CLEAR

***H***

End of Report

MC6)-2

2 /
LABORATORY 1-71-0H 24 Apr 2003@2305 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
Drt requested by: System Generated

@
;b)(6)-4 (b)(6)-4
M/6d 2391 ph#
Mil. Unit: UNKNOWN

b)(6)-2
Ordered by: Col: 24 Apr 2003@2225 Acc#: 1(7)(6)-2
Specimen: OTHER (CEREBRO) Pri: ROUTINE Ord#: mmA

Resulting Lab: LAB Req Loc: IC2
Accession Comment(s):
CSF TUBE#2

NA-2

Entered by: Hon 24 Apr 2003@2226

GRAM STAIN: Final Report

GRAM STAIN: NO CELLS NOTED. NO ORGANISMS NOTED.

2@/
24 Apr 2003@2217 Page 1

LABORATORY 1-71-0

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

(b)(6)-4
ON-4 M/6d 2391 ph# Mil. Unit: UNKNOWN
(b)(6)-2 X6)-2
Ordered by Col: 24 Apr 2003@2128 Acc#: r

b)(6)-4

Ord#:

Specimen: BLOOD (SERUM) Pri: STAT

Req Loc: 1C2

Res Lab: LAB

Result Units Normal range

Test name

NA+ 151 H mmol/L 137 -145
K 4.7 mmol/L 3.6 -5.0
CL-119 H mmol/L 97 - 107
mmol/L 22 - 31

CO2 23

BUN 48 H mg/dL 9 -21
GLUCOSE 210 H mg/dL 76 -110

1.7 H mg/dL 0.8 -1.5

CREAT

*** End of Report ***

1).*
Ze e
-f f,1 5@
IN fs›CcJi. -
25-.
-
:b)(6)-2
(b)(6)-4
LABORATORY 1-71-0H 24 Apr 2003@1242 Page 1 Personal Data - Privacy Act of 1974 (PL 93-579) Priority Result Notification I )rt requested by: System Generated
b)(6)-4

Ordered by: (b)(6)-2 Specimen: URINE/RA (URINE) Res Lab: LAB
Test name
COLOR
APPEARANCE
SG

Interpretation(s): Normal
PH
LEUKO EST
NITRITE
U PROT

Test comment(s): SSA TEST
U GLUCOSE
U KETONES
UROBLGN
U BILI
U HGB
U WBC
U RBC
MUCOUS
U EPI
BACTERIA

WMA I Mi 6d 2391

ph#
Mil. Unit: UNKNOWN

Col: 24 Apr 2003@1117 Acc#: 1(b)(6)-2
Pri: STAT

Ord#: :b)46) 4
Req Loc: -TC2
Result Units Normal range
YELLOW

HAZY

.

1.020 1.010 - 1.020

Range provided is for first morning void.

5.0 4.5 - 7.5

NEGATIVE NEGATIVE
NEG NEGATIVE

30MG/DL MG/DL NEG
PERFORMED WITH RESULT OF 5MG.
NEG mg/dL

NEGATIVE
NEG mq/dL NEGATIVE

0.2 mg/dl

0 - 1

NEGATIVE NEGATIVE
MODERATE H

NEGATIVE

5-10 H /HPF 0 - 2
1-3

FEW

1-5

FEW /HPF

*** End of Report ***

M(6)-2
2J
LABORATORY 1-71-0 24 Apr 2003@1057 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated

MM-4 (b)(6)-4
M/6d 2391 ph#
Mil. Unit: UNKNOWN

CM-2

i(b)(6)-2
Ordered by: Col: 24 Apr 2003@1037 ACC#:
Specimen: BLOOD (BLOOD) P r i : STAT Ord# :1(b)(6)-4
Res Lab: LAB Req Loc: 1C2

Test name Result Units Normal range
WBC 20.5 H K/UL 4.8 -10.8
RBC 3.3 L 1X10 6/UL 4.7 -6.1
HGB 10.4 L g/dL 14.0 -18.0
HCT 30.2 L 42 - 52
MCV 90.9 fL 80 - 94
MCH 31.3 Pg 27 - 32
MCHC 34.4 g/dL 31 -37
HDFAT 14.2 H 12 -14
PLT CNT 790 H lx10 3/UL 150 - 450

Test comment(s): NOTIFIED LT MMR @ 1055.

(b)(6)-2

MPV 7.9 FL H7.4 -10.4

*** ***

End of Report

J
LABORATORY 1-71-0 24 Apr 2003@1202 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

M6)-4 (b)(6)-4@
M/6d 2391 ph# Mil. Unit: UNKNOWN
Acc#: (b)(6)-2
Ordered by: WR-2 Col: 24 Apr 200301037
Specimen: BLOOD (BLOOD) P r : STAT Ord# 1(b)(6)-4

H

Lab: LAB Req Loc: 1C2 Test name Result Units Normal range SEGS/100 WBCH91
Res H
L CD10 6
MONO% 3 1X10 3/UL
PLT ESTHHIGH
MORPHOLOGY NORMAL

*** ***
End of Report
2 /
LABORATORY 1-71-0 24 Apr 2003@1119 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
)rt requested by: System Generated

M(6)-4 (b)(6)-4@
M/6d 2391 ph#
Mil. Unit: UNKNOWN

(b)(6)-2
Ordered by: P*6)2 Col: 24 Apr 2003@1037 Aco#:
Specimen: BLOOD (SERUM) Pri: STAT Ord#:VOR
Res Lab: LAB Req Loc: 1C2
Test name Normal range

ats
CK 1538 H 0 - 203

*** End of Report ***

2 /

LABORATORY 1-71-0H 24 Apr 2003@1120 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
prt requested by: System Generated

(b)(6)-4 w(6)4
I M/6d 2391 ph#

Mil. Unit: UNKNOWN

M(6)-2 Acc#: (b)(6)-2

Ordered by: Col: 24 Apr 2003@1037
Specimen: BLOOD (SERUM) Pri: STAT Ord#: (b)(6)-4
Res Lab: LAB Req Loc: _Luz
Test name Result Units Normal range
MG 3.3 HH1.7 2.2

mg/dL -H
Interpretation(s):

***H***

End of Report

b)(3)-1

24 Apr 21 92211H

Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
NP ORDER (b)(6)-4
Lb)(6)-4@
1.

1Hi st LAB "4.

GRAM STAIN-WARD/CLINIC COLLECT-OTHER-STERILE CON on 24 Apr 2003@2210
(1))(6)-2
LCDR,/SIGNED/PRE-ACTIVE

*** End of Report ***
b)(6)-4 1(0(6)-4 Loc: IC2
18 Apr 2003 M PATIENT ORDER LIST
[UNK]
MEDCOM - 5540

N(3)--1

24 Pip' 003@2050 Page 1 Personal Data - Privacy Act of 1974 (PL 93-579)
NEW ORDER

(b)(6)-4 b)(6)-4 MM-4
1 LAB *STAT*STAT* BASIC METABOLIC PANEL-WARD/CLINIC COLLECT-BLOOD-RED TOP on 24 Apr 2003@2050
MM-2

LCDR,/SIGNED/PRE-ACTIVE

NEW ORDER
;b)(6).4 (b)(6)-4 b)(6)-4
2 Last RAD CHEST, AP (PORTABLE)-Portable-DIAGNOSTIC RADIOLOGY X7420-AMB on 24 Apr 2003-2050
b)(6)-2 @ LCDR,/SIGNED/PRE-ACTIVE
PORTABLE INDICATOR: YES
*** End of Report ***

(b)(6)-4 (b)(6)-4 (b)(6)-4
Loc: IC2 18 Apr 2003 M PATIENT ORDER LIST [UNK]
LABORATORY 1-71-0 24 Apr 200392301 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
I prt requested by: System Generated

b)(6)-4 b)(6)-4 ph#
M/6d 2391
Mil. Unit: UNKNOWN

Ordered by: M(6)-2 Col: 24 Apr 2003@2228 Acc#: wm-2 Specimen: CSF (CEREBRO) Pri: STAT Ord#: (b)(6)-4
Res Lab: LAB Req Loc: 1C2
Accession Comment (s)
CSF TUDE#3
Entered by: (b)(6)-2 on 24 Apr 2003@2228

Test name Result Units Normal range
PROTEIN BF 45.0 H mg/dL 15 - 40

*** ***

End of Report

LABORATORY 1-71-0H 24 Apr 2003@2301 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated

(b)(6)-4
Mn4 M/6d 2391 ph# Mil. Unit: UNKNOWN
MMN

Ordered by: HCol: 24 Apr 2003@2228 Acc#:

Ord#:

Pri: STAT

Specimen: CSF (CEREBRO)HMA-4
ILL
Res Lab: LAB Req Loc:
Accession Comment(s):
CSF TUBE#3

by: (b)(6)-2
Entered on 24 Apr 2003@2228
Normal range

Test nameHResultH

Units

GLU BF 117.0 mg/dL

***H***

End of Report

(b)(6)-4
(b)(6)-4

2.FOREIGN NATIONAL -POW/INTERN 18 Apr 2003 / MALE H:@ W:
M(6)-4
Reg #: Loc: CASREC MAIN Room-Bed:
Spon:(b)(6)-4

Rank: UslIsCVM1 D:
SF519-B Unit: RR:

Transparent print on
Personal Data - Privacy Act 1974 (PL 93-579) .Printed date: 24 Apr 2003@1233 Page: 1 RADIOLOGIC EXAMINATION REPCRT
(b)(6)-4 (b)(6)-4
Patient: FMP/SSN:
(b)(3)-1

COMPUTED TOMOGRAPHY Procedure: CT, HEAD W/0 Exam Date: 18 Apr 2003@1610
(b)(6)-2

Requested by: Status: COMPLETE
Ward/Clinic: CASREC MAIN Exam #: l(b)(6)4

Pregnant:
Reason for Order:

S/P TRAUMA, UNCONCIOUS PT INTUBATED EVAL NERD STATUS

0, ..r Comment:

Result Code . SEE RADIOLOGIST'S REPORT

Report:

NON-CONTRAST I-EAD CT shows mucosal thickening of the maxillary, ethmoid, and
frontal sinuses. Thickening of nasal turbinates.
Brain is normal. No sub or epidural hematoma. No skull fracture.No
hydocephalus. No hemorrhage.

Transcription Date/Time: 18 Apr 2003@1809
(b)(6)-2
Interpreted by: CDR, MC, LEN Supervised by:
Approved by: (b)(6)-2 CDR,MC,USN 18 Apr 2003@1816 Supervised by:
:b)(6)-2
M(6)4 (b)(6)-4
FOREIGN NATIONAL -POW/INTERN 18 Apr 2003 / MALE H: W: Rt@r"@Loc: CASREC MAIN Room-Bed: Sporqwm 4 I Rank: UNKNOWN@D: SF519-B Unit:@ RR:
Transparent print on
Personal Data - Privacy Act 1974 (PL 93-579) @Printed date: 24 Apr 2003K233 Page: 1 RADIOLOCIC EXAMINATION REPORT
(b)(6)-4 (b)(6)-4

Patient: FMP/SSN:
M(3)•1

DIAGNOSTIC RADIOLOGY X7420 Procedure: KNEE, RT (2) Exam Date: 18 Apr 2003@1608
(b)(6)-2
Requested by: Status: COMPLETE
Ward/Clinic: CASREC MAIN Exam #: MOH @1

Pregnant:
Reason for Order:
trauma

Order Comment:
Code' SEE RADIOLOGIST'S REPORT
Report:
AP and lat views of the right knee: significant soft tissue disruption
anteriorly above the patella with associated metallic foreign bodies. No
definite fx identified.

Transcription Date/Time: 18 Apr 2003@1749
Interpreted by: (b)(6)-2@ICAPT,MC,USN
Supervised by:

Approved by: (1°)(6)-2 CAPT,MC,USN@
. 18 Apr 2003@1752
Supervised b @.

LABORATORY 1-71-0 24 Apr 2003@1404 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)

Priority Result Notification
I )rt requested by: System Generated

b)(6)-4
F774 I M/6d 2391 ph# Mil. Unit: UNKNOWN
r(6)-2

Ordered by: Col: 24 Apr 2003C.037 Acc#. px6R Specimen: BLOOD (SERUM) Pri: STAT Ord# 1(b)(6)-4 Res Lab. LAB Reti Loc: 102 Test name Result Units Normal range NA+ 143 mmol/L 137 -145
K 4.4 mmol/L 3.6 -5.0

CL-110 H mmol/L 97 -107

CO2 22 mmol/L 22 -31

BUN 56 H mg/dL 9 -21

GLUCOSE 119 R* mr/dL 76 -110

b)(6) -2
Test comment(s): NOTIFIED IC2
CREAT 2.3 H mg/dL 0.8 -1.5
CA 8.2 L mg/dL 8.8 -10.4

PHOSPHORUS 7.7 H mg/dL 2.5 -4.5
PROTEIN TOTAL 6.8 g/dL 6.3 -8.3
ALBUMIN 3.1 L g/dL 3.5 -5.0
AST 104 H U/L 15 - 46
ALT 81 H U/L 11 - 66
LDH 1937 H U/L 313 -618
ALK PHOS 85 U/L 70 - 250
TBILI 0.6 L mg/dL 1.0 -10.5
GGT 139 H U/L 8 - 7 8
CK 1538 H U/L 0 - 203
MG 3.3 H mg/dL 1.7 -2.2

Interpretation(s) :

*** ***

End of Report

MM-2
2 /
LABORATORY 1-71-0 24 Apr 2003@1416 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated

@ :b)(6)-4@ (b)(6)-4 M/6d 2391 ph#
Mil. Unit: UNKNOWN

(b)(6)-2

Ordered by: (b)(6)-2 Col: 24 Apr 2003@1037 Acc#:
(b)(6)-4
Specimen: BLOOD (SERUM) Pri: STAT Ord#:
Res Lab: LAB Req Loc: IC2
Test name Result Units Normal range
URIC ACID 10.0 H mg/dL 3.3 - 8.4

*** End of Report ***

(b)(6)-2
@

b)(3)-1@
24 Apr JO3a1231PPagel
Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY

For• 12 Apr 03 - 24 Apr 03
M6)-2
Rr 'rt requested by:
(b)(6)-4 (b)(6)-4
Reg #: Itb)(6)-4
M/6d@Ph: Military Unit: UNKNOWN
@
24 Apr 03 @. 1117 (Coll) URINE
@
STAT UA PENDING @
24 Apr 03 @ 1037 (Coll) SERUM STAT CAP @ UNCERTIFIED
24 Apr 03 @ 1037 (Coll) BLOOD
STATWBC@ 20 5 (4.8-10.8)@K/UL FEC @3.3 (4.7-6.1)@1X10 6/UL H213 @ 10.4 (14.0-18.0)@g/dL HCT@ 30 2 (42-52) M3/ @ 90.9 (80-94)@fL MCH@ 31 3 (27-32)@pg MCHC @ 34.4 (31-37)@g/dL R3N 14.2 (12-14) PLT CNT ... .. . .@790 (150-450)@lx10 3/UL
;b)(6)-2
Result Comment: NOTIFIED LT 'b)(6)-2@1055. NFN/ @7.9 (7.4-10.4)@FL SEGS/100 WBC @91 L CD10 @6 !VI:NCR/0 @3 1X10 3/UL PLT EST @ HIGH MORPHOLOGY. @NORMAL
24 Apr 03 @ 1037 (Coll) SERUM STATCK@ 1538@H@(0-203)@U/L MC @3.3@H@(1.7-2.2)@mg/dL Interpretations:
24 Apr 03 @ 0925 (Coll) SERUM Order comment: code blue STAT NA-F @144@ (137-14 5)@mmol/L
K@ 5.9@H@(3.6-5.0)@mmol/L CL-@110@H@(97-107)@mmol/L CO2 @ 15@L@(22-31)@mmol/L
Result Comment: SAMPLE W6 MODERATELY HEMOLYZED. BUN @ 5 1@H@(9-21)@mg/dL GLUCOSE @290@H@(76-110)@mg/dL CREAT @2.7@H .@
(0.8-1.5)@mg/dL
L-Lo H=Hi *=Critical@R=Resi st S=Susc MS=Mod Susc I=Intermed r1 =Uncert /A-Amended Comments= (0)rder, (I)nterpretations, (R)esult
;b)(3)-1 24 Apr .,03@1231.Page 2
Personal Data - Privacy Act of 1974 (PL 93-579) PAT ENT LAB LU 2 Apr 03 - 24 Apr 03
b)(6)-2
Re—rt requested by:
(b)(6)-4 b)(6)-4
M/6dHReg #: r)(6)-4 Ph: Military Unit: 1/1101-01W-
24 Apr 03 @ 0350 (Coll) BLOOD 1/1EC .21.1 H@(4.8-10.8).K/UL R B C .3.6 L@(4.7-6.1).1X10 6/UL H213 . 11.3 L@(14.0-18.0).g/dL HCT . 32.6 L (42-52) MCV. 91.2 (80-94).fL MJ-I . 31.6 (27-32).Pg MCHC @ 34.6 (31-37).g/dL RDW. 14.0 (12 -14)' PLT CNT .942.0 H@(150-450).lx10 3/UL
Result Comment
Critical result verified by repeat analysis

1,1),(6)-2
Notified CDR 1')(5)-2 .on 4FP of result @ 0425 --IvFV .7.8. (7.4-10.4) FL NEUT/100 V1iBC .79.2 NEUT% . 16.7 lx10 3/UL LYMPHS/100 'f8 ..12.9 LY# .2.7 lx10 3/UL MONO/100 WBC .7.9 M2NCP/0 .1.7 1X10 3/UL
24 ..pr 03 @ 0350 (Coll). SERIA
NA+ .144. (13 7-145).mmol/L
K. 4.2. (3.6-5.0).mmol/L
C L-.109.H.(97-107).mmol/L
CO2 . 23. (22-31).mmol/L
BUN . 43.H.(9-21).mg/dL
GLUCOSE .199.H.(76-110).mg/dL
CREAT. 1 8.H.(0.8-1.5).mg/dL

.
24 Apr 03 @ 0350 (Coll) BLOOD (BLOOD)
BLD CULT. PENDING

.
24 Apr 03 @ 0350 (Coll) BLOOD(BLOOD)
BLD CULT. PENDING

21 Apr 03 @ 0355 (Coll). BLOOD
STAT \AEC . 13.4.H.(4.8-10.8).K/U L
RIC .3.0.L.(4.7-6.1).1X10 6/UL
HGB .9.4.L.(14.0-18.0).g/dL
HCT . 27.3.L •.(42-52).%
MCV. 90.4. (80-94).fL
MCH . 31.1. (27-32).pg

L=Lo H=Hi *=CriticalH

R=Resist S=Susc MS=Mod Susc I=Intermed
,Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

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•U . 0E-t...) • ----. ,..i., = a@L.
M U.0 I- g 0- 0 * 0 en N 4-). U en. u.
F- F-a. 11 W
0=3F-Li@4tz4:k viz o •cp • aJ + • @0 .I--00M a 0 u
l) GI -J 0_ W W- - 0 0 0. = L,..7 L. _I 0 = -J Ce.03 03 L, l) L../ U U C3 -I CL. LU LU ›- II -1 C:
S-CLCu4-1 MaZ-1--IMLLICOM 1-U0-M O. ZDLLJUCCILDU 1-3CL=2MMMCCO.MZZ_I II II p
-I
.=. I-. I-

In. .4-1. II
r-I.a). ri I-.C. 0 I-
N!.ce. MI in.I-I. NI IA. II

MEDCOM -5550
DOD 12762
b)(3)-1

24 Apr d03@1231 Page4
Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY For • 12 Apr 03 - 24 Apr 03
MMN

Re^nrt requested by:
b)(6)-4

M/6d
Reg #: Ph: Military Unit:
20 Apr 03 @ 0407 (Coll) BLOOD LY# 2.1 lx10 3/UL MONO/100 V BO 5.3 nom 0.7 1X10 3/UL
20 Apr 03 @ 0407 (Coll) SERUM
STATCA 7.7 L (8.8-10.4) mg/dL PHOSPHORUS 3.3 (2.5-4.5) mg/dL MC 2.3 H (1.7-2.2) mg/dL
Interpretations:
NA+ 137 (137-145) mmol/L K 4.1 (3.6-5.0) mmol/L CL-104 (97-107) mmol/L 002 27 (22-31) mmol /L BUN. 10 (9-21) mg/dL GLUCOSE 128 H (76-110) mg/dL CREAT 0.8 (0.8-1.5) mg/dL
19 Apr 03 @ 0419 (Coll) BLOOD S -_ VEC 12.8 H (4.8-10.8) K/UL .RBC 2.7 L (4.7-6.1) 1X10 6/UL
HGB 8.6 L (14.0-18.0) g/dL
HCT 24.0 L (42-52) %
NCV 89.9 (80-94) fL
NCH 32.4 H (27-32) pg
Nola 36.0 (31-37) g/dL
RIM 12.6 (12-14)
PLT CNT 428.0 (150-450) 1x10 3/UL
NW . 8.1 (7.4-10.4) FL

NEUT/100 \ABa 79.0 %
NEUT% 10.1 1x10 3/UL
LYMPHS/100 ma . 14.4 %
LY# 1.8 lx10 3/UL
MONO/100 \AEC 6.6 %
MONO% 0.8 1X10 3/UL

19 Apr 03 @ 0419 (Coll) SERUM
STAT CA 7.4 L (8.8-10.4) mg/dL PHOSPHORUS 4.0 (2.5-4.5) mg/dL AMYLASE 92 (30-110) U/L LIPASE 645 H (23-300) U/L MG 2.4 H (1.7-2.2) mg/dL
L=Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed :Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
b)(3)-1 24 Apr .03@1231 Page 5
Personal bata - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY

Fnr! 12 Apr 03 - 24 Apr 03
(b)(6)-2

Re—rt requested by:
MMA :b)(6)-4
(b)(6)-4 M/6d Reg #:
Military Unit: UNKNOWN
Ph:
19 Apr 03 @ 0419 (Coll) SERUM Interpretations:
NA+ 134 L (137-145) mmol/L K 4.0 (3.6-5.0) mmol/L CL-100 (97-107) mmol/L CO2 32 H (22-31) mmol/L BUN 11 (9-21) mg/dL GLUCOSE 196 H (76-110) mg/dL CREAT 0.9 (0.8-1.5) mg/dL
18 Apr 03 @ 2222 (Coll) URINE ACETONE POSITIVE
18 Apr 03 @ 2151 (Coll) BLOOD
STATWBC 14.9 H (4.8-10.8) K/UL
RBC 2.8 L (4.7-6.1) 1X10 6/UL
H33 9.0 L (14.0-18.0) g/dL
HCT 25.4 L (42-52) %
MO/ 90 9 (80-94) fL
M3-1 32.3 H (27-32) pg
N4CHC. 35.5 (31-37) g/dL
RDW 12.9 (12-14) %
PLT OW 400.0 (150-450) lx10 3/UL
fVFV 7 7 (7.4-10.4) FL
NEUT/100 MC 88 %
LYMPHS/100 VIEC . . . 8 %
MONO/100 VIEC 2 %
BANDS/100 \AB 1 %
PLT EST NORMAL
MORPHOLOGY NORMAL

18 Apr 03 @ 2151 (Coll) SEM
STAT CA 7.4 L (8.8-10.4) mg/dL
PHOSPHORUS. 4.1 (2.5-4.5) mg/dL
MG 2.2 (1.7-2.2) mg/dL

Interpretations:
NA+ 132 L (137-145) mmol/L K 3.9 (3.6-5.0) mmol/L CL-96 L (97-107) mmol/L CO2 31 (22-31) mmol/L BUN 12 (9-21) mg/dL
L=Lo H=Hi *= Critical R=Resi st S=Susc MS=Mod Susc I=Intermed .Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
W(3)-1

24 Apr J3@1231 Page 6
Personal Data - Privacy Act of 1974 (PL 93-579) PAT ENT LAB UR( For: 12 Apr 03 - 24 Apr 03
(b)(6)-2
Re --, rt requested by:
(b)(6)-4 WM4
M(6)-4
M/6d Reg #.4 Ph: Military Unit: UNKNOWN
18 Apr 03 @ 2151 (Coll) GLUCOSE CREAT 154 0 . 8 (76-110) (0.8-1.5)
18 Apr 03 @ 2142 (Coll) STAT COLOR APPEARANCE YELLOW CLEAR
SG Interpretations: 1.005 L (1.010-1.020)

Normal Range provided is for first morning void.
FH LELND EST NITRITE U PROT U GLUCOSE U KETONES
UROBLCN U BILI ICTOTEST UH2B UVB U REC MUCOUS. U EPI BACTERIA. S S A
18 Apr 03 @ 1641 (Coll) STAT NA+
CL-
8.0
TRACE H
NEC
TRACE
NEG
H

SMALL(15MG/DL)
0.2 NEGATIVE NEGATIVE
LARGE H 20-50 H 100 H
NEC NEGATIVE NEGATIVE
0
133
4.2 96
0O2 H29
BUN 12
GLUCOSE 115
CREAT 0.9
7.6
PHOSPHORUS. 5.3
URIC ACID 2.6
PROTEIN TOTAL 5.8 L
ALBUMIN 2.5 L •
A S T 72
ALT 57

(4.5-7.5) (NEGATIVE) (NEGATIVE)
(NEG)
(NEGATIVE)
(NEGATIVE)
(0-1) (NEGATIVE)
(NEGATIVE)
(0-2)

(0)
(137-145)
(3.6-5 .0)
(97-107)
(22-31)
(9-21)
(76-110)
(0.8-1.5)
(8.8-10.4)
(2.5-4.5)
(3.3-8 .4)
(6.3-8.3)
(3.5-5 .0)
(15 -46)
(11-66)
SERUM mg/dL mg/dL
URINE
MG/DL mg/dL mg/dL
mg/di
/HPF
/HPF mg/100m1
SERUM mmol /L mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL
mg/dL mg/dL mg/dL g/dL g/dL
U/L U/L
L-Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed =Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
b)(3)-1

24 Apr . ,03@1231 Page 7
Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY 2 Apr 03 - 24 Apr 03
b)(6)-2
Re -rt requested by:
(b)(6)-4 (b)(6)-4(b)(6)-4
M/6d.Reg #: Ph: Military Unit: UNKNOWN
18 Apr 03 @ 1 641 (Coll) SEFLM LDH 1 861 H (313-618) U/L ALK PHOS. 98 (70-250) U/L TBILI 0.7 L (1.0-10.5) mg/dL CCT 78 (8- 78) U/L CK 827 H (0-203) U/L MG 2.2 (1.7-2.2) R19/dL
Interpretations:
18 Apr 03 @ 1 641 (Coll) PLASMA
STATAPTT 22.7 L (23.8-35 .5) Seconds
PT 15.7 H (11.6-14.4) Seconds
INR 1.3

Interpretations: The current recommended therapeutic range for INR i s 2.0-3.0 for all indications except prosthetic valves for which an INR 2.5-3.5 is recommended (Chest 108(4):231S-246S; 1995). It should be recognized that these are guidelines and adjustments may be required based on individual patient risk factors. The INR is not useful for the first 7-10 days of
grapy.
18 Apr 03 @ 1 641 (Coll) BLOOD
STATWBC 11.3 H (4.8-10.8) K/UL RBC 3.5 L (4.7-6.1) 1X10 6/UL HGB 10.9 L (14.0-18.0) g/dL HCT 32.1 L (42-52) % MCV 91.0 (80-94) fL NCH 30.9 (27-32) pg MCHC 34.0 (31-37) g/dL RN 12.6 (12-14) % PLT CNT 352.0 (150-450) lx10 3/UL NPV 8.0 (7.4-10.4) FL NEUT/100 WBC 79.7 % NEUT% 9.0 1x10 3/UL LYMPHS/100 WE . 13.2 % LY# 1.5 1x10 3/UL MONO/100 WE 7.1 % MONO%.... 0.8 1X10 3/UL
L=Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed
r1 =Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

b)(3)-1

24 Apr J03@1231.Page8 Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY For! 1r 2 Apr 03 - 24 Apr 03
(b)(6)-2

Re — rt requested by:
(b)(6)-4

(b)(6)-4 M/6dH
Req 1t: b)(6)-4

Military Unit:
18 Apr 03 @ 1641 (Coll) URINE
STATCOLOR. YELLOW
APPEARANCE.CLEAR

..
SG 1.010 (1.010-1.020)
Interpretations:

Normal Range provided is for first morning void.
PH .7.0. (4.5-7.5)
LEUKO EST .NEGATIVE.(NEGATIVE)
NITRITE .NEG.(NEGATIVE)
U PROT. NEG. (NEC).MG/DL
U GLUCOSE . NEG.(NEGATIVE).mg/dL
U KETONES .H.(NEGATIVE).mg/dL

MCCERATE(40MG/DL)
Result Comment: ACETEST = SMALL

.. .
UROBLGN 0.2 (0-1) mg/dl
.
UBILI . NEGATIVE (NEGATIVE)
ICTOTEST.NEGATIVE

.

U H2B . NEG (NEGATIVE)
...
U \NE . 1-3 H (0-2) /HPF

U REIC 10-20 H
I b ..pr 03 @ 1641 (Coll) TRACHEAL ASP(S PUTUM)
RESP CUL: Final Report
Bacteriology Result:
moderate A baumannii . Sens to: Imipenem.

18 Apr 03 @ 1641 (Coll) URINE/CC(URINE)
LA CULT: Final Report
Bacteriology Result:
no growth

18 Apr 03 @ 1641 (Coll) BLOOD(BLOOD)
Order comment: FUNGAL
BLD CULT: Final Report
Bacteriology Result:
AEROBIC PID ANAEROBIC VAI LS, ND CFCVVTH X 5 DAYS

.Ordered for (Uncollected)
L=Lo H=Hi *= Critical.R-Resi s t S-Susc MS-Mod Susc I-Intermed
ri-Uncert /A-Amended Comments= (0)rder, (I)nterpretations, (R)esult

b)(3)-1
24 Apr 03@1231H

Page 9 Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB DIQUItY 2 Apr 03 - 24 Apr 03
b)(6)-2.
Re--rt requested by:

b)(6)-4
(b)(6)-4
M/6d.

Ph: Req tillg;;VN

Military Unit:

24 Apr 03 @ 0924 (OrdFor) BLOOD
Order comment: code blue
STAT CBC HUNACKNOWLEDGED

24 Apr 03 @ 0843 (OrdFor) BLOOD
CBC HUNACKNOWLEDGED

24 Apr 03 @ 0843 (OrdFor) BLOOD
DIFFHUNACKNOWLEDGED

L=Lo H=HiHR=Resist S=Susc MS=Mod Susc I=Intermed
ri.Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

(b)(6)-4 (b)(6)-4
FOREIGN NATIONAL - POW/INTERN
18 Apr 2003 / MALE H: W:
Reg #: (b)(6)-4 Loc: Spon: b)(6)-4 Room-Bed: Rank: UNKNOWN D:
SI Unit: RR:

Transparent print on
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 24 Apr 2003K233 Page: 1 RADIOLOGIC EXAMINATION REPORT
Patient: rb"4 FMP/SSN: 1
b)(3)-1
DIAGNOSTIC RADIOLOGY Im(3)-1Procedure: c,- PINIE—r; VTFW1X TALE LAT AND PP Exam Date: 18 Apr 2003K716
vs)-2 ­Requested by: Status: COMPLETE
Exam #: (b)(6)-4
Ward/Clinic: CASREC MAIN
Pregnant: Reason for Order: IRAQUI MALE, INTUBATED
Order Comment: RIO SPINAL FX
12( lt Code: WW1_
Report:
Normal portable cross-table lateral c-spine.
Transcription Date/Time: 18 Apr 2003@1753
.;13)(6)-2
Interpreted by: CAPT,MC,USN Supervised by:
(b)(6)-2
Approved by: CAPT,MC,USN 18 Apr 2003K754 Supervised by:
b)(6)-4 1[13)(6)-4
FOREIGN NATIOV A l - POW/INTERN 18 Apr 2003 / L _E H:@, :
A A-4
Reg #: Loc: CASREC MAIN Room-Bed:
Spon : !(b)(6) 4 Rank: UslIsCVM1 D:
SF519-13 Unit: RR:

Transparent print on
Personal Data - Privacy Act 1974 (PL 93-579) .Printed date: 24 Apr 2003@1233 Page: 1 RADIOLOGIC EXAMINATION REPORT
(b)(6)-4 (b)(6)-4

Patient: FMP/SSN:
(b)(3)-1

DIAGNOSTIC RADIOLOGYIN3)-1 Procedure: KUB Exam Date: 18 Apr 2003@1716
(b)(6)-2

Requested by: Status: COMPLETE
Exarn it: 1(6)(6)-4
Ward/Clinic: CASREC MAIN Pregnant:
Reason for Order:
IRAQI MALE, INTUBATED
Order Comment:
PLACEMENT CF NC TUBE
Result Code: SEE RADIOLOGIST'S REPORT
R
Portable KB shows shrapnel over the sacrum and air within nondilated small
and large bowel suggestive of ileus. Due to overlying bowel gas, a sacral fx
cannot be excluded. Bones and soft tissues otherwise normal.

Transcription Date/Ti me : 18 Apr 2003@1728
b)(6)-2

Interpreted by: CAPT,MC,USN Supervised by:
1))(6)-2

Approved by: CAPT,MC,USN 18 Apr 2003@1732 Supervised by:
Loc: CASREC MAT Room-Bed:
Reg #r-4
Spon p" Rank: UNKNOWN . 3: SF519-6 Unit: RR:
Tr --sparent print on
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 24 Apr 2003@1233 Page: 1 RADIOLOGIC EXAMINATION REPORT
b)(6)-4
Patient: r)(6)-4 FMP/SSN:
(b)(3)-1

D 13\126T11 RAD IOLOGY [13)(3)-1 Procedure: FO (AP ONLY) Exam Date: 18 Apr 2003@1920 Requested by: Status: COMPLETE Ward/Clinic: X7257 Exam #: i

r6)-4
Pregnant: Reason for Order: VERIFY LEFT 13 PLACEMENT
Order Comment:
Result Code: SEE RADIOLOGIST'S REPORT
Report:
Compared with exam today @ 1726. Interval placement of left I) line - tip in SPNo pneumothorax. ETT ok. No significant change in pulmonary disease.
Transcription Date/Time: 18 Apr 200361940
:b)(6)-2

Interpreted by: tiD LCDR, MC ,USN Supervised by:
:b)(6)-2

Approved by: MD LCDR, MC ,USN 22 Apr 2003@1055 Supervised by:
SF519-B.Unit:. RR:
Transparent print on
Pt ,nal Data - Privacy Act 1974 (PL 93-579) .Printed date: 24 Apr 2003@1233 Page: 1 RADIOLOGIC EXAMINATION REPCRT
(b)(6)-4 M(6)-4
patient: FMP/SSN:
rx„, DIAGNOSTIC RAD IDLOGY procedure: CI-EST, AP (PORTABLE) Exam Date: 19 Apr 20
:b)(6)-2
Requested by: Status: •MPL TE
b)(6)-4
Ward/Clinic: ICU #2 1-78-2 X7257 Exam #:
Pregnant:
Reason for Order:
INTUBATED
Order Comment:
Result Code . SEE RADIOLOGIST'S REPORT
Report:
Portable PP 0R c f yesterday evening. ETT 4.4cm above carina. Left 11 line
unchanged and i n good position. Much better lung volumes on this film with
continued patchy infiltrates greater on the right side than on the left,
vhat improved from the prior even when better volume considered.
01....xwise stable.
Transcription Date/Time: 19 Apr 2003@0835
(b)(6)-2
Interpreted by: CAPT,MC,USN
Supervised by:
CAPT,MC,USN.19 Apr 2003@0838
Approved by: m(6)-2 Supervised by:
b)(6)-4
FOREIGN NATIONAL - POW/INTERN 18 Apr 2003 / MA' H :
Transparent print on
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 24 Apr 2003@1233 Page: 1 RADIOLOGIC EXAMINATION REPORT
(b)(6)-4
Patient: FMP/SSN: WMA
b)(3)-1
D,EINCSTII RAD CLOGY MPH Procedure: PO Exam Date: 20 Apr 200300705 Requested by: Status: COMPLETE Ward/Clinic: Exam #: ifb)(6)-4@
Pregnant•:
Reason for Order:
FOR RULE CUT ATELECTASIS
Order Comment:
Result Code: SEE RADIOLOGIST'S REPORT
Report:
An AP portable chest radiograph is compared to a similar study from the previous day. Interval removal of endotracheal tube and enteric tube. Left internal jugular central venous catheter with tip abutting the wall of the superior vena cava. Low lung volumes with bibasilar atelectasis. No pneumothorax.
IN .ZSSION: S/p removal of endotracheal and enteric tubes with bibasilar
atelectasis.
Transcription Date/Time: 20 Apr 2003@1016
(b)(6)-2

Interpreted by: , CCR , MC, LEN Supervised by:
(b)(6).2

Approved by: CDR,MC,USN.21 Apr 200381303 Supervised by:
(b)(6)-4

FOREIGN NATIONAL - POW/INTERN 18 Apr 2003 / MALE. H:. W:
:b)(6)-4
Reg #: Loc : CASREC MAIN. Room-Bed:
(b)(6)-4
Spon:. Rank: UNKNOWN MEDCOM -5561
Personal Data - Privacy Act 197'4 (PL 93-579) Printed date: 24 Apr 2003@1233
Page: 1 RADIOLOGIC EXAMINATION REPORT
:ientP6)-4 FMP/SSN: (b)(6)-4
:b)(3)-1
DIAGNOSTIC RADIOLOGY X7420 Procedure: CIST. AP (PORTARI fl Exam Date: 24 Apr 2003@1031
b)(6)-2
Requested by: Status: TRANSCRIBED
Exam #:(b)(6)-4
Ward/Clinic: WARD 4 FWD PORTH

4-4)-0 X7117

Pregnant:

Reason for Order:

r/o infiltrates

Order Comment:
Result Code: SEE RADIOLOGIST'S REPORT
Report:
An PP portable chest radiograph is compared to a similar study from 20 April
2003. Central venous catheter entering from the left internal jugular vein
with tip in the superior vena cava. Stable cardiomediastinal silhouette.
Lungs volume are low, unchanged. No new focal parenchymal opacities. No
pneumothorax. Midline trachea.

IMPRESSION: Persistent low lung volumes, but overall, no significant
i -val change from 20 April.

Transcription Date/Time: 24 Apr 2003@1059
b)(6)-2

Interpreted by: CDR,MC,USN
Supervised by:

Approved by:
Supervised by:

*************** x ******ATTENTION***********************
* THIS REPORT I S PENDING APPROVAL BY RADIOLOGY AND
SHOULD NOT BE INTERPRETED AS 11-E FINAL REPORT. ******************************************************
(b)(6)-4
FOREIGN NATIONAL - POW/INTERN @ 18 Apr 2003 / MALE H:HW:
Rey'#:(b)(6)-4
Loc: CASREC MAIN Room-Bed: Spon: (b)(6)-4
Rank: UNKNOWNH

D:
SF519-B Unit: RR:

MEDCOM - 5562
(b)(6)-4

FOREIGN NATIONAL - POW/INTERN
18 Apr 2003 / MALE H: W:

Reg #: (b)(6)-4
Loc: CASREC MAIN Room-Bed:

M(6)-4
Spon: Rank: UNKNOWN D:
SF519-E3 Unit: RR:

Transparent print on
Personal Data - Privacy Act 1974 (PL 93-579) .Printed date: 24 Apr 200361233 Page: 1 RADIOLOGIC EXAMINATION REPCRT
(b)(6)-4
Patient: FMP/SSN: MM4
(b)(3)-1
DIAGNOSTIC RADIOLOGY X7420 procedure: CHEST, AP (PORTABLE) Exam Date: 18 Apr 2003@1604 Requested by: [(b)(6)-2 Status: COMPLETE
M(6)-4

Ward/Clinic: CASREC MAIN Exam #:
Pregnant: Reason for Order: C 7C TRAUMA, COMARM ET TUBE PLACEMENT
Order Comment:
Result Code . SEE RADIOLOGIST'S REPORT
Report:
Portable AP chest without priors shows an ETT 5 an above the carina. Enteric tube(s) off the film inferiorly below the diaphragm..Bilateral airspace process worse on the right suggestive of pneumonia or contusion; a component of failure is also suggested with enlarged pulmonary veins. .Right pleural effusion also present..Bullet fragment overlies the left lateral sulcus. No fx or dislocation identified. No pneumothorax.
Conclusion: Diffuse bilateral airspace disease as noted, right greater than left.
Transcription Date/Time: 18 Apr 2003K731 .
(b)(6)-2
Interpreted by: CAPT,MC,USN Supervised by:
rX6y2
Ar-roved by: CAPT,MC,USN.18 Apr 2003@1737
S . rvised by:@

.
LABORATORY 1-71-0 25 Apr 2003@1306 Page 1
Personal Data -Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
ort requested by: System Generated

(b)(6)-4 (b)(6)-4
M/7d 2391 ph#Mil. Unit: UNKNOWN
(b)(6)-2

b)(3)-1

Ordered by: Col: 25 Apr 2003@1101 Acc#:
Specimen: BLOOD (SERUM) P r i : ROUTINE Ord#: b)(6)

-4

Res Lab: LAB Req Loc: IC2
Test name Result Units Normal range
TSH SENSITIVE TNP MCIU/ML 0.325 - 2.659
Test comment(s): DUPLICATE ORDER SEE TFT RESULT. DMP.\

***
*** End of Report
2 /
LABORATORY 1-71-0 25 Apr 2003®1246 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
Drt requested by: System Generated

(b)(6)-4 (b)(6)-4
M/ 7d 2391 ph#
7137T ENOWN
-
'b)(6)-2 (b)(3)-1
Ordered by: Col: 25 Apr 2003(4)1101 Acc#:
Ord#: (b)(6)-4

Specimen: BLOOD (SERUM) Pri: ROUTINE
Res Lab: LAB Req Loc: IC2

Test name Result Units Normal range
T3 .50 NG/ML 0.50 -1.26
T4 FREE 1.13 NG/DL 0.91 -1.44
TSH SENSITIVE 1.0 MCIU/ML 0.325 -2.659

*** ***

End of Report

gathered:

since day of
:are to )st C/W

I; Xray here no
ed qd as of , but moves it. ted 4/19/03;
M/03 5. )n Nystatin
has RUE
4/24/2003
2 /
LABORATORY 1-71-0 25 Apr 2003@0050 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
prt requested by: System Generated

M(6)-4 (b)(6)-4
M/7d 2391 ph#
Mil. Unit: UNKNOWN

Ordered by: Col: 24 Apr 2003@2227 Acc#: =I
Specimen: CSF (CEREBRO) Pri: ROUTINE Ord#: (0,,,,,
Res Lab: LAB Req Loc: TC2
Test name Result Units Normal range
MN CELLH80
Test comment(s): Result is a percentage 33 of 41 cells counted were mono
PMN CELLSH20HMM3
Test comment(s): result is a percentage 8 of 41 cells counted were poly

***H***

End of Report

(b)(6)-2
.
LABORATORY 1-71-0H 25 Apr 2003@0506 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated

MMA (b)(6)-4 (b)(6)-4
M/7d ph#
Mil. Unit: UNKNOWN

Ordered by: ;W(6)-2 Col: 25 Apr 2003@0432 Acc#. "-I Specimen: BLOOD (BLOOD) Pri: STAT Ord# : Res Lab: LAB Req Loc :
Test name Result Units Norma
WBC 15.9 H K/UL 4.8 - 10.8
RBC 3.1 L 1X10 6/UL 4.7 - 6.1
HGB 9.7 L g/dL 14.0 - 18.0
HCT 28.7 L % 42 - 52
MCV 91.9 fL 80 - 94
MCH 31.0 Pg 27 - 32
MCHC 33.7 g/dL 31 - 37
RDW 14.3 H % 12 - 14
PLT CNT 736.0 H lx10 3/UL 150 - 450

:13)(6)-2
Test comment(s): NOTIFIED LCDR 00Y2 @ 0505.
MPV 8.0 FL 7.4 - 10.4
NEUT/100 WBC 78.5 %
NEUT% 12.5 lx10 3/UL
LYMPHS/100 WBC 15.6 %
LY# 2.5 lx10 3/UL
MONO/100 WBC 5.9 %
MO# 0.9 lx10 3/UL

***H***

End of Report

(b)(6)-2
2 /
LABORATORY 1-71-0H 25 Apr 2003@0529 Page 1
Personal Data -Privacy Act of 1974 (PL 93-579)
Priority Result Notification
)rt requested by: System Generated

(b)(6)-4

M/7d 2391 ph# OWN
b)(3)-1
Ordered by: (b)(6)-2 Col: 25 Apr 2003@0432 Acc#:
(b)(6)-4

Specimen: BLOOD (SERUM) Pri: ASAP Ord#:
Res Lab: LAB Req Loc:
Test name Result Units Normal range
VANCOMYCIN 6.3 ug/mL

***H***

End of Report

(b)(6)-2

2 /
LABORATORY 1-71-0 25 Apr 200380540 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

(b)(6)-4@
M/7d ph#
Mil. Unit: UNKNOWN

Ordered by: )-2 Col: 25 Apr 2003@0432 Acc#: WPP Specimen: BLOOD (SERUM) Pri: STAT Ord# (b)(6)-4 Res Lab: LAB Req Loc: _LUA Test name Result Units Normal range NA+ mmol/L 137 - 145 K 4.3H3.6 5.0
mmol/L -H
CL-120 HH97 - 107

mmol/L
CO2 24Hmmol/L 22 - 31
BUN mg/dL

37 HH9 - 21
GLUCOSE mg/dL 76 - 110
CREAT mg/dL 0.8 -H

1.5

***H***

End of Report

MM-2

LAB FLOW SHEET

PATIENT NAME
Date/Time 4c{10@rikn@ gig
EMINEMOONSOMiti ing* WiatirelM MIK

WBC (4.8-10.8) K/UL 12.1, 12.52, 11.3
RBC (4.7-6.1) 1X10 6/UL

.% ,•z. 3. I
HGB (14.0-18.0) g/DI t.(0 10,0
HCT (42-52) % z9 78.(r A, 4
PLT (150-450) 1x10 3/UL 'lig 405 gol,
NE UT%

I Si ci.u.
A. clIgMRTRYANAM• NOWEVE0Mis: ritek KM* 010WM*1104iii
NA+ (137.145) mmoVL
K (3.6-5.0)—mnioL/L-

A-‘14;6
CL- (97-107) mmoVL Wt. izo U LI Li
CO2 (22.31) mmoVL 1.-1, 13 2,14
BUN (9-21) mg/DI "LS-IS
GLUCOSE (76-110) mg/dL

riA WI 146
CREAT (0.8-1.5) mg/dL b.9 Os
CA (8.8-10.4) mg/d1. 1 A

PROTEIN TOTAL (6.3-8.3) g/dL 5.1 ALBUMIN (3.5-5.0) gkIL
1. to
AST (15-46) UIL LDH (313-618) U/L ALK PHOS (70-250) U/L TBILI (1.0.10.5) mg/CL GGT (8-78) U/1 CK (0.203) U/L MG (1.7-2.2) mg/dL AMYLASE (30.110) U/L
1143 97
LIPASE (23.300) U/L
'631
ALT (11-66) U/L
1 10%. SIMMOSSINAMFMOS tIONV. *Mt INSIV
pH
'@ . (f?
pCO2 /AA p02
3t
HCO3 IC( BE Sao2
Az; relia-Vait NSA* etaigli'wot AVM Molit *UM APTT (23.8-35.5) Seconds 14a.1, PT (11.6-14.4) Seconds L3 IA INR 1.1
t#,MON.Q" QT H4gielAWA4 KtiAti@tvAPil, WOW otaa,
@1(b)(6)-4
b)(6)-4
MEDCOM - 5572
T
DOD 12784

2 /

LABORATORY 1-71-0H 25 Apr 2003@1136 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

:b)(6)-4 b)(6)-4
M/7d r(6)-4 ph#

Mil. Unit: UNKNOWN

Ordered by: (b)(6)-2 Col: 25 Apr 2003@1101 Acc#: Specimen: BLOOD (SERUM) Pri: STAT Ord#: Res Lab: LAB Req Loc:
Test name Result Units Normal range
GLUCOSE 204 H mg/dL 76 - 110

***H***

End of Report

LAB FLOW SHEET
:13)(6)-4
PATIENT NAME
/Is 0, D..1/044.1,-/A ;

btlaM @4 C1
Da ten.ime o-es
c..41 2221_ \9:11r1j-0?)56 inNo
WMPASSUBOONMe@ illatiMittAINEWS, 10
WBC (4.8-10.8) MIL 3 .-`t@t2..% I it 0 041" #5". I
RBC (4.7-6.1) 1X10 6/UL 2.1 ?•0 . 3.0 A-3 3 , :f
HGB (14.0-18.0) g/DI 9. .0 Tz. G 9 -Lf

9 112 71.:T (4;-52) % 32.1 psi 2,1.0 21.3 30-Z-• 21i; 7 PLT (150-450) 1x10 3/UL '1 28 S88 ‘10761. 0 7340 NEUT% 79-7 9O q-s
1.2-
1.1ctigfillsiVoatati ettrix-Prem finffkikallki
NA* (137.145) mmoVL v31 t31. 1.-54 131

@@
K (3.6-5.01mMoUL -."'t -9.0 4.l •
CL- (97-107) mmol/L Cr ct tc) 1 0 11--105 fi9 i
CO2 (22-31) mmoVL . 31-

Za

BUN (9-21) mg/DI 1 1-V2_, . I 10 yY
GLUCOSE (76-110) mg/dL %5-. v61-k V..; 1 94 3/
CREAT (0.8-1.5) mg/dL 0 .-413 t9 -9 o .g 0-(1 4./
CA (8.8-10.4) mg/dL 7f' (Q 6,1
PHOSPHORUS (2.5-4.5) mg/dL 39 ,

.5, 3 '1. I 4.0 3.3
URIC ACID (3.3-8.4) mg/dt. 2..

PROTEIN TOTAL (6.3-8.3) g/dL
fr,lS
ALBUMIN (3.5-5,0) gfdL

AST (15-46) UIL
72-LDH (313-618) U/L ALK PHOS (70-250) U/L '8 TBILI (1.0-10.5) mg/dL 0.1 GGT (8-78) U/L CK (0-203) UIL 82.1 1531
@
MG (1.7-2.2) mg/dL
2-..212-.3 3 ,3
AMYLASE (30-110) U/L

ci 2.
LIPASE (23-300) U/L ALT (11.66) U/L
51
AIMINAMIER PliffirtittNiefi WISMASISISINt
pH pCO2 p02 HCO3 BE Sao2
Kiirtitiftaggr trigm 1414141i2 Vtit *tfat tr1401 MS UM
APTT (23.8.35.5) Seconds PT (11.6.14.4) Seconds
15-.1
INR
WiialitaCIAROAftra4t PASO *tiVA: _VOW W4A4Raigt*Alitfitli
A Pt ca­
mThr F
ifkga) 0.4/.4 /
MEDCOM - 5574
DOD 12786

b)(6)-4
b)(6)-4

CC#,
E:1 b)(6)-4
:1 25-Apr-2003
• 6:18:26 AM

W: 2300, C: 1150• MAG: 23% LOSSLESS
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 25 Apr 2003@0800
Page: 1

RADIOLOGIC EXAMINATION REPORT

:b)(6)-4
Patient: FMP/SSN: b)(6)-4

b)(3)-1
DIAGNOSTIC RADIOLOGY X7420

Procedure: CHEST. ORTABLEO_ Exam Date: 24 Apr 2003@2148

Requested by: (b)(6)-2 Status"

Ward/Clinic: ICU #2 1-78-2 X7257 Exam #:

Pregnam

Reason for Order:

VERIFY NGT PLACEMENT

Order Comment:

Result Code: SEE RADIOLOGIST'S REPORT

Report:

No change cf last CXR of 24 April. NG tube to stomach. Lungs well-expanded.
no PTX. Mediastinum normal. Shrapnel in LUQ abdomen. No new findings.

Transcription Date/Time: 25 Apr 2003@0658

Interpreted by: b)(6)-2 CDR, MC, USN

S -ervised by:

Approved by: b)(6)-2 1 CDR, MC, USN 25 Apr 200300700
Supervised by:

(b)(6)-2

(b)(6)-4
MP-4 FOREIGN NATIONAL - POW/INTERN 18 Apr 2003 / MALE H: W:
Reg #M(6)-4
Loc: CASREC MAIN Room-Bed:

Spon: (b)(6)-4
Rank: UNKNOWN D:
19-B Unit: RR:

Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 25 Apr 2003@0800
Page: 1
RADIOLOGIC EXAMINATION REPORT

(b)(6)-4

(b)(6)-4
Patient: FMP/SSN:

(b)(3)-1

DIAGNOSTIC RADIOLOGY X7420 Procedure: PORTABLE: CHEST (AP ONLY) Exam Date: 25 Apr 2003@0621 Requested by: (b)(6)-2 Status: COMPLETE
Exam #: (b)(6)-4
Ward/Clinic: ICU #2 1-78-2 X7257

Pregnant:
Reason for Order:
eval

Order Comment:

Result Code: SEE RADIOLOGIST'S REPORT

Report:

F -table AP cxr cf yesterday a.m. Left IJ svc has been removed; no PTX. New

i . tip in stomach near the pylorus. Lung volumes remain low but no airspace
disease or effusions noted. NACPD.

Conclusion: NGT in good position.

Transcription Date/Time: 25 Apr 2003@0742

Interpreted by: :b)(6)-2 CAPT,MC,USN Supervised by:
(b)(6)-2

Approved by: CAPT,MC,USN 25 Apr 2003@0747
Supervised by:

(b)(6)-2
b)(6)-4 FOREIGN NATIONAL -POW/INTERN 18 Apr 2003 I / MALE H: W: Reg #:rx6H Loc: CASREC MAIN Room-Bed: Spon: (b)(6)-4 Rank: UNKNOWN D: SF519-B Unit:
RR:
:13)(6)-2
2 It'

LABORATORY 1-71-0 25 Apr 2003@0839 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated

(b)(6)-4
1(b)(6)-4

(b)(6)-4 M/7d ph#
Mil. Unit: UNKNOWN

(b)(6)-2 Acc#: :b)(3)-1

Ordered by: Col: 24 Apr 2003@2227
Ord#: (b)(6) -4

Specimen: CSF (CEREBRO) Pri: ROUTINE

Res Lab: LAB Req Loc: IC2

Result Units Normal range

Test name

WBC 1 /A MM3

Test comment(s):

result ammended to reflect the nearest whole number

Result .56 reported on 24 Apr 2003@2355 (#1523) has been amended.

RBC 11 /A MM3

Test comment(s):

result ammended to reflect the nearest whole number

Result 11.1 reported on 24 Apr 2003@2355 (#1523) has been amended.

*** End of Report ***

(b)(6)-2

b)(3)-1 25 Apr 200380722 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
For: 24 Aur 03 - 25 Apr 03

: P*6)-2

R,port requested by

b)(6)-4 b)(6)-4 M/7d b)(6)-4
Reg #:
Ph: Military Unit: UNKNOWN

25 Apr 03 @ 0432 (Coll) BLOOD

STATWBC 15.9 H (4.8-10.8) K/UL
RBC 3.1 L (4.7-6.1) 1X10 6/UL
H GB 9.7 L (14.0-18.0) g/dL
HCT 28.7 L (42-52) %
MCV 91.9 (80-94) fL
MCH 31.0 (27-32) pg
MCHC. 33.7 (31-37) g/dL
RDW 14.3 H (12-14)
PLT CNT 736.0 H (150-450) lx10 3/UL

I@ 0505. 1(6)(6)-2
Result Conment: NOTIFIED LCDRM(6) 2
MPV 8.0 (7.4-10.4) FL
NEUT/100 WBC 78.5
NEUT% 12.5 lx10 3/UL

LYMPHS/100 WBC 15.6
LY# 2.5 lx10 3/UL
MONO/100 WBC 5.9
MO# . . .. 0.9 lx10 3/UL

2' Apr 03 @ 0432 (Coll) SERUM

2 NA+ 152 H (137-145) mmol/L
K 4.3 (3.6-5.0) mmol/L -
CL -120 H (97-107) mmol/L
CO2 24 (22-31) mmol/L

BUN 37 H (9-21) mg/dL
GLUCOSE 242 H (76-110) mg/dL
mg/dL

CREAT 1.4 (0.8-1.5)

25 Apr 03 @ 0432 (Coll) SERUM
ASAP VANCOMYCIN 6.3 ug/mL

L=Lo H=Hi *=Critical "-Resist S=Susc MS=Mod Sr --I=Intermed
MEDCOM -5580

DOD 12792
LABORATORY 1-71-0H 26 Apr 2003@1848 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

(b)(6)-4
1(b)M-2
Ordered by:
Specimen: BLOOD (BLOOD)
Res Lab: LAB
Test name

NEUT/100 WBC
LYMPHS/100 WBC
MONO/100 WBC
PLT EST
MORPHOLOGY

pl)(6).4
@ M/8d 2391 ph# Mil. Unit: UNKNOWN
:b)(3)-1

Col: 26 Apr 2003@1806 Acc#-

b)(6)-4

Pri: STAT

Ord#:
Req Loc: 1C2

H

Result Units Normal range

91
6

3
NORMAL
NORMAL

***

End of Report ***

.
LABORATORY 1-71-0 26 Apr 2003@1854 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification

)rt requested by: System Generated

rM)-4
(b)(6)-2
Ordered by-
specimen: BLOOD (SERUM)
Res Lab: LAB

Test name
NA+
EL-

BUN

GLUCOSE
CREAT

PHOSPHORUS
URIC ACID

ALBUMIN
AST

ALT
ALK PHOS
TBILT
GGT

1m(s)-4 b)(6)-4
M/ 8d ph#
Mil. Unit: UNKNOWN

Col: 26 Apr 2003@1806HAcc#.0(3)-1

Pri: STAT

149 H Units
mmol/L
122 H mmol/L
27 H
138 H mg/dL

1.3 mg/dL

3.2 mg/dL

5.2 mg/dL

2.6 L mg/dL

236 H g/dL
130 H U/L
132 H U/L

93 U/L

0.4 L mg/dL
141 H U/L

*** ***

End of Report

(
b)(6)-4
Ord#.

Req Loc: IC2
Normal range
137 - 145

393 - IOU

9 - 21
76 -H

110

0.8 -1.5

2.5
-4.5

3.3
-8.4

3.5 -5.0
15 - 46
11 -66
70 -250

1.0 -10.5
8 - 78

2 /
LABORATORY 1-71-0 26 Apr 2003@1845 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
1 )rt requested by: System Generated

@
(b)(6)4

MM-4 MOY4 ­
M/8d ph#
Mil. Unit: UNKNOWN

(b)(6)-2

Ordered by: Col: 26 Apr 2003@1806 Acc#:
Specimen: BLOOD (BLOOD) Pri: STAT Ord#:
Res Lab: LAB Req Loc:
Test name Result Units Normal range
WBC 12.2 H K/UL 4.8 - 10.8
RBC 2.8 L 1X10 6/UL 4.7 - 6.1

HGB 8.6 L g/dL 14.0 - 18.0
HCT 25.5 L % 42 - 52
MCV 92.1 fL 80 - 94
MCH 31.0 Pg 27 - 32
MCHC 33.7 9/dL 31 -37
RDW 14.3 H % 12 - 14
PLT CNT 406.0 lx10 3/UL 150 -450
MPV 8.2 FL 7.4 -10.4
***H***

End of Report

(b)(6)-2

-
2J

LABORATORY 1-71-0 26 Apr 2003@1855 Page 1
Personal Data -Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated

;b)(6)-4
M(6)-4 (b)(6)-4
M/Fid ph# Mil. Unit: UNKNOWN
Acc#: (b)(3)-1

Ordered by: MA-2 Col: 26 Apr 2003@1806
(b)(6)-4

Specimen: BLOOD (PLASMA) Pri: STAT Ord#:
Res Lab: LAB Req Loc: 1C2
Test name Result Units Normal range
APTT 18.6 L Seconds 23.8 -35.5

*** ***

End of Report
(b)(6)-2
2 / LABORATORY 1- 7 1 - 0 26 Apr 200391855 Page 1 Personal Data - Privacy Act of 1974 (PL 93-579) Priority Result Notification I )rt requested by: System Generated
MOH b)(6)-4 (b)(6)-4 ph#
M/8d
Mil. Unit: UNKNOWN

b)(6)-2 b)(3)-1
Ordered by: ICol: 26 Apr 200391806 Acc#: Specimen: BLOOD (PLASMA) Pri: STAT 401
Ord#:

Res Lab: LAB Req Loc:

Test name Result Units Normal range
PT 13.2 Seconds 11.6 - 14.4
INR 1.1

Interpretation(s):
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2,5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

*** ***

End of Report

.
LABORATORY 1-71-0H 26 Apr 2003631854 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

(b)(6)-4 (b)(6)-4@ (b)(6)-4
M/8d ph#
Mil. Unit: UNKNOWN

Acc#•

Ordered by: XeR Col: 26 Apr 2003631806Hpom

Specimen: BLOOD (SERUM) Pri: STATH

Ord# kb)(6)-4@
Res Lab: LAB Req Loc: IC2
Test name It Units Normal range
LIPASE 631 HH23 - 300

) U/L

***H***

End of Report

C3,0 e-e C2/71

2 /
LABORATORY 1-71-0H 26 Apr 2003@1854 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

1(b)(6)-4 (b)(6)-4 M/8d (b)(6)-4@ ph#
Mil. Unit: UNKNOWN
MM-2Ordered by: Specimen: BLOOD (SERUM) Col: Pri: 26 Apr STAT 2003@1806 Acc#: Ord#: b)(3)-1 ,b)(6)-4
Res Lab: LAB Req Loc: 1C2
Test name Result Units Normal range
AMYLASE 126 H U/L 30 -110

***H***

End of Report

2H

/
LABORATORY 1-71-0H 26 Apr 2003@1854 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
)rt requested by: System Generated

(b)(6)-4 (b)(6)-4 (b)(6)-4
14/8d ph#
Mil. Unit: UNKNOWN

(b)(6)-2
Ordered by: Col: 26 Apr 2003@1806 Acc#: MP-1
Specimen: BLOOD (SERUM) Pri: STAT Ord#: 0(6)-4
Res Lab: LAB Req Loc:
Test name Result Units Normal range
CO2 22 mmol/L 22 - 31
CA 7.9 L mg/dL 8.8 -H

10.4
PROTEIN TOTAL 5.9 L g/dL 6.3 8.3

-H
LDH 1866 H U/L 313 - 618
CK 711 H U/L 0 - 203
MG 2.4 H mg/dL 1.7 2.2

-H
Interpretation(s):

*** End of Report ***

2H

.
LABORATORY 1-71-0 27 Apr 2003@0627 Page .1

(PL 93-579)

Personal Data - Privacy Act of 1974H

Priority Result Notification
art requestedby: System Generated

(b)(6)-4
(b)(6)-4 r)(6, M/ 9d ph#
Mil. Unit: UNKNOWN

Ordered by: Specimen: (b)(6)-2 BLOOD (BLOOD) Col: Pri: 27 Apr STAT 2003@0551 Acc# : Ord#-OR1
Res Lab: LAB Req Loc: 1C2
Test name WBC Result 18.1 H Units K/UL Normal range 4.8 -H
10.8
RBC HGB 3.2 L 10.0 L 1X10 6/ULg/dL 4.7 -H
6.1 14.0 -H
18.0
HCT 29.0 L 42 - 52
MCV 90.1 fL 80 - 94
MCH 31.1 pg 27 -32
MCHC 34.5 g/dL 31 - 37
RDW 14.3 H 12 - 14
PLT CNT 429.0 lx10 3/UL 150 - 450
MPV 8.1 FL 7.4 -H
10.4
***H*** End of Report

2 /

LABORATORY 1-71-0H 27 Apr 2003@0629 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
J )rt requested by: System Generated

;13)(6)-4 M/9d (b)(6)-4 ph#
Mil. Unit: UNKNOWN
Ordered by: Specimen: BLOOD (BLOOD) Res Lab: LAB MR-2 Col: 27 Apr 200380551HAcc#-Pri: STATHOrdif-M1 Req Loc: 1C2 b)(3)-1
Test name Result Units Normal range
NEUT/100 WBC 84
LYMPHS/100 WBC 10
MONO/100 WBC 3
EOS/100 WBC 4.0
BASO/100 WBC 1.0
PLT EST NORMAL
MORPHOLOGY NORMAL

***H***

End of Report

2 /

LABORATORY 1-71-0 27 Apr 200300716 Page 1
Personal Data - Privacy Act of 1974H

(PL 93-579)
Priority Result Notification
ort requested by: System Generated

M(6)-4 :b)(6)-4 (b)(6)-4
M/9d ph#
Mil. Unit: UNKNOWN

b)(3)-1

(b)(6)-2

Ordered by: Col: 27 Apr 2003@0551 Acc#:

b)(6)-4

Specimen, BLOOD (SERUM) Pri: STAT Ord# :
Res Lab: LAB Req Loc: 1C2
Test name Result Units Normal range

NA+ 147 H mmol/L 137 -145
K 4.0 mmol/L 3.6 -5.0
CL-120 H mmol/L 97 -107
0O2 23 mmol/L 22 -31
BUN 25 H mg/dL 9 - 21
GLUCOSE 124 H mg/dL 76 -110
CREAT 1.1 mg/dL 0.8 -1.5

*** End of Report ***

2 /
LABORATORY 1-71-0H 27 Apr 2003@0716 Page 1
Personal Data - Privacy Act of 1974 (PL 93 -579)
Priority Result Notification
prt requested by: System Generated

(b)(6)-4 :b)(6)-4
M/9d MMA ph# Mil. Unit: UNKNOWN
Acc#: (b)(3)-1

Ordered bytm2 Col: 27 Apr 2003@0551

Ord#: (b)(6)-4
Specimen: BLOOD (SERUM) Pri: STAT
Res Lab: LAB Req Loc: IC2
Test name Result Units Normal range
LIPASE 423 H U/L 23 - 300

***H***

End of Report

2 /
LABORATORY 1-71-0H 27 Apr 2003@0715 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
Drt requested by: System Generated.

(b)(6)-4@
(b)(6)-4 M(6)-4
M/9d ph#
Mil. Unit: UNKNOWN

(b)(3)-1
Ordered by: r)(6)-2 Col: 27 Apr 2003@0551 Acc#:
Specimen: BLOOD (SERUM) Pri: STAT Ord#: (b)(6)-4
Res Lab: LAB Req Loc: 1C2
Test name Result Units Normal range
AMYLASE 92 U/L 30 - 110

***H***

End of Report

2
1

LABORATORY 1-71-0H 27 Apr 200380659 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
)rt requested by: System Generated

M(6)-4 (b)(6)-4
(b)(6)-4
M/9d
Mil. Unit: UNKNOWN

:b)(3)-1Ordered by: (b)(6)-2 Col: 27 Apr 2003@0606 Acc#: Specimen: OTHER (SPUTUM) Pri: ROUTINE Ord#TR4 Resulting Lab: LAB Req L c:
GRAM STAIN: Final Report

GRAM STAIN: FEW PMNS. RARE MONOS. RARE GPCS IN CLUSTERS AND PAIRS.

ph#

1
2 /
LABORATORY 1-71-0H 28 Apr 2003@1220 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

(b)(6)-4 jo)(6)-4 MM-4
M/lOd ph# Mil. Unit: UNKNOWN
Ordered by: (b)(6)-2

Col: 28 Apr 2003@1133

Acc#: WOP
Specimen: BLOOD (SERUM) Pri: STAT Ord#: kb)(6)-4
Res Lab: LAB Req Loc: 1C2

H

Test name Result Units Normal range

H

GLUCOSE 202 H mg/dL 76 - 110

***H***

End of Report

2 f
LABORATORY 1-71-0 28 Apr 2003@0942 Page 1
Personal Data - Privacy Act of 1974H

(PL 93-579)
Lab Certified Result Notification
Drt requested by: System Generated

(b)(6)-4 MM-4 M/23d ;b)(6)-4
ph#
Mil. Unit: UNKNOWN

b)(6)-2 (b)(3)-1
Ordered by: 'I Col: 28 Apr 2003@0815 Acc#•

:13)(6) -4
Specimen: BLOOD (SERUM) Pri: ROUTINE Ord#:
Res Lab: LAB Req Loc: 1L2
Test name Result Units Normal range
K 3.7 mmol/L 3.6 -H

5.0
BUN 18 mg/dL 9 - 21

***H***

End of Report

2 /
LABORATORY 1-71-0 28 Apr 2003@0956 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
Drt requested by: System Generated

(b)(6)-4

MM4 Mp4@
M/10d ph#
Mil. Unit: UNKNOWN

M(6)-2
Ordered by: Col: 24 Apr 2003@1714 Acc#:0M-1
Specimen: SPUTUM (SPUTUM) Pri: ROUTINE Ord# : m(6)-4
Resulting Lab: LAB Req Loc: IC2

RESP CULT: Final Report

BACTERIOLOGY result(s): REFER TO bT 1104 FOR ID AND SENS.4/26/03

2H

/

LABORATORY 1-71-0 28 Apr 2003@0455 Page 1
Personal Data (PL 93-579)

-Privacy Act of 1974H

Priority Result Notification
prt requested by: System Generated

(b)(6)-4 :b)(6)-4 M(6)-4
M/10d ph#
Mil. Unit: UNKNOWN

Ordered by: M(6)-2 Col: 28 Apr 2003@0422 Acc#. (b) (3)-1
Specimen: BLOOD (SERUM) Pri: STAT Ord#: (000
Res Lab: LAB Req Loc: J-C2

Test name Result Units Normal range NA+ 1 mmol/L 137 - 145 K mmol/L 3.6 -5.0 CL-H mmol/L 97 - 107 CO2 24 mmol/L 22 -31 BUN 18 mg/dL 9 -21 GLUCOSE mg/dL 76 - 110 CREAT 9 mg/dL 0.8 -1.5
***H***

End of Report

(b)(6)-2
2H

/

LABORATORY 1-71-0 28 Apr 2003@0432 Page 1 Personal Data - Privacy Act of 1974 (PL 93-579) Priority Result Notification )rt requested by: System Generated
(b)(6)-4

Ordered by: MM-2
Specimen: BLOOD (BLOOD)
Res Lab: LAB

Test name
WBC
RBC
HGB
HCT
MCV
MCH
MCHC

RDW
PLT CNT
MPV
NEUT/100 WBC
NEUT%
LYMPHS/100 WBC
LY#
MONO/100 WBC
MONO%

(b)(6)-2

(b)(6)-4

M/10d
Mil. Unit: UNKNOWN

Col: 28 Apr 2003@0422

Pri: STAT

Result

12.8 H

3.1 L

9.7 L

28.6 L

91.2

30.8

33.8

14.0

405.0

7.9

74.7

9.6

22.1

2.8

3.2

0.4

***

Units
K/UL
1X10 6/UL
g/dL

fL
pg

g/dL
%
lx10 3/UL
FL

lx10 3/UL

lx10 3/UL

1X10 3/UL

M(6)-41
ph#
Acc#:r"" Ord#: MR-41 Req Loc: 1C2 Normal range
4.8 -10.8

4.7 -6.1

14.0 - 18.0
42 - 52
80 - 94
27 - 32
31 - 37
12 - 14

150 - 450

7.4 -10.4

End of Report ***

b)(6)-2
LABORATORY 1-71-0 28 Apr 2003@0506 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

@
,b)(6)-4 1(b)(6)-4 (b)(6)-4
M/10d ph#
Mil. Unit: UNKNOWN

NOR Col: 28 Apr 2003@0422 ACC#T"M
Ordered by: Hb)(3)-1
Specimen: BLOOD (SERUM) Pri: STAT Ord#:
Res Lab: LAB Req Loc-(bib
Test name Result Units Normal range
PHENYTOINH10.2 ug/mL 10.0 -20.0

***

*** End of Report

(b)(6)-2

M(6)-2
LABORATORY 1-71-0 28 Apr 2003©1918 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
prt requested by: System Generated

N(6)-4 (b)(6)-4 M/10d (b)(6)-4 ph#
Mil. Unit: UNKNOWN
Ordered by: M(6)-2 Specimen: BLOOD (SERUM) Res Lab: LAB Col: 28 Apr Pri: STAT 2003(4)1827 Acc#: Ord#: Req Loc: 1C2 (b)(3)-1 (b)(6)-4
Test name Result Units Normal range
GLUCOSE 119 H mg/dL 76 - 110

*** End of Report ***

LABORATORY 1-71-0 28 Apr 2003(0955 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Result Notification

WR-2

I .Drt requested by:

b)(6)-4 b)(6)-4 Im/lod rx6)-4
ph#
Mil. Unit: UNKNOWN

Ordered by: 1(b)(6)-2 Col: 24 Apr 2003@1641 Acc#.pg Specimen: SPUTUM (SPUTUM) Pri: ROUTINE
Ord#:m6y4

Resulting Lab: LAB Req L

RESP CULT: Final Report

BACTERIOLOGY result(s): many A. Baumannii. Sens to: amp/sulbactam, imipenem

ORGANISMS: (1) ESCHERICHIA COLI quantity: many

(1)

Mcg/ml Interp
AMIKACIN S S
AMP/SULBACTAM R R
CEFOXITIN S S
CEFTAZIDIME R R
CIPROFLOXACIN R R
GENTAMICIN R R
IMIPENEM S S
TICARCILLIN R R
TOBRAMYCIN R R

,TRIMETH/SULFATE R R

*** ***
End of Report

LABORATORY 1-71-0 29 Apr 2003@0126 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

(b)(6)-4

:b)(6)-4

(b)(6)-4
@( mind ph# Mil. Unit: UNKNOWN
(b)(3)-1
Ordered by: M(6)-2 Col: 29 Apr.2003@0020 . Acc#:
Specimen: SLOOD (SERUM) Pri: STAT Ord#: (b)(6)-4
Res Lab: LAB Req Loc. iL2

H

Test name Result Units Normal range

H

GLUCOSE 102 mg/dL 76 -110

*** End of Report ***

2 /

LABORATORY 1-71-0H 29 Apr 2003@0544 Page 1
Personal Data -Privacy Act of 1974 (PL 93-579)
Priority Result Notification
srt requested by: System Generated

M(6)-4
M(6)-4
(b)(6)-4 M/lld ph#
Mil. Unit: UNKNOWN

:b)(3)-1

Ordered by: ;b)(6)-2 Col: 29 Apr.2003@0500 ACC#:
b)(6)-4

Specimen: BLOOD (SERUM) Pri: STAT Ord#:
Res Lab: LAB Req Loc: 1C2

Test name Result Units Normal range NA+ 141 mmol/L 137 -145 K 3.4 L mmol/L 3.6 -5.0 CL-111 H mmol/L 97 - 107 CO2 26 mmol/L 22 -31 BUN 15 mg/dL 9 - 21 GLUCOSE 104 mg/dL 76 -110 CREAT 0.8 mg/dL 0.8 -1.5
***H***

End of Report

(b)(6)-2

.
LABORATORY 1-71-0 29 Apr 2003@0546 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
I )rt requested by: System Generated

(b)(6)-4

Ordered by: MP-2
Specimen: BLOOD (BLOOD)
Res Lab: LAB

Test name
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLT CNT

MPV
NEUT/100 WBC
NEUT%
LYMPHS/100 WBC
LY#
MON0/100 WBC
MONO%

r
p)(6)-4 M/11d (b)(6)-4
ph#
Mil. Unit: UNKNOWN

(b)(3)-1

Col: 29 Apr.2003@0500 Acc#.
Pri: STAT .
Reci(I.14C; I'XI'2
Result Units Normal range

11.3 H K/UL 4.8 -10.8

3.3 L 1X10 6/UL 4.7 -6.1

10.2 L g/dL 14.0 -18.0

29.4 L % 42 - 52

90.3 fL 80 -94

31.2 pg 27 - 32

34.5 g/dL 31 - 37

14.2 H % 12 -14

383.0 lx10 3/UL 150 - 450

8.7 FL 7.4 -10.4

73.2

8.3 lx10 3/UL

21.9

2.5 lx10 3/UL

4.9

0.6 1X10 3/UL

*** ***

End of Report

(b)(6)-2

LABORATORY 1-71-0H 29 Apr 2003@0556 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: System Generated

MMA
lirm--n—UNKNONN11d fb)(6" ph#
417—Uni
Ordered by: r6)-2 Col: 29 Apr.2003@0500 Acc#:p0)-1 Specimen: BLOOD (SERUM) Pri: STAT Ord#: Res Lab: LAB Req Loc: 1C2 Test name ResultHNormal range
Units PHENYTOIN ug/mL 10.0 - 20.0
***H***

End of Report

MMN

b)(3)-1
26 A 2003@1648 Page 3
Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY r-.r Mar 03 - 26 Apr 03
b)(6)-2

Re'- •"t requested by'
M(6)4 Reg #: (b)(6)-4
b)(6)-4
M/8d Ph: Military Unit: UNKNOWN
18 Apr 03 @ 1641 (Coll) SERUM STAT CK 827 H
18 Apr 03 @ 1641 (Coll) TRACHEAL AS
RESP CUL: Final Report
Bacteriology Re-SliTt-:-
oderate A. baumanni . . Sens to: Imipenem.

18 Apr 03 @ 1641 (Coll) URINE/CC(URINE)
1.14 CULT: Final Report
Bacteriology Result:
no growth

18 Apr 03 @ 1641 (Coll) BLOOD(BLOOD) Order comment: FUNGAL BLD CULT: Final Report Bacteriology Result: AEROBIC PND ANAEROBIC VAI LS, M CFONTH X 5 DAYS
L=Lo H=Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed ri--Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
WM-1
26 A, . 2003@1648 Page 2
Persona Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY For: 24 Mar 03 - 26 Apr 03 Re -'rt requested by: im6)-2
b)(6)-4 b)(6)-4 MM-4
M/8d Reg #: Ph: Military Unit: UNIINDAN
24 Apr 03 @ 1641 (Coll) URINE/CC(URINE) LP CULT: Final Report".' Bacteriology Result: NO CFCWIH
24 Apr 03 @ 1641 (Coll) SPUTUM RESP CUL: Iiaermediate Report Organism: (1) ES RICHIACOL-1----Quantity: many
(1)
Mcg/mlgterp AMIKACIN AMP/SULBACTAM CEFOXITIN S CEFTAZIDIME R R CIPROFLOXACIN R R GENTAMICIN R R IMIPENEM TICARCILLIN R TOBRAMYCIN R R TRIMETH/SULFATE R R
24 Apr 03 @ 1639 (Coll) BLOCID(BLOOD) BLD CULT
24 Apr 03 @ 1637 (Coll) PENDI G BLOCID(BLOOD)
BUD CULT
STAVIK03 @ .1037 (Coll). (0-203) U/L sERIA

24 Apr 03 @ 1037 (Coll) SERUM STAT CK (0-203)@U/L
24 Apr 03 @ 0350 (Coll) BLOOD(BLOOD) BLD CULT. PENDING
24 Apr 03 @ 0350 (Coll) BLOOD(BLOOD) BLD CULT PENDING
L=Lo H=Hi *=Critical R=Resi st S=Susc MS=Mod Sus c I=Intermed n=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
b)(3)-1@
26 A. 2003@1648 Page 3
Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY r 24 Pyr 03 - 26 Apr 03
^@
Rer—rt requested by: (bo) 2
b)(6)-4 b)(6)-4 M/8d Reg # : T I
Ph: Military Unit: LNINDAN
24 Apr 03 @ 2228 (Coll) CEREBROSPINA
24 Apr 03 @ 2227 (Coll) CEREBROSPINA WBC /A 1VTV3
Result Comment: result amended to reflect the nearest whole number Result .56 reported on 24 Apr 2003@2355 (#1523) has been amended.
FEC 11 /A MM3
Result Comment: result amended to reflect the nearest whole number Result 11.1 reported on 24 Apr 200302355 (#1523) has been amended.
COLOR COLORLESS
APPEARANCE CLEAR
MJ CELL 80

Result Comment: Result i s a percentage 33 of 41 cells counted were mono FMN CELLS 20 Mv13 Result Comment: result is a percentage 8 of 41 cells counted were poly
;b1(6)-2
L=Lo H=Hi *=Critical R=Resi s t S=Susc MS=Mod Susc I=Intermed ri.Uncert /A=Amended Comments= (0)rder, (I)nterpretations , (R)esult
@===. @
(b)(3)-1

26HPage 2

2003@1648H

Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
For: 24 Mar 03 - 26 Apr 03

(b)(6)-2
rt requested by:

(b)(6)-4
M(6)-4
M/8d
Ph: Military

25 Apr 03 @ 1101 (Coll)
STAT GLUCOSE 204H-. (76-110)

HH
TSH SENSITIVE .H. TNP (0.325-2.659)

.HH
Result Comment:H

DUPLICATE ORDER SEE TFT RESULT. (b)(6)-2
25 Apr 03 @ 0432 (Coll)
STAT WBC H15.9H(4.8-10.8)

H

RBC H3.1H(4.7-6.1)

L

HGB H9.7H(14.0-18.0)

L

L (42-52)

HCT H28.7H

MCV H91.9 (80-94)
MCH H31.0 (27-32)
MCHC H33.7 (31-37)
RDW H14.3 (12-14)

PLT CNT H736.0H(150-450)

H

@ 0505. (b)(6)-2

NOTIFIED LCDR (b)(6)-2

Result Comment:H

MPV H8.0

(b)(6)-2

NEUT/100 WBC H78.5
NEUT% H12.5
LYMPHS/100 WBC.H15.6

.
LY# H2.5
MONO/100 WBCH5.9
MO# H0.9

25 Apr 03 @ 0432 (Coll)

STAT NA+ H152 H
K H4.3
CL-H120 H
CO2 H24
BUN H37 H
GLUCOSE H242 H
CREAT H1.4

25 Apr 03 @ 0432 (Coll)
ASAP VANCOMYCIN H6.3

24 Apr 03 @ 2228 (Coll) Accession comment: CSF TUBE#3 by: ;b)(6)-2
EnteredHon 24 Apr 2003@2228

STAT GLU BFH117.0
PROTEIN BF H45.0

(7.4-10.4)
(137-145)
(3.6-5.0)
(97-107)
(22-31)
(9-21)
(76-110)
(0.8-1.5)

(15-40)

Reg #: M(6)-4
Unit: UNKNOWN

SERUM
mg/dL
MCIU/ML

BLOOD
K/UL
1X10 6/UL
g/dL

fL
Pg
g/dL

lx10 3/UL

FL

\-96

1)(10 3/UL

lx10 3/UL

lx10 3/UL

SERUM
mmol/L
mmol/L
mmol/L
mmol/L
mg/dL
mg/dL
mg/dL

SERUM
ug/mL

CEREBROSPINA

mg/dL
mg/dL

R=Resist S=Susc MS=Mod Susc I=Intermed
=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

L=Lo H=Hi *=CriticalH

Ir.)(3)-1 26 A,. 2003@1648 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579) PAT INT LAB IICUIB' Fnr.: 24 Mar 03 - 26 Apr 03 Re--rt requested by: r6)2
(b)(6)-4 Ph: "b)(6)-4 HI M/8d Reg #:1"6)-4 I Military Unit: WkNowN
26 Apr 03 @ 1324 (Coll) Order comment: right arm BLD CULT PENDING BLOOD(BLOOD)
26 Apr 03 @ 0522 (Coll) PHENMOIN 9.4 (10.0-20.0) ug/mL SEFLM
25 Apr 03 @ 1 101 (Coll) T4 FREE T3 TSH SENSITIVE 1.13 .50 1.0 7 (0.91-1.44) (0.50-1.26) (0.325-2.659) SERUM NG/DL NG/ML MCIU/ML

H

25 Apr 03 @ 1 101 (Coll) SEFLM TSH SENSITIVE . . . "MP 2.659) MCIU/ML Result Comment: DUPLICATE CRDER SEE TFT RESULT
24 Apr 03 @ 2225 (Coll) CSF (CEREBROSPINA) Accession comment: CSF TUBE#2 Entered by: (b)(6)-2 on 24 Apr 200362226
Si. BF CULT PENDING
24 Apr 03 @ 2225 (Coll) OTHER(CEREBROSPINA) Accession comment: CSF TUBE#2
b)(6)-2
Entered by: ion 24 Apr 200362226
CRAM STA Final Report Gram Stain: NO CELLS NOTED. IC ORGANISMS NOTED.
24 Apr 03 @ 1714 (Coll) SPUTUM(SPUTIJM) RESP CUL: Intermediate Report Bacteriology Result: REFER TO bT 1104 FCR ID PND SENS.4/26/03
24 Apr 03 @ 1714 (Coll) ND(INTERNAL JUG) V\ND CULT PENDING
L=Lo H-Hi *-Critical R=Resist S=Susc MS=Mod Susc I=Intermed
rl-Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

— .udy Report Page 1 / 2—
Patient information
b)(6)-4
Patient Name:.
(b)(6)-4
Patient ID:.Patient Sex:.M Date of Birth:.18-Apr-03 Status: Pregnancy Status:.N/A Medical Alerts:.N/A Contrast Allergies:.N/A
Study Information
(b)(6)-4
Accession Number:
(b)(6)-2
Referring Physician: Reason For Study: WEAK IN LEGS, R/O LUMBAR FX Study Date:.25-Apr-03 Study Time:.1:25:00 PM
b)(6)-2@
Requesting physician:
Study Description:.L-SPINE (2)
Procedure code:.574
Procedure description:.L-SPINE (2)
Resource Name:.574
Modality:.CR

Report Information Report Status: APPROVED Diagnostic Code:.REPORT Impression:.APPROVED Interpretation Date:.25-Apr-03 Interpretation Time:.5:21:00 PM Interpretation transcribed:
AP and lateral views of the L-spine reaveal no osseous abnormality. There are
— . Ludy Report Page 2 1 2-----
a number of shrapnel fragments overlying the sacrum. Again noted is significant
amounts of colonic gas. The lateral is virtually unreadable due 1 patient
immobility and resultant inability to obtain a standard upright film.
:b)(6)-2
Report Author:
(b)(6)-2 divisior4b)(3)-1
Interpretation Ap rover:
ELECTROLYTEPROTOCOL
Do not institute if Creat 2.0
Potassium (KCl)
If K 4.0 meq/dl Give 40meq po as KDUR(1500mg)
If NPO or enteral feeds give 40meq 1V over 4 hours
Calcium (Ca) (This not the ISTAT Calcium)
If Ca++ 7.0mg/dI If Ca is less than 7, recheck with ISTAT, If ionized Ca is less than 1.15, give 1 amp Calcium Gluconate IV over 15 minutes
;
Magnesium 6VIgl
If Mg 2.0 mg/dl Give 2 grams Magnesium Sulfate IV over 30 minutes
Phosphorous (Po4) If P 2.0 mg/dl
Give 30nuno1 K204 in 250cc D5W or NS IV over 4 hours
W: 2300, C: 1150
MAG: 23% LOSSLESS
b)(3) -1

26 2003431648 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579) PATIENT LAB INQUIRY For: 24 Mar 03 - 26 Apr 03 Re-^rt requested by: :b)(6)-2
WM4 0)(6)-4 M/8d
Req #:Ph: Military Unit:
26 Apr 03 @ 1324 (Coll) BLOOD (BLOOD) Order comment: right arm BUD CULT PENDING'
26 Apr 03 @ 1020 (Coll) URINE OSMOLALITY. A 5 2 (50-1400) MOSMOL/KG
26 Apr 03 @ 1007 (Coll) SERUM OSMOLALIN }..2( (275-295) MOSMOL/KG
26 Apr 03 @ 0522 (Coll) Z BLOOD WBC 12.8 (4.8-10.8) K/UL RBC 2.8 (4.7-6.1) 1X10 6/UL H G B 8.8 (14.0-18.0) g/d1.
HCT 25.8 (42-52) MCV 92.2 (80-94) fL MCH 31.4 (27-32) Pg MCHC 34.0 (31-37) g/dL RDW. 14.3 (12-14) PLTCNT 632.0 (150-450) lx10 3/UL NPV 8.4 (7.4-10.4) FL NEUT/100 VABLI 74.7 NEUT% 9 6 lx10 3/UL LYMPHS/100 VABLI . 20.5
:b)(6)-2

LY# 2.6 lx10 3/UL MONO/100 WBC 4.8 MO# 0.6 lx10 3/UL
26 Apr 03 @ 0522 (Coll) SERUM PHENYTOIN 9.4 (10.0-20.0) ug/mL NA+ 154 (137-145) mmol/L
4.4 (3.6-5.0) mmol/L CL-124 (97-107) mmol/L CO2 25 (22-31) mmol/L BUN 24 (9-21) mg/dL GLUCOSE 128 (76-110) mg/dL CREAT 1.2 (0.8-1.5) mg/dL
25 Apr 03 @ 1101 (Coll) SER.IV1 T4 FREE 1.13 (0.91-1.44) NG/DL T3 .50 -(0.50-1.26) NG/ML TSH SENSITIVE 1.0 (0.325-2.659) MCIU/ML
L=Lo H-Hi *=Critical R=Resi st S=Su sc MS=Mod Sus c I=Inte rmed =Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult
RESPIRATORY THERAPY TREATMENT SHEET
DATE: wavo 3 TIME: 0(oo 7.md
TREATMENT: U b aelat
PRE TREATMENT: HR-, RR-/6 , Sa02-?n POST TREATMENT: HR-/2q , Sa02-on RA. exii SPA LUNG SOUNDS:
PRE-ilmdgimVje2gs,fdrdaili:en.
POST-.0 41s
COUGH/SPUTUM: COMMENTS: Pi_id—tx_
otieed
1b)(6)-2
THERAPIST SIGNATURE: i/free/vsn/exr
DATE: vaiica TIME: 0 /00 TREATMENT: up (4,462.7,4)
,
PRE TREATMENT: HR-S a RR-kr, , Sa02-9 V. POST TREATMENT: HR-1 e, RR- /10 , Sa02- T7.'
cyll t9 hn LUNG SOUNDS: PRE-,.11) E red cpud,2,942
POST-rZ A
COUGH/SPUTUM: -6- c A . COMMENTS: 7°41 tra.//Ail. 0 ardite-C-A2 -49-0e7L;719 ilatLef 0
b)(6)-2

THERAPIST SIGNATURE: Ifettfr re.
DATE: yi,Ag,e).1 TIME: 4,, O 3 TREATMENT: of) caul/4 p
PRE TREATMENT: HR-97 , RR-AO , Sa02-41970 POST TREATMENT: HR- /0 a, RR-AO Sa02-797 ovQa. orn
LUNG SOUNDS:
PRE-dAi P)/$ ED) . daA4 +/a E___creid amodaiii POST-.a A 's COUGWSPUTUM: COU AL COMMENTS: (if /61/ Lteff_(_ %NO
luk]
b)(6)-2

THERAPIST SIGNATURE:
DATE: TIME: TREATMENT:
PRE TREATMENT: H R - ,R R - , Sa02-POST TREATMENT: H R - ,RR- ,Sa02-
LUNG SOUNDS: PRE-
POST-
-
COUGH/SPUTUM: COMMENTS:
THERAPIST SIGNATURE: ADDRESSOGRAPGH: ORDERING PHYSICIAN:
(b)(6)-4

DIAGNOISIS:
..
27 A 2003@0654 Page 1 Personal Data - Privacy M o1 1974 (PL 93-579) PATIENT LAB INQUIRY
For: 26 /Npr 03 - 27 Apr 03
13)(6)-2
RP -rt requested by'

Reg #: (b)(6)-4
',13)(6)4

M/9d Military Unit: UNKNOWN
Ph:
27 Apr 03 @ 0606 (Coll) TRACHEAL ASP(SPUTUM) RESP CULT PENDING
27 Apr 03 @ 0606 (Coll) OTHER(SPUTUM) CRAM STA Final Report Cram Stain: 1:13N FIMNS. RARE fVON.IDS. RARE GPM I N CLUSTERS AND PAIRS.
27 Apr 03 @ 0551 (Coll) BLOOD STAT V\E. 18.1 H (4.8-10.8) K/UL RBC 3.2 (4.7-6.1) 1X10 6/UL HGB 10.0 (14.0-18.0) g/dL HCT 29.0 (42-52) M3/ 90.1 (80-94) fL MJ-I 31.1 (27-32) Pg
MJ-IC 34.5 (31-37) g/dL EON 14.3 (12-14) PLT CNT 429.0 (150-450) lx10 3/UL
8.1 (7.4-10.4) FL NEUT/100 IABa 84 LYMPHS/100 VVBC . 10
MONO/100 VVBC 3
EOS/100 \AE. 4.0
BASO/100 1ABa 1.0
PLTEST NORMAL
MORFHOLOGY NORMAL (b)(6)-2

27 Apr 03 @ 0551 (Coll) SEM
STAT AMYLASE PENDING
LIPASE PENDING
BVP PENDING

L-Lo H-Hi *=Critical R=Resist S=Susc MS=Mod Susc I=Intermed r1=Uncert /A=Amended Comments- (0)rder, (I)nterpretations, (R)esult
2 /
LABORATORY 1-71-0H 27 Apr 2003@1237 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Lab Certified Result Notification
F )rt requested by: System Generated

M(6)-4
(b)(6)-4 (b)(6)-4

M/9d ph#
Mil. Unit: UNKNOWN

(b)(6)-2

Acc#: (b)(3)-1

Ordered by• Col: 26 Apr 2003a11836

OM-4

Specimen: URINE/CC (URINE) Pri: ROUTINE

rd#:

Resulting Lab: LAB Req Loc: IC2

UA CULT: Final Report

BACTERIOLOGY result(s): no growth

(b)(6)-2

2 /
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 27 Apr 2003@1314
Page: 1
RADIOLOGIC EXAMINATION REPORT

b)(6)-4

Patient: FMP/SSN; (b)(6)-4

MPH

DIAGNOSTIC RADIOLOGY X7420

Procedure: PORTABLE, CHEST (AP ONLY) Exam Date: 27 Apr 2003@1239

Requested by: M(6)-2 Status: COMPLETE
Ward/Clinic: ICU #2 1-78-2 X7257 Exam #: ffOk

pregnant:

Reason for Order:

R/0 INFILTRATES

Order Conunent:

NONE

Result Code: SEE RADIOLOGIST'S REPORT

Report:

Low lung volumes. Continued right lower lobe infiltrate. NG tube tip in
stomach. Shrapnel in lug abdomen. No other findings.

Transcription Date/Time: 27 Apr 2003@1312

(b)(6)-2

7 -erpreted by: CDR,MC,USN
brvised by:

)(6)-2
Approved by: (bCDR,MC,USN 27 Apr 2003©1314
Supervised by:

2 I
LABORATORY 1-71-0H 27 Apr 200381149 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
F )rt requested by: System Generated

;b)(6)-4
tom-4

M/ 9d roH ph#
Mil. Unit: UNKNOWN

mm-2

Ordered by: Col: 27 Apr 2003©1055 Acc# : i

r;3)-1

Specimen: BLOOD (SERUM)HPri: STATHOrd#: WP-4
Res Lab: LABH Req Loc: ic2
Order comment: NONE
Test nameHResultHNormal range

UnitsH
PHENYTOINH5.4 LH10.0 - 20.0

ug/mL

***H***

End of Report

ELECTROLYTE PROTOCOL
Do not institute if Creat 2.0
Potassium (KCl)
If K 4.0 meg/di Give 40meq po as KDUR(1500mg)
If NPO or enteral feeds give 40meq KC1 IV over 4 hours
Calcium (Ca) (This not the ISTAT Calcium)
If Ca44 7.0mg/d1 If Ca is less than 7, recheck .i,vitli ISTAT. If ionized Ca is less than 1.15, give 1 amp Calcium Gluconate IV over 15 minutes
I
Magnesium ' IfMg 2.0 mg/di Give 2 grams Magnesium Sulfate ry ovIr 30 minuter
Phosphorous (Po4) IfP 2.0 mg/di Give 30mmol 10)04 in 250cc D5W or N'S TV over 4 hours
(6)(6)-4
:6)(6)-4
;b)(6)-4
(b)(3)-1
2 /
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 27 Apr 2003@2121
Page: 1
RADIOLOGIC EXAMINATION REPORT

Patient: 1(b)(6)-4 MM-4
FMP/SSN:

b)(3)-1

COMPUTED TOMOGRAPHY
Procedure: CT HEAD W/O Exam Date: 24 Apr 200381405
Requested by: r)6 -2 Status: COMPLETE

Exam #: (b)(6)-4
Ward/Clinic: ICU #2 1-78-2 X7257

Pregnant:
Reason for Order:
R/0 CVA

Order Comment:
NONE

Result Code: SEE RADIOLOGIST'S REPORT

Report:

Compared with exam 18APR03. There is interval improvement of the sinus
mucosal disease - and interval clearing of the mastoids. No acute bleed,
infarct or fracture. However, there is mixed luccency near the mastoids which
could represent fracture(s) but was also present on prior exam before todays
event.

anscription Date/Time: 24 Apr 2003@1445

(b)(6)-2

Interpreted by: MD LCDR, MC ,USN
Supervised by:

Approved by: b)(6)-2 MID LCDR, MC ,USN 27 Apr 2003@2121
Supervised by:

b)(6)-2
W: 2300, C: 1150
MAG: 23% LOSSLESS
2 /

LABORATORY 1-71-0H 28 Apr 2003(0940 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
Priority Result Notification
ort requested by: :b)(6)-2

b)(6)-4 b)(6)-4 @ M/10d b)(6)-4
ph#
Mil. Unit: UNKNOWN

;b)(3)-1
Ordered by: (b)(6)-2 Col: 24 Apr 200301714 Acc#: (b)(6)-4
Specimen: WOUND (INTERNA) Pri: ROUTINE Ord#:
Resulting Lab: LAB Req Loc: I C2

WND CULT: Final Report

BACTERIOLOGY result(s): ACINETOBACTER SUSCEPT TO IMIPENEM AND AMP/SULBAC ONLY

ORGANISMS: (1) ESCHERICHIA COLI quantity: 100 COLONIES

(2)STAPHYLOCOCCUS SP (MAG. NEG.) quantity: 100 COLONIES

(3)ACI.NETOBACTER SP quantity: 100 COLONIES

(1) (2 ) (3 )
Mcg/mJ Jiterp Mcg/ml Interp Mcg/ml Interp AMIKACIN AMP/SULBACTAM I I AMPICILLIN R R CEFOXITIN S S CEFTAZIDIME I I CIPROFLOXACIN R R R R ERYTHROMYCIN R R GENTAMICIN R R IMIPENEM OXACILLIN R R PENICILLIN R R TETRACYCLINE S S TICARCILLIN R R TOBRAMYCIN R R TRIMETH/SULFATE S R R VANCOMYCIN
glg_1=)

*** ***

End of Report

2 1
Personal Data - Privacy Act 1974 (PL 93-579) Printed date: 28 Apr 200340832

Page: 1

RADIOLOGIC EXAMINATION REPORT

(b)(6)-4
Patient:m" FMP/SSN:

b)(3)-1
DIAGNOSTIC RADIOLOGY X7420
Procedure: PORTABLE, CHEST (AP ONLY) Exam Date: 26 Apr 200341752

b)(6)-2
Requested by• Status -COMPLFTE Ward/Clinic: ICU #2 1-78-2 X7257 Exam # : b)(6)-4
Pregnant:
Reason for Order:
TUBE PLACEMENT

Order ConEent:

Result Code: MAJOR ABNORMALITY, PHYSICIAN AWARE

Report:

Portable AP CXR cf 12 hours earlier.

New NG tube with tip in left lower lobe bronchus. Treating physician is
aware and has rectified the problem.

New bilateral lower lobe infiltrates, greater on the right. Upper lobes
c'-ar, Otherwise no change.

conclusion: New bilateral lower lobe pneumonia, right greater than left.
NGT malpositioned in airway.

Transcription Date/Time: 27 Apr 2003@0040

(b)(6)-2
Interpreted by: CAPT,MC,USN
Supervised by:

Approved by: b)(6)-2 CAPT,MC,USN 28 Apr 2003@0832 Supervised by: b)(6)-2

Doc_nid: 
3557
Doc_type_num: 
72