1 / 2

CLINICAL PATHOLOGY WORKSHEET

Accession #____________________________________ Common Name:________________________________ ID #__________________________________________. Collection Information Type of Restraint: Phys. Chemical Behav. Date of Collection: Day______ Mo_______Yr______

korbin
Download Presentation

CLINICAL PATHOLOGY WORKSHEET

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Accession #____________________________________ Common Name:________________________________ ID #__________________________________________ Collection Information Type of Restraint: Phys. Chemical Behav. Date of Collection: Day______ Mo_______Yr______ Time of Collection:________:_________ Health Status: Normal Abnormal Fasting Time: < 2 hours 24-48 hours 2-8 hours > 48 hours 8-16 hours 16-24 hours Activity: very low low elev. highly elev. variable indeterminate Actual Weight:__________ kg lb gm Collection Site: Jugular Vein Femoral Artery Cephalic Vein Saphenous Vein Femoral Vein Ear Vein Cardiac Puncture Tail Vein Wing Vein Other Person Collecting Sample:_____ ______ ______ Hematology Tests and Results WBC:__________ x 10(3)/mm(3) RBC:___________ x 10(6)/mm(3) HGB:___________gm/dl HCT:___________% Reticulocytes:___________% Segmented Neutrophils:___________%________/mm(3) Neutrophilic Bands:___________%___________/mm(3) Lymphocytes:______________%_____________/mm(3) Monocytes:________________%_____________/mm(3) Eosinophils:________________%_____________/mm(3) Basophils:_______________%_______________/mm(3) Metamyelocytes:_____________%___________/mm(3) Nucleated RBCs:_______________________/100 WBC Azurophils:__________________%___________/mm(3) Coarse Eos Granulocytes:__________%_______/mm(3) Fine Eos Granulocytes:___________%_________/mm(3) Platelet Estimate:___________________ Granulated Thrombocytes:________%________/mm(3) Thrombocyte Estimate:__________________ Erythrocyte Sed Rate:________________/mm/hr Total Protein (refractometer):______________mg/dl CLINICAL PATHOLOGY WORKSHEET Hematology Analysis Information Date of Analysis: Day______ Mo______Yr_______ Time of Analysis:__________:___________ Time of Blood Smear:_________:_________ Laboratory:_______________________________ Automated Analysis: Yes No Person Performing:______ _______ _______ Additive EDTA Citrate Heparin Other___________ Oxalate Not recorded Anticoagulant Form: Dry Liquid Sample Clotted: Yes No Diff Quik Wrights Giemsa May-Grumwald Sample Appearance: Hemolytic Lipemic Sample too small: Yes No Initial Conditions: Ambient < 10 hours Chilled 10-24 hours Frozen 24-48 hours >48 hours Condition: not deteriorated deteriorated Manual Differential: Yes No Morphology Occ. Mild Mod Marked 1+ 2+ 3+ 4+ Anisocytosis Poikilocytosis Polychromoasia Howell-Jolly Bodies Target Cells Basophilic Stippling Hypochromis Rouleaux Formation RBC: Normal WBC: Normal WBC is estimate Morphology Comments:_________________________________ ______________________________________________________ ______________________________________________________ Reason for tests/Tests Requested:

  2. Collection Information Type of Restraint: Phys. Chemical Behav. Date of Collection: Day______ Mo_______Yr______ Time of Collection:________:_________ Health Status: Normal Abnormal Fasting Time: < 2 hours 24-48 hours 2-8 hours > 48 hours 8-16 hours 16-24 hours Activity: very low low elev. highly elev. variable indeterminate Actual Weight:__________ kg lb gm Collection Site: Jugular Vein Femoral Artery Cephalic Vein Saphenous Vein Femoral Vein Ear Vein Cardiac Puncture Tail Vein Wing Vein Other Person Collecting Sample:_____ ______ ______ Accession #______________________________ Common Name:_____________________________ ID #:____________________________________ Chemistry Tests and Results Glucsose:________________________mg/dl BUN:___________________________mgdl Creatinine:______________________mg/dl Uric Acid:_______________________mg/dl Calcium:________________________mg/dl Phosphorus:_____________________mg/dl Sodium:_________________________meq/dl Potassium:_______________________meq/dl Chloride:________________________meq/dl CO2:____________________________MMOL/L Alk Phos:________________________IU/L AST (SGOT):_____________________IU/L ALT (SGPT):_____________________IU/L Cholestrol:_______________________mg/dl Total Protein (C):__________________gm/dl Total Protein (R):__________________gm/dl Total Bilirubin:____________________mg/dl GGT:____________________________IU/L Amylase:_________________________IU/L BUN/Creatinine Ratio:________________mg/dl Albumin:__________________________g/dl CK:______________________________U/L Globulin:__________________________g/L Alb/Glob Rato:____________________ CLINICAL PATHOLOGY WORKSHEET Chemistry Analysis Information Date of Analysis: Day______ Mo______Yr_______ Time of Analysis:__________:___________ Laboratory:_______________________________ Automated Analysis: Yes No Person Performing:______ _______ _______ Type of Sample: Serum Plasma Whole Blood Anticoagulant: EDTA Citrate Heparin Other___________ Oxalate Not recorded Anticoagulant Form: Dry Liquid Sample Quality: Hemolytic Lipemia Sample too small: Yes No Initial Conditions: Ambient < 10 hours Chilled 10-24 hours Frozen 24-48 hours >48 hours Condition: not deteriorated deteriorated Extra Chemistry Tests:__________________________________ ______________________________________________________ ____________________________________________________________________________________________________________ Comments:____________________________________________ ______________________________________________________ ______________________________________________________ ____________________________________________________________________________________________________________

More Related