Transcript CLINICAL PATHOLOGY WORKSHEET

CLINICAL PATHOLOGY WORKSHEET
Collection Information
Type of Restraint:
Phys.
Accession #____________________________________
Chemical
Behav.
Date of Collection: Day______ Mo_______Yr______
Common Name:________________________________
ID #__________________________________________
Time of Collection:________:_________
Health Status:
Normal
Fasting Time:
< 2 hours
2-8 hours
8-16 hours
16-24 hours
Activity:
very low
low
variable
Abnormal
Hematology Tests and Results
24-48 hours
> 48 hours
RBC:___________ x 10(6)/mm(3)
HGB:___________gm/dl
elev.
highly elev.
kg
lb
HCT:___________%
Reticulocytes:___________%
indeterminate
Actual Weight:__________
Collection Site:
Jugular Vein
Cephalic Vein
Femoral Vein
Cardiac Puncture
Wing Vein
WBC:__________ x 10(3)/mm(3)
Segmented Neutrophils:___________%________/mm(3)
gm
Femoral Artery
Saphenous Vein
Ear Vein
Tail Vein
Other
Person Collecting Sample:_____ ______ ______
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)
Hematology Analysis Information
Fine Eos Granulocytes:___________%_________/mm(3)
Date of Analysis: Day______ Mo______Yr_______
Platelet Estimate:___________________
Time of Analysis:__________:___________
Granulated Thrombocytes:________%________/mm(3)
Time of Blood Smear:_________:_________
Laboratory:_______________________________
Automated Analysis:
Yes
No
Person Performing:______ _______ _______
Additive
EDTA
Heparin
Oxalate
Anticoagulant Form:
Sample Clotted:
Diff Quik
Citrate
Other___________
Not recorded
Dry
Yes
Liquid
No
Wrights Giemsa
Sample Appearance:
Sample too small:
Initial Conditions:
Hemolytic
May-Grumwald
Lipemic
Yes
No
Ambient
< 10 hours
Chilled
10-24 hours
Frozen
24-48 hours
>48 hours
Condition:
not deteriorated
deteriorated
Manual Differential:
Yes
No
Thrombocyte Estimate:__________________
Erythrocyte Sed Rate:________________/mm/hr
Total Protein (refractometer):______________mg/dl
Morphology
Occ.
1+
Mild
Mod
Marked
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:
CLINICAL PATHOLOGY WORKSHEET
Collection Information
Type of Restraint:
Phys.
Accession #______________________________
Chemical
Behav.
Date of Collection: Day______ Mo_______Yr______
Common Name:_____________________________
ID #:____________________________________
Time of Collection:________:_________
Health Status:
Normal
Fasting Time:
< 2 hours
2-8 hours
8-16 hours
16-24 hours
Activity:
very low
Abnormal
low
variable
24-48 hours
> 48 hours
Glucsose:________________________mg/dl
BUN:___________________________mgdl
elev.
highly elev.
indeterminate
Actual Weight:__________
Collection Site:
Jugular Vein
Cephalic Vein
Femoral Vein
Cardiac Puncture
Wing Vein
Chemistry Tests and Results
kg
lb
Creatinine:______________________mg/dl
Uric Acid:_______________________mg/dl
Calcium:________________________mg/dl
gm
Femoral Artery
Saphenous Vein
Ear Vein
Tail Vein
Other
Person Collecting Sample:_____ ______ ______
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
Chemistry Analysis Information
Cholestrol:_______________________mg/dl
Date of Analysis: Day______ Mo______Yr_______
Total Protein (C):__________________gm/dl
Time of Analysis:__________:___________
Total Protein (R):__________________gm/dl
Laboratory:_______________________________
Automated Analysis:
Yes
No
Total Bilirubin:____________________mg/dl
Person Performing:______ _______ _______
Amylase:_________________________IU/L
GGT:____________________________IU/L
BUN/Creatinine Ratio:________________mg/dl
Type of Sample:
Serum
Anticoagulant:
EDTA
Heparin
Oxalate
Anticoagulant Form:
Sample Quality:
Plasma
Citrate
Other___________
Not recorded
Dry
Hemolytic
Whole Blood
Liquid
Albumin:__________________________g/dl
CK:______________________________U/L
Globulin:__________________________g/L
Alb/Glob Rato:____________________
Lipemia
Extra Chemistry Tests:__________________________________
Sample too small:
Initial Conditions:
Condition:
Yes
Ambient
Chilled
Frozen
not deteriorated
______________________________________________________
No
______________________________________________________
< 10 hours
10-24 hours
24-48 hours
>48 hours
deteriorated
______________________________________________________
Comments:____________________________________________
______________________________________________________
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