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N A T A L S P R U IT H O S P I T A L

- T O S S IN G O P E R A T IN G " C H A R S -j s ^ a z .

WARD: ____T . V . vV-r........ .. . DATE

PATIENT'S FULL NAME

HOSPITAL N O : . W . . .... AGE:

RACE

DR:

iTAL NO: . \ ."“i • i-{. • v i • i •... AUt-: s . .wj.. r\... SEX: .............

........... NATURE OF QPERATI ( ^ ^ ^ ^fi~fi'.X.

Result:Enema given: . Yes/No . t-r-. <.......... Time given: . r-..

Last feed gi v e n a t : . ........................... . 'amh/p.m.

Urine tested: ' Yes/No: ■ . . ............ Result: . .,.

'SIGNATURE: ............ (Responsible for the above)

5.

6 .

7.

8.

c

' Consent form signed: Yes/No~.. ......... .

Artificial teeth, eyes, lenses, limb remobed:

. .. time Quantity S.Patient, passed urine at

Patient catheterized atc ... . w W time Quantity: ............................

Any special pre-operative treatment given e.g. .<r?~rr?;.

Any pre-operative complications; e.g. blood pressure, haemoglobin:

&><?. . . . K - 3 . 9 .

-LINIESE VERPLEEGDOKUMENT O PSOMM ING GESONDHEIDSP'* N KONT/>' TE (NIE-VERPLEEGKUNDi A x

REKORD VAN GENEESKUNDIGE / AANVULLENDE GESONDHEIDSGROEPE BESOEKE ens. | | | REKORD VAN LAB. TOETSE / SPES. ONDERSOEKE / PROSEDURES |

Pasient C2^ ^ a Dr.<- <

xx N o m m e r van betrokko v o r m en toepasliko hlnrisy (Voorheold: T P H 114/6 p. 3) S.O.S.

:r>3

CL ‘KLINIESE V E R P L E E G D O K U M E N T : VERPLEEGBERAM ING— PEDIATRIE C LIN IC A L NURSING D O C U M E N T : NURSING A S S E S S M E N T— PEDIATRICS

ALGEMENE W AARNEM INGS / GENERAL OBSERVATIONS

L.W . VERSTREK VOLLEDIGEDATA B Y E LK E OPSKR/F N.B. SUBM IT COMPLETE DATA UNDER EACH HEADING

WYSE VAN AANKOMS IN SAAL o O r „ A MODE OF ARRIVAL IN WARD .D U S y e . C I U e r '

Vergesol deur / Accompaniedc j f b e J r S

ALGEMENE INDRUK VAN TOESTAND GENERAL IMPRESSION ABOUT THE CONDITION

HOOFKLAGTES \n , e mediese diagnose nie\ MAI N COMPLAI NTS ' n o ! medical diagnosis)

q l p r y ig j - ^ ,

BEWUSSYNSVLAK LEVEL OF CONSCIOUSNESS[M e ld ook pupilreaksie / A lso state p u p il reactionJ

Cct\&dc i d L

SIGBARE DEFEKTE VISIBLE DEFECTS

tk

HIDRASIEVLAK HYDRATION LEVEL

STEUNMAATREeLS REEDS INGESTEL SUPPORTIVE MEASURES ALREADY INSTITUTED

“ " I T U c W e .y t '

Beskrywino / Description

• i <Zc*Jbi sj^i (.4^ _________

TOESTAND VAN VEL EN HARE CONDITION OF SKIN AND HAIRN. B: M eldposis ie en omvang van enige vellelsels NB: Slate position and extent o f any skin lesions

VOEDINGSTOESTAND NUTRITIONAL STATE

UITSKEIDINGELIMINATIONUrinering / Urination

Stoeloano / Stools

Toiletonderria : Spesifiseer / Toile t tra in ing : specify

SLAAPPATROON SLEEPING PATTERN

VOORNAME EN VAN / NAMES AND SU' '<VME £ t e / y i A s J f c '

SINTUIGLIKE FUNKSIES SENSORY FUNCTIONS

MOBILITEITMOBILITYM eld graad van a fhanklikheid / State degree o f dependency

V

f\Ouers / Parents

K ind / Child

BASIESE BEHOEFTES BASIC NEEDSTipe voedinp Type of feea

Tye Times

Vaste kosse Solids

u , J I H i

Eet self / Eats by h imself____________/

SPESIALE SPEELDINjJ FAVOURITE TOY

Moet oevoer word To be fed

SPESIALE VERSOEKE SPECIAL REQUESTS

r e p -NO. | T \ DR- T .

TPH 114/2a

KLINIESE VER P LEEG D O K U M EN T CLINICAL NURSING D O C U M E N T

V

___________ TPH 114/1

HOSPITAAL/HOSPITAL fU -C b DISSIPLINE/DISCIPLINE C&J—— .... L .

r o l u lV | ^ AL/W AnpDEPAnTEMENTSHOOF/KONSULTANT HEAD OF DEPARTMENT/CONSULTANT L

VERPLEEGKUNDIGE OPNAME/NURSING ADMISSION

Pasient C T . . Patient V <VanSurname

VoorlettersInitials

AdresAddress

GeneesheerDoctor

Ouderdom Age

T d .N 0.70*1- / 10/ f a a t B

Privaat I 1 Private I___I

Hospitaal f ~ 3 f . Hospital 1^1 ]un

OPNAME EN SAALTOELATINGSCHRONOLOGIE ADMISSION AND W ARD INTAKE CHRONOLOGY

Aankoms in Saal A rriva l in WardGeneesheer verw ittig (Saal) Doctor notified (Ward)

Gc.ieeskundige aandan verkry (Saal) Medically attended to (Wi-rd)

Aanvangs van Vooroeskrewe Behandeling (Saal) Commencement of Prescribed Treatment (Ward)

Neel I Verw ittig No I___ I Notified

Familie bewus Family aware Yes

DatumDate

( 9 6

( p g

Tyd T ime

2£> c:O O

o~ C >

Geteken (Verantwoordelike Persoon) Signed (Responsible Person)

\ s -

i w i e _ U w

BVKOMENDE BESONDERHEDE ADDITIONAL PARTICULARS

Bespreekte geval Booked case

Mediese Fonds en Nr. Medical A id and No.

Onbespreekte geval Unbooked Case

Kerkverband en Gemeente Religion pnd Congregation

Nood - Direk Urgent - Direct

Huistaal Home Language

Pasient Positief geidentifiseer Patient Positively identified

RasRaceHuwelikstaat Maritai StateOPNAMEDATUM DATE OF ADMISSION

W

G /M

K /C

E/S W

S/B W it identifikasieband aangesit W hite identification band applied

GeskeiDivorced

Geel allergieband aangesit Yellow allergy band applied

VOORLOPIGE DIAGNOSE PROVISIONAL DIAGNOSIS

TydTime

Ligroos operasieband aangesit Pink operation band applied

(o g JMedicalert-skyfie aan pasient Medicalert disc on patient

NOODKOMMUNIKASIEEMERGENCY COMMUNICATION

Dag/Day N ag/N ightTelefoonTelephone

Kode/Code No. Kode/Code No.

& en

Medisyne in besit van pasient Medicine in possession of patientEnige middels verklaar of gevind? Any drugs declared or found?

r f OIndien ' ja ' is dit:If ' yes' were they:

By pasient gelaat Left w ith patientIn bewaring geneem Taken into custodyAan fam ilie oorhandig

■ Handed over to relatives

JaYes

NeeNo

Lys van Middels List of Drugs

In bewaring geneem deur Taken into custody by

Naam en Rang Name and RankTerug ontvang deur Received back by

VOORGESKREWE ADM IN I STRATI EWE PROSEDURES NAGEKOM PRESCRIBED ADMINISTRATIVE PROCEDURES CARRIED OUT____m.b.t. 1 Klerasie oorhandig vir volledige bewaring (Klerekamer) i.r.o. Clothing surrendered for safekeeping (K it Room)

Naasbestaar.de Next of Kin

2 Geld en kosbaarhede v ir volledige bewaring (Kassier) oorhandig * Money and Valuables surrendered for safekeeping (Cashier)

TaalLanguage

VerwantskapRelationship

1 Artikels op eie risiko deur pasient gehou Articles kept at own risk by Patient

AdresAddress

1 Spalke en Toestelle van elders ann/by pasient ~"Splints and Appliances from elsewhere on /w ith Patient

oen/ofand/or

(Kyk bo) aan familie vir verwydering oorhandig 1

NvtN/a

-1-

JaYes

Verantwoord op (Kwitansie ot bewys) Accounted for on (Receipt or Voucher No.)

SERTIFISERINGCERTIFICATION

p a s iEn t AKUUTHEIDSVLAKKE PATIENT ACUITY LEVERS

Verpleegkundige opname deur Nursing admission by \ |

DatumDate /

1 Klas •— Class

Handtekening en Rang fzA /lfr Signature and Rank f -1 r f)Bair C* TlS. _______P-l,i /-AVerantwoordelike verpleegkundige Responsible nurseHandtekenina en Rang Signature and Rank

TelefoonTelephone

Dag/Day

Kode/Code No

Alternatiewe Persoon Alternative PersonTaalLanguage

AdresAddress

N ag/N ight SPESI ALE VERSOEKE SPECIAL REQUEST

ode/Code No.

' 'erwantskap Relationship

l b.S '

TPH 114/1

v E r p l e e g o u d itr j ,j f i o : ' ' i , : LA U D iT _

%

-?•• :;V v .V •;’ •;'•• • \ : ;v^ >

■/■ ; v

.H osp italT.P.H. 91

SWArAtROL C - u. /

This fonn, duly com p leted an d signed, m ust b e p laced In each p a ck of sw abs prepared .

TYPE O F SW A B NUMBER OF B U N E fcfiS^ (___

A bdom inalL arg e .. 3 ° r i $ 'J ^ S ^

S m all( -

D issectingL arg e t q i s -

Sm all

PaintL arg e PSm all

,—r— 1--------

Tonsil

A

L arge..........4 .........i ..._ z _ r ........................

S n ia ll

_ >, - - ,

I, the undersignfed.. h ereb y certify th at this pack contains the item s stated ab ov e, th at I h av e ch eck ed ea ch bu ndle and that each bu ndle contains five (5) sw abs.

1. S ign atu re ....2. S ign atu reU v i2 _

Rank _______ .............................. If ia .

' w s s s s s 0 g m % u 7 ^ - - s

M

D ate

m m mm V»-» m

• rS v : -m *

KATALSPRUIT HOSPITAL NS. 131

PRE-OPERATIVE THEATRE FORM

• PRE-OPERATIVELY

Patient's name and surname: E y £ 0 4 n ............ ..................................................

Registration number: J fn a v f7*,....:;................... .................

Ward: C A W . A W t t ......................................

Age: ,. ..................................

Sex: .. H *r^r.........................

Mature of operation: PJy A r.

Surgeon: .1^.. . ^ M W V .......................

Date and time seqt.for: .P&f. ... !£>.•’. Bfi.

Signature: .............................................

of arrival of stretcher in ward: . ■ l^VK^V.C'!.......................

Time of departure from the ward: ........................................

Signature of officer: ................................

Time of arrival in theatre: ...........................D.f).................Patient checked and received by: .... iTTrrT................................

POST OPERATIVELY

( RECOVERY room

Time of arrival: .........?K.‘. .........

LEVEL OF CONSCIOUSNESS COMPLICATIONS

Jnconscious - Pr6S6n*tSemi conscious ^ - If present state nature and

- Conscious _ action

- Not present v—"

BLOOD PRESSURE ? BL0(JD pR£SSURE QN DISCHARGE(Rate /0 2 _ -fe yV^ Kite]

. - Pulse: Rythm - Pulse : Rythm)- Bleeding ^o+ hj#ec/ Cynosed) ~ ,

BREATHING - Colour: Pale ) -— *Endotracheal' tube ^ 1 —

- Airway _ - Level of consciousness: Spontaneous breathing — Unconscious

DRAINAGE Semi-conscious. Conscious- Urinary _ 3 c>0<u/-5 C___________________-- Porto vac -

- Others N - h i b L Jz?Out/s - Muscle tona: Can lift headc_^

COLOUR Can 9“ip <_-

- Cynosed _

- Pink L / Aka&UhSl- % & Uadfie/'c/. ■

DISCHARGED BY: ................ ..... TIME OUT: ............... TRANSFERRED OUT B\y * V ........................................

///

N! r 95398THE SOUTH AFRICAN IN STITUTE FOR M E D IC A L RESEARCH

i

d ° c t o r n ‘ d & iDOKTFR U t O L M M j > r n k j u

' AODFjESSADRFS S l ss K S H

ons. TEL. UO/NR. POSTAL CODE POSKODE .

EMPLOYER/WEflKGEWe/7 POSTAL, CODEP O S K O C g j ^

TEL NO./NR.

HOSPITALHOSP

WARD I “X HOSP. CLASS L I S-dil/ ^ HOSP K1 AS ' /N ■

(■' O '"tr E S l b 7 ^ - 7 h ' vCD

TOWf. ro _ STAD ■

aRACE SEX DATE OF BIRTH *1 0 L| T.S RAS GESLAQ G F BOOR TE DATUM j

r

1 1 . 6 l - l ■ HT/t WBC

f 3 • 4 3 L* 10 " / t RBC

r—4

CO

r— s

g /d t Hb

• . . . ' j i s 3 I . . . RATIO Hct

1 0 5 • 9 HIt MCV

3 4 . 4 I - pg MCH

; 3 2 . 5 var MCHC

RDW

< 10*t PLT

% Pet

• i t MPV

• PDW

39407Perso.Perso<.

; MAIALSPBUtluvtanng

m e d ic a l a idMEDIESE FONDS .

MED AID NO. MED. FONDS NO..

SPECIMEN £ \ 1 r >

TIGATfbAlINVES ONDERSOEK.PROV. DIAGNOSIS p_L= ,l /k , VOORLOPIGE DIAC3.G rftlfc> £^eK_f>

COLLECTION DATE DA TUM

INSAMELINCS

S f l t f p J . \T d J 3 t - ° _ g _

DIFFERENTIAL LEUCOCYTE COUNT DIFFERENSI^LE LEUKOSIETTELLING

% * 10*/t .■

NEUTROPHILS - - NEUTROFIELE

MONOCYTES i MONOSIETE -

»•LYMPHOCYTES ' , LIMFOSIETE

EOSINOPHILS - i EOSINOFIELE

BASOPHILSBASOflELE

-NORM06LASTS100 LEUCOCYTES NORMCBLASTE/100 LEUKOSIETE ‘ ;

STAFFCEILS

METAMYELOCYTES

MYELOCYTES

PROMYELOCYTES *

BLASTBLASTE

RETICULOCYTES „ RET1KUL0SJETE %

WESTERGREN mm IN ONE HOUR mmlNEENUUR

Guillemot 11879 ^ 035-2001

FILM COMM ENTS BLOEDSMEERKOI^MENTAARErythrocytes EntrosieteNormocytosrs..........Nor mochromia........ . . NormochromieAmsocytosis............Microcytosis..........Amsochromia.......... AmsocfvomieHypochrornia.......... HijjochromieBasophilia Basnfdx?

Punctate.................. ............. Gesti|){x‘kiPoikilocytosis Tear drop.......... . . . 1 raanvrxniKj P(Mklositose

Perv.il . . ». .............StifselBurr Cells................ .................Burselle

Fragmentation (Tyfx*l. .................... Ft •qriH-nHrrimj ( T i| m*)Macrocytes Round......... . Rond Makrosiete

Oval . OvaalRouleaux Formation Hi Nrlt*anxv(irmirH|Auto agglutination. Onto a<|i|HitinasMrHowell Jolly Bodies HowHl JollyliqtjamoHein/ Bodies.......... J i/lujtjariM.'Spherocytes SfrrrosMrti:Target Cells......... ! 1 eikenselleElliptocytes............. V

...................... 1 Elh|)tosH*te

Leucocytes VLeukosiete

Neutrophils Left Shift . . Linksverskuiwirx'i NtmtrofHik*Riyht Shift. R*;qsv«rrskuiwintj

Toxk Granulation........................... ...................... Inksrese KrxrefwxjAtypical Lymphocyt fS ........................................ Atifjujsi? Limfosiete

Platelets\1 Plaa^es

Morphokxjy Normal............... ...............Normaal MorfokxjN.Abnormal.............. Atmnrmaal

Nun ilx*r Normai . . . . .............Nrxmaal AantalDecreased ........... VermiixJr^llrK;reaserJ. . . ......... Verrneerderd

N O TE C O M M E N T S :X *

O VERLEAF

N O TEER K O M M E N T A A R : V O M M E S Y D E

6 0 : 5 1 6 - tU V 7 6 .

PW0487

Note that results are now expressed in S1 units. Numerical values remain the same w ith the exception of the platelet count and Haematocrit.

Let op dat resuhate nou urtgedruk word in S.I. eenhede. Waardes bty dieselfde met die uitsondering van die plaatjietelling en hematokrit.

r OF HAEMATOLOGY 1 *0 .0 0 6 AFDEIHG

FOR DIRECTOR / NAMENS DtflEKTEUR

' -NAP ( 94)

bpm 96!

MiHs&bPi# 20 50 100 150 200

ii ii ii An ii ii ii «i ♦

BP 144/ 62 17:33MAP ( 93) ►...0.....

bpm 98 *

EP 145/7? 17:30MAP (109) ►nHiiii0miiiii

bpm 93 *

minHs&bPBi 20 50 100 15@ 280

PATIENT’S NAME

PHVSICIAN’S NAME

PROCEDURE /I / /

DATE

COMMENTS

/6 ?

CRITIKON DINAMAP 1846P VERSION 031

-Nf 9 5399THE SOUTH AFRICAN INSTITUTE FOR M ED IC AL RESEARCH 111 n

DIE SUID-AFRIKAANSE IN STITU U T VIR MEDIESE N AV O R SI^C N° 3 g ^ q q

DOCTOR 30KTER _

5.0DRESS 10RES :

C 1 1 ) i ' c .— A e V

HOSPITALHOSPITAAL.

■ VTOWN .0 3 7”

. aSTINGVASTEND

PATIENT PASIENT. IV I n r a k J L ^

ADDRESS AORES . ! * S H

.IRS. TEL. NO/NR. POSJ>»-eODEp OZk o d e

e m p lo y e r /WERKGEWER ■posta l- c o d e p o sK 0 b e '.‘ ,

TEL NO ./NR. /

WARD SAAL _____

HOSP. NO. HOSP. NO..

HOSP. CLASS .HOSP. KLAS .

RACE RAS _

SEX . GESLAG

DATE OF BIRTH ^ >c£.GEBOORTEDATUM _ f Z _ _ j .

Pb---- ' MrALSPSUflPersoon verantwoorovn*

MEDICAL AID MEDIESE FONDS_______

•• -..~n n g

MED. AIO NO. MED. FONDS NO..

SPECIMEN ptO N S T E R ______

Tnv^ t ig a t io nONPERSOFK

J ~ rt p cp c J

U 4 €

PROV. DIAGNOSISVOORLOPIGE DIAG.

COLLECTION DATE DATUM

-LECTION INSAMELINGS ME

.TYD

YES NO

C H E M IC X l P A T H O L O G Y REPORT C H E M IE S E P A T O LO G IE VERSLAG

SERUMM ocroscop ieMakroskopies □Haemolysed

Gehemoliseer I I UI___I U

Lipaemiclipem ies

received o n o n tvan g op

- — - - - - - '

Icteric J Geel

date of report datum v a n VERSLAG

F class n o .

TESTTOETS

RESULTUITSLAG

REF VALUES 'VERW.-WAARDES

CLASSNO.

TESTTOETS

RESULTUITSLAG

REF. VALUES VERW.-WAARDES

3325/ 3335PotassiumKalium 3.3 - 5.0 m m ol/2 2780

2775Tot. Bilirubin Tot. Bilirubien , < 2 1 m ol/ 2

SodiumNatrium 135 - 147 m m o l/ i 2785

2786Dir. Bilirubin Dir. Bilirubien < 5 mol/ 2

28402845

C hlorideC hloried i o X .

9 9 - 1 1 1 m m ol/2 33503355

Tot. Protein Tot. Proteien 55 - 85 g/2

28902895

Content 1 Inhoud D - Z

1 8 - 2 9 m m ol/2 26952700

Album inAlbumien 35 - 50 g /2

34553450

Urea-Ureum

f i t ..2.6 - 7.0 m m ol/2 3295

3290Aik. Phosphatase Aik. Fosfatase

29602955

CreatinineKreatinien

/ / M: < 130 nmol/2 F/V: < 110 (jmol/S

30403035 GGT

3255 O sm olalityOsm olatite it 280 - 295 m osm /kg 2685

2680 ALT

30203015

G lucoseGlukose

Fasting/Vastende 3.0 - 6.0 m m o/2

27552750 AST

4060 GLYC haem og lob in < 8 % 29252920 CK

29302935 CK - MB

3465 “ 3460

Uric Acid Uriensuur

M: 0.22 - 0,45 mmol/J F/V: 0.15 - 0.35 mmol/S

31253130 LD

28152825

C alc iumKalsium 2.15 - 2.65 m m ol/2 3055

3060 a - HBD

33153320

Inorg. Phosphate Anorg. Fosfaat 0.8 - 1 . 4 m m ol/2 3280

3287Tot. Acid Phosphatase Tot. Suurfosfatase

32053210 M agnesium 0 . 6 - 1 . 1 m m ol/ 2

32853286

Prost. Acid Phosphatase Prost. Suur Fostatase

3185 LithiumLitium

Tnercipeuiv: Ronge Te<ooeuftese VloWce 0 6 - 1 . 2 mmol/ 2

27252730

AmylaseAmilase

34353440

TriglyceridesTrigliseriede < 2 . 0 m m ol/ 2 3264 pH 7.3 - 7.43

28552850 Cholesterol 'See Age Related Ref

Ranges Attached Po3 9.3-11 KPa

31003105

IronYsler

M: 14 - 31 ^ mol/2 F/V: 11 - 29 y mol/2

26652670 PCOj 4,7 - 5,6 KPa

31103115

TJ.B.C.T.Y.V.K. 45 - 74 v mol/£ Std. Bicarbonate

Std. Bikarbonaat ^ ® ° n 2 2 m m ol/ 2 Gem

4140 % Saturation % Versadiging

M: 20 - 501 F/V: 15 - 50*

Base Excess Basis Oorm aat - 2 !° , + 1 mmol/ 2 tot

34253430

TransferrinTransfemen U - ¥ f C I £ V 7 -

0j Saturation 0 , Versadiging

9 6 -9 7 *------ n -------

DATE/DATUM

T1ME/TYD

TELEPHONE/

GETELEFONEER

CHECKED

NAGESIEN

B »p o rt w c t / w d b y ./ V ts lo g o n tva n g d o u r.

SAJMR P.441609 R n lM d 5/91

D. :OLOr r ’ A N 's v

Z~\jT' ' I t

f o r D i r e c t o r / N a m * n t D ir& k tm jr

«-'•*! >> :■ -

THE SOUTH AFRICAN IN STITUTE FOR MEDICAL RESEARCH

cl cl O _____ ___________

JR / 0 / L C < i ^ 5 " S r £tSLl*r> m e t b ^ *Dr. A. J. Arain

: m r r ^ ^Pakistani

/ADDRESS ADRES . - .

................ '9?El. n o / n r . POSTAL C O D E____

POSKODF ------ -^MPLOYER/WERKGEWER POSTAL CODE/-’Xi>

POSKODE r >

TEL NO ./NR.

t a l WARD / -s HOSP. CLASS / / . CAAI t r j~ HOSP. KL.AS I I I

2 °£ IS 3 i

----------- - .vO . -------------- ;---------RACE SEX /^DATE OF BIRTH l j £ R4.C ' j CiFSl AG 1 GEBOO RTF DATUM f v

# V

< N° 3 9 1 1 0NATALSP«UI1

MEDteAtrvviD MEDIESE FO NDS.

MED. AID NO. MED. FONDS N O ..

;im e n MONSTER.

INVESTIGONDERSOEK________PROV. DIAGNOSIS VOORLOPIGE D IAG.

COLLECTION DATE DATUM_

INSAMELINGSTIME. rra_________

TINGrASTEND

SERUM

YES NO

M acroscopieMakroskopies

C H E M IC A L P A T H O L O G Y REPORT C H EM IE SE PATO LO G IE VERS LA G

□ Haemolysed Li|

Gehemoliseer |_____| Li|

RECEIVED ON ONTVANG OP

. /f^o rm a l Normaal

LipaemicLipemies □ Icteric

Geel

DATE OF REPORT DATUM VAN VERSIAG

CLASSNO.

TESTTOETS

RESULTUITSLAG

REF. VALUES VERW.-WAARDES

CLASSNO.

TESTTOETS

RESULTUITSLAG

REF. VALUES VERW.-WAARDES

3330 / 3 3 3 5

3325 / J J J 5

PotassiumKalium V L

3.3 - 5.0 m m ol/2 27802775

Fot. Bilirubin Tot. Bilirubien < 2 1 u m o l/ 2

3370/ 3 3 7 s 3365 /

SodiumNatrium

1 /

/ Z L135 - 147 m m ol/2

27852786

Dir. Bilirubin Dir. Bilirubien

< 5 y m o l/2

28402845

ChlorideChloried

9 9 - 1 1 1 m m ol/2 33503355

Tot. Protein Tot. Proteien

55 - 85 g /2

28902895

r n Content Inhoud a ~ i

1 8 - 2 9 m m ol/226952700

AlbuminAlbumien

35 - 50 g /2

34553450

Urea-Ureum

2.6 - 7.0 m m ol/232953290

Aik. Phosphatase Aik. Fosfatase

29602955

CreatinineKreatlnien

----------- 7 i_M: < 130 fjmol/S F/V: <110 ymol/B

30403035 GGT

3255OsmolalityOsmolatiteit

280 - 295 m osm /kg26852680 ALT

30203015

GlucoseGlukose

Fasting/Vastende 3.0 - 6.0 m m o/2

27552750

AST

4060 GLYC haem og lob in < 8 %29252920 CK

29302935

C K - M B

34653460

Uric Acid Uriensuur

M: 072 - 0.45 mmol/2 F/V: 0.1S - 0JS mmol/2

31253130 LD

28152825

C alciumKalsium

2.15 - 2.65 m m ol/230553060 a - H B D

33153320

Inorg. Phosphate Anorg. Fostaat

0.8 - 1 . 4 m m ol/2 32803287

Tot. Acid Phosphatase Tot. Suurtostatase

32053210

Magnesium 0 . 6 - 1 . 1 m m ol/ 232853286

Prost.Acid Phosphatase Prost. Suur Fosfatase

**3185 Lithium.Uttum

27252730

AmylaseAmllase

34353440

TriglyceridesTrigliseriede

< 2 . 0 m m ol/ 2 3264 pH 7.3 - 7,43

28552850 Cholesterol

"See Age Related Re( Ranges Attached

Po39 .3 -11 KPa

31003105

IronYster

M: 14 - 31 V mOl/2 F/V: 11 - 29 m mol/2

26652670 PcOj 4.7 - 5.6 KPa

31103115

TJ.B.C.T.Y.V.K.

45 - 74 n mol/2Std. Bicarbonate Std. Bikarbonaat

M ean ^

4140 * Saturation 4 Versadiging

Z O : 9 1 2 ■ « m 50V C .F/VTT5 - 50?

Base Excess Basis Oormaat

- 2 !° , + 1 m m o l/ 2 tot

3425 Transferrin 1.9 - 4.3 g/B0, Saturation 0, Versadiging A

96 - 9 7 \

A )

DATE/DATUM

T1ME/TYD

TELEPHONE/

GETELEFONEER

C H E C K E D

p . p . k ; , v _r j , - i . .V lA G E W E N

1..

.7? 55875 0THE SOUTH AFRICAN INSTITUTE FOR M ED IC AL RESEARCH

DIE SUID-AFRIKAANSE INSTITUU T VIR MEDIESE NAVORSING

DOCTOR DOKTER .

-Dr. Q & / k I i f fADDRESS ADRES _

r aMBBS (Pakistan)

ORS. TEL. NO/NR POSTAL CODE pnsKnnF------

HOSPITALHOSPITAAL.

TOWI> OO STAD O

P ^ r / T h k o e ^ ^

ADDRESSAHRFS

EMPLOYER/WERKGEWER POSTAlCCDDE P O S KC m / j p

TEL NO ./NR.

WARD / SAAt ' &

HOSP. CLASS// fHDSP Kl a h n - L -

/ % >RACE flAS _

DATE OF BIRTH GEBOORTEDATUM

MED. AID NO. MED. FONOS NO.

SPECIMEN fyO N S TE R .

i N v e i f u w i o N ONDERSC

•^P-i o o c /

F £ C ~PROV. DIAGNOSIS VOORLOPIGE DIAG.

COLLECTION

M W " l M / 9 l TZ CINSAMELINGS

CDCO r

• O a ao » 3

^ 5

o i

r

* I OP COOES COMMENTS/KOMMENTAAR

1 6 • 5 H * i< r/c WBC

* 10” / f R8C

1 4 • 5 g/d t Hb *•1• 4 5 7 RATIO Hcl

1 O 5 • 6 H It MCV J3 • 6 I I pg MCH y.

3 .1 • fci L._ OAJf MCHC. ROW

•o*? PIT *% Pci

• 1C MPV• PDW

DIFFER EN TIAL LEU C O C YTE C O U N T D IFFER EN SlSLE LEUKOSIETTELLING

* 10*/f

NEUTROPHILSNEUTROFIELE

MONOCYTESm o no s iete

LYMPHOCYTES . ' LIMFOSJETE

e o s in o p h ils : : EOSINOflELE \

b as o p h ilsBASOFIELE

NORMOBLASTS/100 LEUCOCYTES NORMOBLASTE'IOO LEUK0SIETE

STAfFCELLS J

METAMYELOCYTES *

MYELOCYTES •

PROMYELOCYTES • ~

BLASTBLASTE ;

RETICULOCYTES v < RETIKULOSIETE %

WESTERGREN mm IN ONE HOUR J mm IN EEN UUR '!Guillenx* 11879 IT 835-2001

FILM COMMENTS BLOEDSMEERKOMMENTAARErythrocytes EritrosieteNormocytosis.................................. NormositoseNormochromia................................ . NormochromteAnisocytosis.................................... ....... AmsositoseMicrocytosis.................................... Mikrositose

Hypochrornia.................................. HipochromieBasophilia Diffuse........... ............. Verspreid Basofilie

PuiKtate....... ........... GestippeldPoikilocytosis Tear drop........ ......... 1 raanvormig Poiklositose

Pencil........... ...................Stifsi.-IBurr Cells. . . ................. Bursello

Fragmentation (Type)................. ........ ........... Fragm«*nterwK| (Tij)f*)Macrocytes Rouivi........... ...................Rond Makrosiete

Oval. OvaalRouleaux Formation........... R(Hil«!iiuxvofmingAuto agglutination. ()llt»> >111(|llit l lU lS H *

Howell Jolly Bodies H i iwHI Jt iliyligUtimeHein/ Bodies. ..................... HiMii/lKjijamfSpherocytes . SferosHrteTarget Cells. 1 f.*iki*nselleElliptocytes................................ Ellipiofyetc

Leucocytes LeukosieteNeutrophils Left Shift. Linksv«.*rskuiwing Neutrofmk?

Right Shift. Ri.*gsvi?r skin wingToxic: Granulation................. . . . . Tr>ksiese Korrehng

Atypical Lymplxxiytes................. ....................... Aiijxese Limlosieie

Platelets PlaatjlesMorpfiology Normal . . . . . Normaai Morfokxjw.

Al>normal. . . . ........ . AlmormaalNumber Normal.......... .................Normaai Aantal

Decreased ........... VerminderdIncreastxJ. . ..........Vermeerderd

NOTE COMMENTS: OVERLEAF

NOTEER KOMMENTAAR:h

OMMESYDE

f e D L i l i 8 - t ld V Z 6 .

Note that results are now expressed in S1 units. Numerical values remain the same w ith the exception of the platelet count and Haematocrit.Let op dat resuhate nou urtgedruk word in S.I. eenhede. Waardes Wy dieselfde met die uitsondering van die IAMFNS CXRfKTFUfl

" I

* j

*m t .p .h . 1 P A T IE N T N O .

I NAMES AL

iSS— UNE-1

- 2

____________________

f / M . - y , * \ / < e , , , ~ , , ,

s i i i i____ i i____ i £ ~ i ( / i ^ M «

J = J =

P « . IN C H A R G E

IO E N T IT V /frO .

i I____ I____ I____ !____ I—___l____ I------ 1------ 1_ , I,

- I-------L- _l____ L _J____ !_

______L _____L_ - I____ L_ I I

/ ■ I , 1 11 . f X h - , L ,fh P \ u . . <S,g , c ,7~,i ,o ,

-J----- r-U- — *— *— — 1— r — r — r — 1— H — r 1 ■ i 1 ■■ ■ 1 i 1— 1— ! t - - .- 1— — — 4— 1— L-r i t I ‘ ^ex M j F Race W C | A | B | M arita l state M S | W | D Age in Years(

O A T » QP y ) M IS S IQ N

T IM E O F A D M IS S IO N

C L A S S IF IC A T IO N

REC L A S S IF IC A T IO N

' 2

1 L 3 a 7

7O A T 1 QF W E C C A S S Ip lC A T lO N

J -----1___ LDate o f B irth

-I--------U

0

Malden Name .........................................................................Church C ongregation ...............................M inister

Name and Address o f E m p loye r

O ccupation /R ank ........................................... ......................Telephone No. (Hom e) .......................................S tate

Name o f n e x t o f K in ....................................................... .......................... ......................... ... ..R e la tio n s h ip *

Telephone No.(W ork) .

H u s b a n d W ife G u a r d ia n

Residential Address .

,Telephone No.

Name o f fa m ily d o c to r ..........................................................................................Referred to hosp ita l b y /fro m

D ATE TIM E In ju ry on d u ty *Road

acciaent*

C C ID E N T In case o f accident or Jr^ury, state

Reg. num ber o f vehicle used to transpo rt p a tien t to hospital

Place

REASON FOR A D M IS S IO N * I'lness [ ~ J In ju ry Q j s u lc id e d ] A “ a u lt Q P o is in ing QO t h e rReason □

SOURCE O F A D M IS S IO N * ' Booked Case Q U nbooked Case | | P rivate /M edica l A id D o c to r} | Transferred □

Ex Out-Patients: O wn H ospita l Q O ther Hospita l Q Ex C asaulty: O w n Hospital □ Other Hospital I I

D epartm ent A d m itte d to : Medical Q Surgery Q Gynaecology and O b s t e t r ic s ^

N a m e a n d A d d r e s s o f F r i e n d

T e l C D h o n e n o . :

AUTHORITY ‘ r .S T iru r i O N POSSIBLY RESPONSE? FOR HOS*!TAL CW-iWf-ESSURNAVS /. I'iSTlIOTiO.N

J ____ !____ L i i i____ i . i____ i____ i i____ i " i i i i i i i J ____ I___ J ____ LN A V £ 0 5 S tR = = T / P.O. A '.D N ._ ".'5 E *

J ____ L I . I____!____ I__ _L___ 1 ... .. I____L I - I I I I I I I I 1 I I I I______I_____ I______LC'TY / TOWN

.1 _ I____ Lp o s t a l c o d e

J ____I____ I____ !____I____!____!____L I I- J ______I I I I I I I I I I I I I ____ LN A M E OF S iC K F U N D / I ' /e D 'C A L A : 0 S O C IE T Y A N D M c V .B E R S H lP N u V B c R

• » I I I t ___ I I I 1 ' 1— J 1— — 1____ L

PARTICULARS OF PERSON RESPONSIBLE FOR PAYMENT OF THE ACCOUNT

Surname ............... ................... ...................... ....................................................... . Christian Names . ........ .

Postal Address ................ ............................................................................. .................. . . . . . . 1 % ? : * . ' . . . ' . . Tel. No^ .................

Residential Address ......................... .......................... ........ ...... ................. .................................... ................................ ...................... .

I.D. No..........:..... .............................. ...... ....................... ........ ;...................Resident Permit/Passport No. .....:..... ;.......

Other Particulars (eg P.F. Number) ...... .............................. .

Name and address of employer ...;............. ................

. . . . . . . Occupat ion

Fu ll name o f youngest ch ild at school ags

Name o f school w h ich ho/sl\e a tte n d s . . . . .

r P A R T IC U LA R S FO R C LA S S IF IC A T IO N■ ■ • • • ' • r . • » ‘ - - . . . . I .— 1 i « r I - T H '4 'e *

N U M B ER OF PERSONS IN H O U SEH O LD (Breadw inner and d a - '* ' . ' • " . ' - f Vy.n o n H a n l c a v r l i l i ^ i n n m i n n r r h M * < r u n r t f 1 R « i O ld e C W h O • f-A.-.?pendants exc lud ing m inor ch ild ren o f 16 years and oldec se lf-supporting 'A N N U A L GROSS INCOME OH F A M IL Y b y w a y o f salary and allowances^ bonus, comrrussoo. preart w in n e r

>Monih/VVeel< i - • 'itZY'ear .

I hereby c e r tify tha t the above-m entioned particu lars furnished > _W:,;« . ‘ j T. r% r- :by me are to the best o f my knowledge true and correct. , : S ignature: ..... ;r ....

I f n o t p a tien t, state: in itia ls and Surname ....................

A d d r e s s V . . ' v . . f . V . ,v.*! . . . . . . . . . . . . . . . . V . . . . . . . * . .......................... ........... .............. 7 / . R el a t T o n sh i p t o p a t i e n t . . .V .%

FOR O FFIC E USE:C lassification and Ion Adm ission

A d m itt in g O ffic

Per d a y f ^ o m ir i a l b y . ■R R ; , -. :'-

- ■ .. -r. : D a t e . ' . 1 . . . . ' . . . . . . . : .

M a r k a p p l i c a b r o o o x w i t h X PLEASE SEE O V E R LE A F FOR FU R T H E R A D D IT IO N A L P A R T IC U LA R S

ADMISSION FORM TP.H. 1" f t • '*

t ^Hospita l . . . ^ ^ . . . . . i

y

PATIENT NO. P W . IN C H A W Q 6

/ . SURNAMEi c h « j :

.» RESIDENTIAL'S A D O R E S ^ -U fK * l

III H

3 i * " ^ t / i _________ i— — i i J ' i t - '- i— i i____j ____— i—

, 1 . 1 »____ l____ 1 i- l ' 7 - . t ^ i (/ i ^ 1 ' ^ K ~ \ . U i i -------i 2 _ J — _M ' T r ib l B~ P W & ' ^ k ' k 7 ^ | o V 3

I I I i______ I______I______ I I - I______L _ ___I______I______I 1 i i 1 ' i______I______L _

a'v-n:# i : I c l f r l A- S. ( - f - ' o f - y(•— j. / ! _ j t j _ i _____i____ i— =_i___ j _ __4____ i---- 1— a— i . l__ I i J____ I____ I____!_

J .....: ..... : ............. : 1 1 1M t F Race W cj A B j M a rita l state M S W D Age in Years

- 1— - t -

Malden N a m e .........

Name and Address 'o f E m ployer

.^ ... 'C h u rc h ..................... .............................. C ongregation . .M in ister

.Telephone No. (Home) ........................................................Telephone N o .(W o rk ).State .*• ” “

Name o f next o f K jn ......................................................................... ......................................... ..R e la tionsh ip * Husband W ife Guardian

J Residential Address* ' * * • • "

""•■•'•x-.. " V ......... ......... ................................" ......................... ...............................................^ Name o f fam ily do c to r ...........................................................................................Referred to hospital b y /fro m

.Telephone No.

D A TE TIM E In ju ry on . d u ty * /Road -

accident*

O C C ID E N T - 'C . fn casa o f accident or Iryu ry, jta te ’ ' ■./--*

Reg. number o f vehicle used to tra n sp o rt p a tie n t to hospital

Place

’U ^ ' ^ f A ^ O N ’FO R A D M IS S IO N * l t t n « » ~ - In ju ry | } I - A ssau lt Q Poisoning Q Reason □’** ' * **' '<r\j _____ \ . ' •' - - - '

f I SO URCE C£F A D M IS S IO N * B ooked Casa Q Unbooked Case Q p r iva te/ M ed ica l A i d D o c t o r } { T ran sfe rred □

' ' ^ - V X Ex Out-Patients: O w n H osp ita l Q O ther Hospita l Q E x C a s a u l t y : O w n Hospita l I I Other H o s p ita l E H

D epartm ent A d m itte d to : M edical □ . / Surgery Gynaecology at^ o b s te trics ! I

Nama and Address o f F riend ......................................................................................................................................... .......................................................................... .................

.......................................... r / . ' . . . . . . . . . . . ............ .........Telephone no .: ................................................................... ......... ....................................” A U T H O R IT Y / IN S T IT U T IO N PO SSIBLY. R ES P O N S IB LE F O B H O S P IT A L C H A R G E S

S U R N A M E A IN S T IT U T IO N

:»• >•» >I M I I— J___!__X I I i t ‘ i I - r ' I I I i l l i ' \ \ - l i -‘ 1 ■ - ' I -

- J v - ' - -N A M E OF STR EE T / P.O. BO X A N D N U M B E R

I ‘1 I T I I I - l~___ |____ I I -i' V l I.......I I ~ r i - i i • i I i V i r - K 'C IT Y / T O W N - '

I -I : . | • I I 1 ’ I l / l - ‘ .1 ~ -tN A M E OF S IC K F U N D / M E O IC A l A ID S O C IETY A N D M E M B E R S H IP N U M B E R .;.* '' ■ ' . . » : T ~ 2 V

•■’ I ' 1

I V

posTAt-cope&

! 1 i t r • • t <J t i r i •I- / i v : I; PARTICULARS OF PERSON RESPONSIBLE FOR PAYMENT OF THE ACCOUNT^

-£r -• *f!* .....Christian KJamfiS ............................................ ......................... *,• • • • “ -r~> ■ • • .*■ •»

" ' ' '....... "c....................................... ’

v'

.................. ........................................................ .............................. : ................... n T e i. n o .

'Jf. M a r k 'a O l i l i c V j i r f V B o * W i th X PLEASE SEE OVERLEAF FOR FURTHER A D D IT IO N A L PARTICULARS ' . j -

Collection Number: AK2702 Goldstone Commission of Enquiry into PHOLA PARK Records 1992-1993 PUBLISHER: Publisher:-Historical Papers, University of the Witwatersrand Location:-Johannesburg ©2012

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