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    Imaging Request: Diagnostic Procedure

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    Marielle Chua
    This document is an imaging request form for a 10-month-old male patient named Benjie Sarmiento. He is admitted to the COVID ward and is diagnosed with community acquired pneumonia with hypoxia. The requesting physician is requesting a decubitus chest x-ray that is marked as a stat exam. The patient's clinical information and examination details are included for radiology.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Imaging Request: Diagnostic Procedure

    Uploaded by

    Marielle Chua
    29 views4 pages
    This document is an imaging request form for a 10-month-old male patient named Benjie Sarmiento. He is admitted to the COVID ward and is diagnosed with community acquired pneumonia with hypoxia. The requesting physician is requesting a decubitus chest x-ray that is marked as a stat exam. The patient's clinical information and examination details are included for radiology.

    Original Title

    NDH Imaging Request

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    This document is an imaging request form for a 10-month-old male patient named Benjie Sarmiento. He is admitted to the COVID ward and is diagnosed with community acquired pneumonia with hypoxia. The requesting physician is requesting a decubitus chest x-ray that is marked as a stat exam. The patient's clinical information and examination details are included for radiology.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    29 views4 pages

    Imaging Request: Diagnostic Procedure

    Uploaded by

    Marielle Chua
    This document is an imaging request form for a 10-month-old male patient named Benjie Sarmiento. He is admitted to the COVID ward and is diagnosed with community acquired pneumonia with hypoxia. The requesting physician is requesting a decubitus chest x-ray that is marked as a stat exam. The patient's clinical information and examination details are included for radiology.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    IMAGING REQUEST

    ELECTIVE STAT PORTABLE

    Name: _ Sarmiento_____ __Benjie__________________________________


    (Surname (Given Name) (Middle Name)
    Address:
    Date: 04/05/2021 Age: 10 Gender: Male
    mnths. old
    Out-Patient In-Patient Room: COVID Ward Birthday:
    DIAGNOSTIC PROCEDURE
    X-RAY ULTRASOUND Type of Examination:
    CT SCAN 2D ECHO CXR-APL stat

    Creatinine: Pedia
    Adult
    Height: _____
    Weight: _____

    CLINICAL DIAGNOSIS: Community Acquired Pneumonia - high risk with hypoxia.

    Chua, Marielle P./Delos Reyes, E.


    _______________________ NDU BSN 2 NDU CI
    _______________________
    Requesting Physician 04/05/2021 7:30AM Radiologic Technologist
    Staff On Duty
    Scheduled Case No: Note: All blanks must be properly filled up.
    Time: Request must be sent prior to the examination.
    IMAGING REQUEST
    ELECTIVE STAT PORTABLE

    Name: _ Sarmiento_____ __Benjie__________________________________


    (Surname (Given Name) (Middle Name)
    Address:
    Date: 04/05/2021 Age: 10 Gender: Male
    mnths. old
    Out-Patient In-Patient Room: COVID Ward Birthday:
    DIAGNOSTIC PROCEDURE
    X-RAY ULTRASOUND Type of Examination:
    CT SCAN 2D ECHO CXR – decubitus

    Creatinine: Pedia
    Adult
    Height: _____
    Weight: _____

    CLINICAL DIAGNOSIS: Community Acquired Pneumonia - high risk with hypoxia.

    Chua, Marielle P./Delos Reyes, E.


    _______________________ NDU BSN 2 NDU CI
    _______________________
    Requesting Physician 04/05/2021 7:30AM Radiologic Technologist
    Staff On Duty
    Scheduled Case No: Note: All blanks must be properly filled up.
    Time: Request must be sent prior to the examination.

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