Abbas Alwan Fadil died while in US custody at Abu Ghraib prison. There is a verbal report only of pain. Cause of Death: Acute Myocardial Infarction 2nd: Peritonitis of undetermined etiology. Manner of Death: Natural
A i. ,,
oc. 31. 0L1-cl,9 78q eF39fr
INTER 140)(6)-4
CERTIFICATE OF DEATH For um of this form. lee AR 190 ,8; the proponent agency Is DC8P ER. F ROM:
61.7vr-Ex Dta--)UT/013 Fiicte.iry
TO:
r,b)(6)-4 ..... ^
GRADE ND DATE
DATE OF BIRTH NAME. ADDRESS, AND RELATIONSHIP OF NEXT OF KIN
PLACE OF BIRTH FIRST NAME OF FATHER
CAUSE OF DEATHPLACE OF DEATH DATE OF DEATH
I/7. 14 4-1-1---t:41^-DATE OF SURIA
e 1-4 hs-J Gyrrto. I g
PLACE OF B6RIAL
IDENTIFICATION OF GRAVE
PERSONAL EFFECTS (To Or filled in by Office of Dont, Chief of Staff for PmenPIII) RETAINED BY DETAINING POWER FORWARDED WITH DEATH
_FORWARDED SEPARATELY TO CERTIFICATE TO irspecity) (Specify/
BRIEF DETAILS OF DEATH/BURIAL BY PERSON WHO CARED FOR THE DECEASED DURING ILLNESS OR DURING LAST MOMENTS (Doctor, Num, Miramar of Religion, Fellow Internee/. IF CREMATED. GIVE REASON. (If more apace Le required, continue on reverse Aldo).
t. (K.
AcPF 14 Le k,4 7.IttA,t:;--.
..
)1/4/. r,. r" 1 9 td
.. c •
X.
‘;‘-'-rv‘1/4-1 is C(04. (er--/./L-ty1-7-75-
e9 / LA-42) t)0}2
Gov
DO NOT WRITE IN THIS SPACE
CERTIFIED A TRUE COPY ADDRESS
SIGNJi7U RE
ADDRESS
SIGNATURE
OA FORM 2689•R. Mlly 132 EDITION OF 1 JUL 63 IS OBSOLETE.
MEDCOM - 556 c/‘
DOD 003619
t4 - Of,
He" 00,)i 0/ • co
NAME AND LOCATION OF SPIT AL
HOSPITAL REPORT OF DEATH DT/0/-fit citiry
eil&tioll 0 Ca3r6! L. erbW
FORK SEE AR 40-2. THE PROPONENT AGENCY IS OFFICE OF THE SURGEON GENERAL
OF USE OF THIS
Instructions - Medical Officer in attendance will:
Send form, without delay to the Registrar or Administrative Officer vre, in one copy only, Items I through 10 and sign Item 11. of the Day, for necessary action and for preparation of required or type entries. number of copies.
SECTION A ATTENDING MEDICAL OFFICER'S REPORT
PERSONAL DATA b)(6}4 3. MEDICAL EXAMINER!
2. TIME OF DEATH rtiour-dav-rmarh-year!
CORONER'S CASE
q,5 -/y
67 575-YES NO
NOTIFIED
5. CHAPLAIN
4. RELIGION
0 YES
6 NAME. ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND
PRESENT AT DEATH
Patient's name (Last, first, middle initial) Grade,
. Social Security Account No., Register Number and Ward Number APPROXIMATE INTERVAL
BETWEEN ONSET
CAUSE OF DEATH AND DEATH
DUE TO (or as a consequence off
7a. DISEASE OR CONDITION DIRECTLY LEADING TO
DEATH (This does not mean the mode of dying. e.g.. 2 W.
-
bean failure, asthenia, etc. it means the disease. injury, or complication which caused death?
DUE TO (or asia consequence oh ¦. 11 )
7h. ANTECEDENT CAUSES (Morbid conditions. if any,
Cert,
stating the aafferiValfl condition last)
giving Iron the above canoe.
12)
a.
IL OTHER SIGNIFICANT CONDITIONS CONTRIBUTING
DEATH. BUT NOT RELATED TO THE DISEASE
.., *""N.
b.
ONDITION CAUSING IT (17)(0).2
GRADE OF MEDICAL OFFICER10. TYPED OR PRINTED NAME
9. DATE
b)(6)-2
lin.p
19 M1 0 4-
SECTION B - ADMINISTRATIVE
INmALS OF elez • ONSIBLE OFFICER HOUR
YEAR
MONTH
DAY
TYPE OF ACTION
12.
TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON
POST ADJUTANT GENERAL NOTIFIED
13.
14.
IMMEDIATE CO OF DECEASED NOTIFIED
INFORMATION OFFICE NOTIFIED
15.
POST MORTUARY OFFICER NOTIFIED
16.
17.
RED CROSS NOTIFIED
113 OTHER (Specify)
19 .
SECTION C RECORD OF AUTOPSY
(Signature)
21. AUTOPSY ORDERED BY
yes. give dale and place?
20. AUTOPSY PERFORMED
YES 0 NO
22. PROVISIONAL PATHOLOGICAL FINDINGS
25. SIGNATURE OF PHYSICIAN PERFORMING AUTOPSY
24. TYPED NAME AND GRADE OF PHYSICIAN PERFORMING
23. DATE
AUTOPSY
28. SIGNATURE OF REGISTRAR
27, TYPED NAME AND GRADE OF REGISTRAR
DATE
.M1•01071...••¦¦¦11
" USAPPC V2.05 REPLACES DA FORM 8-257, 1 JAN 61, WHICH WILL BE USED .
DA FORM 3894, OCT 72
-
MEDCOM - 557
DOD 003620
EMER ENCY RESUSCITATION RECORD -PARI
For use of this form see MEDCOM Or 40-6 cojr • zit?. 83ift Complete this report within 2 hours following the arrest/event. Place the original in the patient's record and provide a copy to the Nursing Supervisor.
2. LOCATION OF RESUSCITATION EVENT
1. DATE: / 9 ill /1 4/ 0 r
3. ARREST? . MICU . SICU . CCU . NICU /ED . PACU . OR . WARD:
. DIAGNOSTIC / PROCEDURE AREA:
YES . NO 1:::1 UNKNOWN
MONITORED AT ONSET? . OUTPATIENT GUMC:
. CMARRTEL--A_. /Ca) ea-2a
YES . NO OTHER (Specify): —
COMMENTS
-INSET® DURING
4. !MERV TIONS ,/ - IN PLACE AT START OF ARREST)
. Time:
IV Access
Erc.ime:
.
Endotrachael Tube
0 Time:
.
Mechanical Ventilation
. Time:
.
Arterial Line
. Time:
.
Central Venous Line
T •
.
Pulmonary Artery Catheter
. Time: MC
.
Nasogastric Tube
. Time:
.
Pacing Device (Specify type):
. Time:
.
Implantable Defibrillator / Cardioverter
*6., latime: 6.9$0,e;1
. Other (Specify):
7. INITIAL 60N
8. RESUSCITATION ATTEMPTED
6. IMMEDIATE CAUSE OF ARREST / EVENT CONSCIOUS
(Check one) . YES (Check all that were used)
Et7Yes . No
Chest Compressions
. Lethal Arrhythmias BREATHING . Defibrillation. Hypotension
. No
114rway Management aes
. Respiratory Depression PULSE
. NO (Check one)
. Metabolic
False alarm/arrest (BLS / ALS not needed)
eS . No
. Myocardial Infarction or Ischemia . Site:
Do not attempt resuscitation (DNAR)
.
.
Unknown
. Found dead. Considered futile
.
Other:
10. GLASGOW COMA SCALE
9. EVENT TIMES
8. INITIAL RHYTHM 1Poot-resaireusion)
Mt= ere required to calculate the American Heart Amin and
tatal.
European firsuseltslion Ceara In-howital chain of survivs1.1 arch. glil
. Perfusing Rhythm HOUR MN
. Ventricular Fibrillation EYE OPENING
. Bradycardia. Ventricular Tachycardia 4 - Spontaneously
Collapse / Arrest Onset:
. Asystole
. Pulseless Electrical Activity 3 - To voice
CPR Started: 2 - To pain
RETURN OF SPONTANEOUS CIRCULATION (ROSCI o response . . Never achieved 1st Defibrillation:
. Retuned at:
. 20 min Airway Achieved: VERBAL RESPONSE
. 20 min
. Unsustained ROSC:
1st Dose Epinephrine:
5 - Oriented, conversesCPR STOPPED AT: (7?/
4 - Disoriented, converses
Code Team Called:
WHY: . ROSC 0 DNAR 3 - Inappropriate responses
. Yes . No Time: 2 - Incomprehensible sounds
. Considered futile Death
(:) No response
Code Team Arrived:
PATIENT DISPOSITION: MOTOR RESPONSE
Time:
Yes . No
.
6 - Obeys verbal commands
0 97
5 - Localizes painful stimulus
1
b)(6)-4
4 - Withdraws from pain stimulus AGE 3 - Flexion, decorticate posturing 2 - Extension, decerebrate
GENDER:
_ posturing HEIGHT (in): ()No movement WEIGHT (lbs): SCORE: Z)."
PIC V2.00
PREVIOUS EDITIONS ARE OBSOLETE
MEDCOM FORM 679-H (TEST) (MCHO) AUG 99
EY 3
MEDCOM - 558
DOD 003621
a—cc3. two -041--ozco I —amu)
I
/ I ///tur u
• ERida- CY RESUSCITATION RECORD - TART 0' cv3P•ay eyozrf. go& TIME !Hr/Mb,):: ()kV oaa3 of hejc O i)25-. of-46--okb13 ,..5-os51, p9a9 09or oo/o 0‘14 5-
BLOOD PRESSURE s-iy,, R 3i 9 3/ / ) 1-1?"1 HEART RATE I * = CPR/ / .;. /191 /3 3 1 09 P3 2i7 .1°,4,..6.-.•
....-
v RHYTHM ..wia-pz„....,
57-S i
c./
I PULSE PALPABLE (Y/N) 4,r, (1,62_._ ef' 7( c fi.' po. T DEFIBRILLATION b)(6)-2
A 410016= 200. 300, 360) L
CARDIOVERSION
S
Paul= 60, 100, 200, 900, 360)
PACING PERFORMED ( .)
RESPIRATIONS
fil )44.4;4.‘
BAGGED w / 100% 02 (,./. ) ewt., ,
INTUBATED (. ) OA it
MASK 1900e3V1VP6) iDaki. /J1E_'/3 P(M PPZ
% OXYGEN A50 02, PD?e,
,A) . 10
EPINEPHRINE
(1 mg -IV /ET tubed /a) Aei-Yr
ATROPINE
4
10.6 -1 mg - IV i ET tube)
LIDOCAINE
(1-1.6 mp / kg -N /ET tube)
t
/t ti iimi
ca..pr, aezrza„, a
LIDOCAINE 11 GM I 250= -
IV at 1 -4 mg I min)
DOPAMINE (400 ma / 260ce -
N att-20rnegtkpfardn ,
PP.174..-
/t) /WO CC:'}24-4t,
ii 5 i4oc c e.,(04y6, 4--c,
POTASSIUM (K).
GLUCOSE
CALCIUM (Ca)
MAGNESIUM (Mg)
Okiz._
C 6
PN ilea4 ' pCO2 p02 HCO3
( T-C-4 /¦_-
... .
-" n ..
/
/ 1 0
MEDCOM - 559
DOD 003622
'44.' .-....,
I MEDluAL RECORD - PATIENT ACTIVITIES FLO1n-41EET
For use of this form, see MEDCOM Circular 40-5 003,P-O• no 2/5 `"?...WP SECTION I - PATIENT ASSESSMENT I HOSPITAL DAY:
I POST-OP DAY: COMPLETE ONLY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
DATE: I q r ,..,.i ("j I PATIENT ACUITY LEVEL :
NR = Non rebreather
NC = Nasal cannula
Time To From Il AMBULATORY 111 CRUTCHES I WHEELCHAIR II STRETCHER
T Total ER/RR/PACU time Physician Anesthesia (Specify):
R A N Procedure/Diagnosis LOC B/P Neurovascular checks P R T
s Dressing/cast Tubes
F Intake IIV, po) Output )EBL, other) Voided 111 No IN Yes Amount:
E Medication
R Other
Report From Received By
TIME: Dray,) 0-73(j
BP ARTERIAL LINE
V BP CUFF 117/41,
I T A TEMPERATURE PULSE V 140
L RESPIRATORY RATE "S(c..
OXYGEN 01%1
S PULSE OXIMETER 9 . 374
I 02 METHOD ijk
G
N
S FM = Face mask VM = Ventu ' mask
Oxygen Method Key: MT = Mist tent PR = Partial rebreather A = Aerosol TC = Trach collar
O. ct —Z 01-2 eucc
I I
TIME:
TIME:
E
--77
Z
U) 0. UJ C.) --CC —J.LutuC]up
I ::::
'Skin breakdown
prevention
• Falls prevention protocol
* Restraint protocol
•
Seizure precautions
•
Isolation precautions
YESTERDAY S WEIGHT:
TODAY'S WEIGHT:
to
PAIN
s
•'
.
. . . . . . . .
.
"
•'
INTENSITY
. . . . . .
.
. .
. . . .
D
.
. .
MED ADMINISTERED IY/NI
RELIEF ACCEPTABLE IY/NI
TIME:
FINGER STICK GLUCOSE
INSULIN IY/NI
WEIGHT CHANGE:
Per hospital policy. Stool TOTAL OUT
I
TOTAL IN Urine
PO IV #1 IV #2
24 HOUR
TOTALS PATIENT IDENTIFICATION
DIAGNOSIS: 1..(' .0,11: 7L- bi, i
p)(6)-4 ADMISSION DATE: ' If !; ' A q (iLi
DRG:.
LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER:) ,f ::
ISOLATION REQUIRED (Specify):
Page t of pages MC V1.00
PREVIOUS EDITIONS ARE OBSOLETE
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
MEDCOM - 560
EY i i
DOD 003623
MEDICAL RECORD - PATIENT ACTIVITIES FLOWSHEET
For use of this form, see MEDCOM Circular 40-5 &3t -Oct-C'X) • 8,3yff SECTION I - PATIENT ASSESSMENT DATE: J ) ri•)1".1. 0-I I PATIENT ACUITY LEVEL : I POST-OP DAY: I HOSPITAL DAY: / COMPLETE ON LY AT TIME OF ADMISSION OR PATIENT TRANSFER IN - TELEPHONE REPORT:
Time To From IN AMBULATORY II CRUTCHES 111 WHEELCHAIR I STRETCHER
I-CC ZU)U-11.11:t ct --1co —o z u) 0.¢-Z 01-IIAJCC
Total ER/RR/PACU time Physician Anesthesia (Specify):
Procedure/Diagnosis B/P P R T LOC Neurovascular checks Dressing/cast Tubes Intake (IV, poi Output IEBL, other) Voided I No . Yes Amount: Medication Other
Report From Received By TIME: /56-mo a3c.s At.pb BP ARTERIAL LINE J547.a /f.1-A,%.ii 34 131k1
BP CUFF
TEMPERATURE q6g c159 cti'
'11) 6
PULSE
t32-0)C 1 41 ^i ti:3 . RESPIRATORY RATE J.S J' 411 0 LI(..) OXYGEN 11/96)
,-------/---'4 .-"*.----PULSE OXIMETER qz.vb 951, 9 .0../ q S .10 02 METHOD ,eri-eft RA Q.P.
IC = Nasal ca NR = Non rebreather FM = Face mask VM = Venturi maskOxygen Method Key: AT = Mist ten PR = Partial rebreather A = Aerosol TC = Trach collar
TIME: ii-60 .1.044S t`-:-5 t. C TIME: in g000 10 •• • Skin breakdown
. . .,c . . . . . .
• prevention tt --al PAIN ••
. .
'Falls prevention protocol u...._ L.
INTENSITY 5
0
1• •••
. . . ,
. .
Wt) - -1ZILIWO
. . . ,
. •
'Restraint protocol 0--94_
"Seizure precautions
Ph-
. .
MED ADMINISTERED NMI \I
4 t
RELIEF ACCEPTABLE ITN
41\1
TIME:
FINGER STICK GLUCOSE
INSULIN Iv/NI
*Isolation precautions
04
YESTERDAY'S WEIGHT:
TODAY'S WEIGHT: WEIGHT CHANGE:
.Par hospital policy.
24 HOUR PO IV #1 IV #2 TOTAL IN Urine Stool TOTAL OUT
TOTALS
PATIENT IDENTIFICATION (b)(6)-4 DIAGNOSIS: 4C.u..-ti .66,c •
DRG: ADMISSION DATE: / 9 ; ' j,1 2 ),
LOS: EXPECTED RELEASE:
CASE MANAGER:
PRIMARY CARE MANAGER: nr-, r, ,
Bec/ // ISOLATION REQUIRED (Specify):
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 pages MC VI 00
12
MEDCOM - 561
DOD 003624
JIPP
a brief
SECTION II - PATIENT ASSESSMENT - REVIEW OF SYSTEMS
in the small box indicates patient assessment criteria have been MET. If all the stated criteria are nor met,
IISTIALS: eL
,ECT/ONS: A check .
ilanation of abnormal findings will be noted in the appropriate column. 10 0 INITIALS: TISTE:•
of
3? Nows: n
TIME:
NEUROLOGICAL: Alert and oriented to ne place arid name. Responds appropriately. rnmunication is adequate to express needs.
vils equal and reactive to light.
Pulse regular & rate. CARDIOVASCULAR: range for age. No dependent edema.
tithin
lailbeds and mucous membranes pink. No calf
(See page 3 for extremity
endemess.
'effusion)
l
PULMONARY: Respirations within normals
3.
rate for age group; quiet and regular. Depth regular. No cough. No abnormal breath
. &i.r&SIS
sounds. av,trs
TE t•-1 L
iX N
G.L: Abdomen soft and non-distended.
4.
Bowel sounds active. Reports no NNlpain
1-V NAci-
S Rs-1g
with eating and no problems chewing/
RiAA0 t3
swallowing. Denies constipation, diarrhea or 01,) PM:SCAL-A-nob)
rectal bleeding.
G.U.: Reports no dysuria, retention,5.
urgency, frequency, nocturia. Urine clear,
yellow/amber. No unusual discharge.
Normal muscle
MUSCULOSKELETAL:6.
development and mass for age. No
deformities. No assistive devices needed.
Normal active ROM without pain. No joint
swelling/tendemess, weakness or paresthesia.
SKIN: Warm, dry, intact. Good turgor. No
7.
rashes, inflammation, ulcers, breaks in skin.
irritation over bony
No redness, blanching,
prominences. Mucous membranes moist.
I=1 c o PA 10
B. PAIN: No complaints of pain/ discomfort. RIAS Niso
(See page 1 for documenting pain intensity.)
PSYCHOSOCIAL: Behavior is appropriate9.
to the situation. Anxiety is controlled or mild
and appropriate to situation. Interacts
OK - No swelling/redness * - Central line)
appropriately with others.
te d R - Reddened
(LEGEND: P - Puffy I - Infiltra INITIALS: IV SITE ASSESSMENT:
TIME:10. INMALS:
hr:
11ME:a 0 0 q
IV patency
INITIALS:
TIME: 12 IV patency . q 8 hr: IV site care provided:
IV patency q hr: IV site care provided: -
IV tubing changed:
IV site care provided: CONDITION
IV tubing changed: LOCATION CCONDITIONIV tubing changed: LOCATION
CONDMON IV Site #1:
LOCATION
IV Site #1:
IV Site #2:
IV Site #1: IV Site #2:
Comments:
Comments:
Comments:
IV Site #2:
Page 2 of 4 pages
MEDCOM FORM 689-R (TEST) (MONO) MAR 99
•
MEDCOM - 562
DOD 003625
003P-P-ev 2fr Alf",
SECTION III - PATIENT INTERVENTlq$ & TEACHING
SITE:
TIME:
lx-ee
COLOR
CAPILLARY REFILL
NC
TEMPERATURE
EC
EDEMA
U
SENSATION
R
MOTION
0
PASSIVE FLEXION
V
PERIPHERAL PULSE
A
LEGEND
S
Color: P-pink (normal); C-cyanotic; W-pale, white
C
Capillary Refill: 1 -10-2 secs); 2-(3 -5 secs); 3-( 5 secs)
U
Temperature: C-cool; W-warm; H-hot
L
Edema: 0-None; 1-mild; 2-moderate; 3-severe; 4-pitting
A Sensation: A-absent; N-numb; T-tingling; S-sensation (present)
R Motion: U-unable to move; M-move-no pain; P-move-pain; R-full ROM Passive Flexion: D-dorsal flexion pain; P-plantar flexion pain; 0-no pain Peripheral Pulse: 0-absent; 1-weak; 2-normal; 3-strong; 4-bounding; D-doppler, P-palpable
BREAKFAST
LUNCH
D
TYPE:
PERCENT CONSUMED:
E
HOW TOLERATED:
T
. SELF . ASSIST
BATH/ORAL CARE
A
D
L
TYPE OF ACTIVITY
S
(Circle all that apply)
TIME:
mo
CONTENT:
T E
A
C H
N G
TYPE:
PERCENT CONSUMED:
HOW TOLERATED:
. COMPLETE . SELF . ASSIST
0700-1500
.
SELF . COMPLETE
.
ASSIST . TOTAL
BEDREST . SELF
AMBULATE . ASSIST
BSC
# TIMES/SHIFT
BRP CHAIR
INITIALS:
. Patient/Family Verbalizes Understanding
PATIENT IDENTIFICATION
TIME: CONTENT:
MEDCOM FORM 689-R (TEST) (MCHO) MAR 99
MEDCOM - 563
TIME:
i2doc
S ID band visible/legible
LL
A Orient to environment pm
Ai
F
Side rails (2/4) up
E
Bed position low QL
T
Call light within reach
JIJA
Review & post lab results Notify MD abnormal labs 12.L
Incontinent urine/stool
0
Linen change pm
Tum/reposition q2h E ROM q2h if immobile
H MI— 5.6e-
R
Antiembolic hose
DINNER
TYPE: AFT;
PERCENT CONSUMED: HOW TOLERATED:
. COMPLETE . SELF . ASSIST . COMPLETE
1500-2300
. SELF . COMPLETE
. ASSIST . TOTAL
BEDREST . SELF
AMBULATE . ASSIST
BSC
# TIMES/SHIFT
BRP CHAIR
INITIALS:
. Patient/Family Verbalizes Understanding
I INITIALS I
(b)(6)-2
(b)(5)-2
2300-0700 SELF . COMPLETE
. ASSIST . TOTAL
BEDREST . SELF
LAT P . ASSIST
BSC
# TIMES/SHIFT
C.1) CHAIR
TIME: INITIALS: CONTENT:
. Patient/Family Verbalizes Understanding
SIGNATURE SHIFT
A
`/11.1/114
Page 3 of 4 pages
1 4
DOD 003626
P's
SECTION III - INTERVENTIONS & TEACHING (Conti Do. 0- Pi. r o714 • 93 c 0
TREATMENTS LOCATION OF WOUND APPEARANCE AND DRESSING CHANGE
SECTION IV - NOTES
1it.7: gt, ,r,,,,,,,) cryet,v, 2--: ,q-5
a.,„,
Mlatri 01/ 67" /1-1.) . 94-(-14(t-4-261ilici 11-20-71
Lx 6/1 y 061 plA„k2i MC-(2t ei6 etbee p-tcAi pit: Os' di4,itaf //lei . q65. plz.z.i.../
up)) 4u-r-u-iiittilL:' , abd -1e,tfiti, --/c: -/buz.k) e4Oaezer-2-Zelea/1,1 ,6,) uod.,,,,_0 ;(6,p-
Azit-,/, bi". ei-Ortici 42/716.wel. ,-- -.5--6(c. 1. Li (//klz_4.,1 -/r) /32A-1,4,C". - --ea-L; a
L.5:04 .....CLE1:9 4444-x-a giLL,t__, 1:0 ,021 ' /e.-1L1 ei)Ltr.-4-4) -ft /211-1A-Litk -----rP dri
(I
r7lit) -0 e/tat.4-L17,, , le-k3.? .43/. 21 ic,7.5 iki,f) cur. 41-6648? -6214-xeY-1_,c,e, 60eA-,46,/ --k) .6‹.
41,6A,141 Zzir kow • -2..eiedic../(e-z? -/6 (AV O'ee" il-,10 /re/e2. ac:72e2z-a-• W-6:-/./zeur-i-a
az,./,,,,,,.4,/, moo 4,,,,,,...„. -_ 607: en -
1')-1) - (,!rt ICvnutte )012W pizdt“ fid. 4--2Eltzetc,e23 It-VC. OkVauf ei,dicci ti-eu I,'. 6,
....._ (70,_ J,)(6)-2
If?,
.1 . 9 MAO (1 `4 010 0 ASS)ES.-5 AIG , 111(.00.0 OA Wog -P.-. ?i HAD bvt,\ 12-v i A
ri2 40-4_ A-n.)2-"gm WAS me (-) AdiVcr a Mr) Di.51-60 Dr-,O 1-1%-f PO Aca 1 if 6-35 I 3 Ck.kk & D Ero i65 RUQ (4 Poei A vf,-)CIA u-Tisc-rx ni.) Pc Cii) V--oDE--_ L -r-t, R. LA Q . Pi 1-1 AD 'PI-N.(1-5 ce r-ww5-,i 5 ) kiPoo (SLA 1 -rasu'l b . 00 D 1 o q ? i-Aef- c
A if?__ P.,--)Luc , PT G,Ivc.. (=.} LS A el
111J ooka.-. .. ?LkOc--Ivv:,70..sT C AO v4..0 b•-•
( O e. 1 . f
" -•-,s1:-.-.-' .•2 in".C. 1 i) k•\ 6:-Nt2 .
VALR 1:::, 9._ :13)(8)-2
4-
1-7:--9-0 OA P A t IJ 1(31-E D . P-c -No 1,-(2,k,i 65-)-a a 0-o
6)(8)-2
1C) C2-;N - Tv S (..C. QT MC, --eA EA^'N \ -2-NJ V.-Pori tl .
-1 VU2'ono 1•3 0-0 2- • 5H-quAl6 11 /V\ A- b4 01 o 0 ,4picitA a Lon-. fa. -P3(...t-!;(...2 ` 1 I— 1 -VC e-L4s 0Y-74 ?&-5 Pe rterlt
PT coOT 10 aci,s To C o'M 4" 14 1 t.OF-PA ir. .. ' r ''''''""- "--"LC , T.0
'EDCOM FORM 689-R (TEST) (MCHO) MAR 99 Page 4 of 4 pages
MEDCOM - 564
OUTPUT 00,3F ' OY' Cit)70 ' Vt. I 7),
URINE NASOGASTRIC
TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL TIME AMOUNT TYPE ACCUM TOTAL
f
EMESIS
CHEST ACCUM TOTAL
TIME AMOUNT TYPE I ,I) ,(24')66 dati bteun,--) ,Z TIME AMOUNT ACCUM TOTAL TIME AMOUNT ACCUM TOTAL
STOOLS
TIME COLOR CHARACTER AMOUNT ACCUM TOTAL
OTHER OUTPUT AMOUNT TYPE
ACCUM TOTAL
Pi 00 A.ZU 1,2 ./-et2 era' TIME
GRANO TOTAL OUTPUT
REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last,
first, middle; grade; date; hospital or medical facility)
INTAKE EQUIVALENTS (Serving levels cc) b)(8)-4
HALF PINT MILK .......240 SMALL FRUIT CUP 120
MEDICINE GLASS (1 az) .30
LARGE SOUP sowL.....240 COFFEE CUP 160
LARGE WATER GLASS..240 LARGE COFFEE MUG 180
PLASTIC OR PAPER JUICE CONTAINER... 180
DD _...... EDITION OF I SEP 54 IS OBSOLETE. REPLACES OA FORM 3FORM
JA
I JUL 72 WHICH MAY BE USED.
N71792
LI -3
11 6
MEDCOM - 565
DOD 003628
b)(111)-4
ooh ca72,1.)311-1 -
T 0. EHDOURS
C01;: tDATE
FROM Pia HOUR
I
TWENTY-FOUR HOUR PATIENT INTAKE AND OUTPUT WORKSHEET TO PIM) HOUR diliti( )1/
I
INTAKE
INTRAVENOUS
ORAL
ACCUM
AMOUNT TIME
TYPE
AMOUNT
ACCUM TIME COMPL TOTAL
AMOUNT (Include Medications) RECO
TIME TY PE TOTAL ST ARTEC
i
b..-5 Liz& kall6°
44a& -7 l'/1/0 IOW
MVO 5C4-) ti 143e)
i......-
MO -00 JO( ark-e4-Jir -6-c) h V
IRRIGATIONS (N/G, Madder, etc.)
ACCUMULATIVE
AMOUNT
TYPE
TIME TOTAL
BLOOD/BLOOD DERIVATIVES
TIME ACCUM OTHER INTAKE
TIME PRODUCTO .e. 82, AMOUNT STARTE• TOTAL
Ate, P. cella, etc.) COMPL
ACCUMULATIVE
AMOUNT
TYPE
TIME TOT AL
GRAND TOTAL INTAKE
MEDCOM - 566
003k-• .09- 049215•
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST TIMC
PAT IFIUT INIMUTICIIATI" 13)(6)-4 4. DATE OF ORDER /9 Moai Oki TIME OF ORDER 0-14 0 HOURS ORDER NOTED AND SIGN
I. O. P"-• SUC.... hD nna..n. icA.C.n
Oa. s.,..t. e 5,6% or 9 res:J4u._
a . A I-. 0.L.,, 1 - .2.. ri-1_ Iv Fix-^ ex9 i kaion
cy.h p.A-n 0 r
NURSING UNIT ROOM NO. BED NO. 3 Aolciol o. Er nlci W 0-41 V 0 Cot b)(6)2 - 6 h Pu, L-rc, PIO
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. BED NO. DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION
HOURS
NURSING UNIT ROOM NO. BED NO. DATE OF ORDER TIME OF ORDERPATIENT IDENTIFICATION HOURS
NURSING UNIT ROOM NO BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA ,FAOpri„ 4256
MEDCOM - 567
18
DOD 003630
_ ev3t • et,- ch0715'
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST
AT nra-rPIFNT iGocirecrtn ha
4k DATE ORDER TIME OF ORDER
b)(6 )-4 ORDER S
0 4.. NOTED AND
HOURS
( 3e7-0 SIGN
e p,...),,
Lot, ,-
-)-v. J. c ,.... ,, .01..... Tt,..._ L...:-.L,-
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ti„.
UV
PATIENT IDENTIFICATION DATE OF 0 ER TIME OF ORDER
HOURS
'6)(6)-4
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NURSING UNIT ROOM NO. BED NO.
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/
JCC L'O C•) e••-.,At.
PATIENT IDENTIFICATION DATE OF ORD TIME F OR ER
HOURS
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T. V.
. /..,,
NURSING UNIT ROOM NO. BED NO.
IIP op UL) „I,. Oft;
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PATIENT IDENTIFICATION DATE 0 •1 -• " TIME OF ONlaGT1 1'),-;
•:-
6)(6) 4
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NURSING UNIT ROOM NO.
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REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
DA 4256
1 FAOPT479
it U.S. GOVERNMENT PRINTING OFFICE: 1994-383.710 e¦ ..--f", ..-, ,-, e•-• r ""-.-.
"USE BALL POINT PEN—PRESS FIRMLY I NO CARBON PAPER REQUIRED"
10
MEDCOM - 568
DOD 003631
cog to. co 711 F3
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
ORIENTED MEDICAL RECORD
EACH SET OF ORDERS. IF PROBLEM
f
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. LIST TIME
TIME OF ORDER
DATE OF ORDER ORDER
PATIENT IDENTIFICATION
PATIENT IDENTIFICATION
t5 /41 200t( 2JZ J NOTED AND SIGN
ditt F /Oki - L
) ere.--1- .4„ Lypi-7,4 7
/5)
NURSING UNIT ROOM NO. BED NO. f . v.e A ' 0-1 /5
(5) rOD DATE OF ORDER TIME OF ORDER b)(6)-2
HOURS
e
4 O D i y sura 2,
/411.4
(tit, S t
C IJr
b)(6)-2
lk
ROOM NO. BED NO.
NURSING UNIT
TIME OF ORDER PATIENT
DATE OF ORDER
IDENTIF ICATION
al c -o
HOURS
Iv n2,41 oci 1.714b-m/ eeY 619,/ -MG)72.4h6 T
6)(6)-2
NURSING UNIT
ezzi
PATIENT IDENTIFICATION
bX6)-2
1111111111111111111&"
111
.
ROOM NO. BED NO.NURSING UNIT REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
FORM
DA 4256
,A,..79
b' 3 26
MEDCOM - 569
DOD 003632
Theater Trauma Registry Record
coy 0:49711
For use of this form see Aft 40-6d: the prepuces agency is OTSG
SOME REGULATION
AUTHORITY:
To provide a standard means of documenting eozehat trauma for are ecbeloos 1-3 PURPOSE: The "Blanket Routine Uses" set forth at the beginning of the Army compilation of systems otreccetts notice apply. ROUTINE USES:
This is protected health information. HIPAA laws scale
b)(6)4
DISCLOSURE:
c04!," 1
"Iss*
b)(6)-4 —
8 c 0 F
MTF DESIGNATION:
Service
ARRIVAL METHOD: 0 USA. 0 SOF
o Civilian
O WALKED o USN o NGO (
o Combatant
O CARRIED . USMC o Other
o Contractor
Non-MED AIR
O . USAF
. OTHER
Wound DTG:
WOUNDED BY: .
UNK
O ENEMY
O FRIENDLY HELMET
/A
. CIVILIAN (Host Country)
FLAK VEST
a TRAINING
CERAMIC PLATE. SELF ACCIDENT
O SELF NON-ACCIDENT EYE PROTECTION
O
SPORTS-RECREATION OTHER: O OTHER:
SEDATED! IMI
IMMOB
L R air/blood
Chest Tube COLLOID CRYSTALLOID
Tame on
Time off
YIN specify:
Liters/min Unit!
U Unit
Pack o-
Fresh Whole Bld
EVACUATED to
DISPOSITION: A 'xi ant On
ICU in if..170: 0 -.URGENT
. RTD C-.. URGENT SURGICAL Off cryl...4; Out • DECEASEP
SPECIALTY: DATE: y y-0 I ,
PROVIDER:
est orrn
[y
21
MEDCOM - 570
oo5r• oz/-6v 7i-r Theater Trauma Registry Record
F. weed& form. see DA PAM XXX; the proposes wee,' is OTSO
Observations/Notes (Holding, En route, -ex)
ROUTE uav
IIMP:91111. MENTAL Status DRUG DOSE
6}2 -111
TIME 7111MEMEIrb)("7"1
10.11=11
D 1111111111111111111. ,—.11M1111111111 1WRI
g Imo nizsarimmuumarrai
IN=
. • ginliMINEMPZI raill=111111111E111111111116
AVPU
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b)(6,2
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NOTES; ,t1 •
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ll C
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/ 300 #114,1117.6-1r-
b)(6)-2
47-c 0.4
PMH:
XRAYS:
LABS:
MEDICATIONS:
Allergies:
\P 1014
Discharge Summary Information (Diagnosis, Procedures and Complications)
Head and Neck:
Chest:
Abdomen: ,b)(6)-2
6)(6)-2
-
Upper:
Pelvis:
‘
(-627 1'1\j 6411
Lower:
Skin:
Cause of Death at
ANATOMIC:
.Pelvis 0 Extremity (Upper/Lower) 00ther
.Head 0 Neck OCiest 0Abdomen
.Airway
PHYSIOLOGIC:
. Sepsis .Multi-organ failure 0 Other
0 Breathing OCNS 0Hemorrhne OTotal Body Disruption
2
MEDCOM - 571
LAST NAME FIRST NAME (MS, -ell-C402.6-lifCi• MIDDLE INITIAL ID NUMBER
DATE NOTES
f 9 11 t 4 0 9 . 4:0--. W)T A$4,--ro...,L., Q1 ,--4.-t .,..... „,......... ..i., 5 ..¦. -€.4'vt T• . 8314P3.:, ...a .v. „........ . .. ....:.. /_L._1 "--Igi. rite,: ,-0,.,„.„4., ruz_ = 4-5— • ¦IZ' '..¦ ....¦ el", ¦ /-41..a........... . S-_._________ . ...u., .. dit P . ..._,..e.,,.._ i
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STANDARD FORM 509 (REV. 5119991 US APA V I 00
MEDCOM - 572
DOD 003635
f
on3 oq. co211
AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
NOTES
DATE
g-u
1.334-4,-4,, .64 271
11,
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SPONSOR'S ID NUMBER
SPONSOR'S NAME
RELATIONSHIP TO SPONSOR
I ' HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
DEPART./SERVICE
WARD NO.
REGISTER NO.
I
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name • last, first, middle;
ID No or SSN: Sex; Date o/ Birth; Rank/Gradei
PROGRESS NOTES Medical Record
1)(8)4
STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA,ICMR FPMR (41CFRI 101-11.2031W/10
USAP A V 1.00
-By'
3 2 4
MEDCOM - 573
DOD 003636
v o3t.P9-0,02t5 • 5131,171
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES '
DATE NOTES
6 .
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RELATIONSHIP TO SPONSOR SPONSO NAME
ISSN or Other)
FIRST MI
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DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY ECORDS MAINTAINED AT WARD NO.
PATIENT'S IDENTIFICATION: (For typed or written entries give: Name - last, first, middle; REGISTER NO. ID No or SSIV; Sex; Date of thrth; Rank/Grade)
:b)(13)-4 PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV, 5/199!
Prescribed by GSAIICMR FPMR (41CFR) 101.11.20310111(
USAPA VI 0
2" 5
MEDCOM - 574
DOD 003637
opo oq• co-291. gi3 fkt
MIDDLE INITIAL ID NUMBE:LAST NAME FIRST NAME
NOTESDATE
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USAPA VI 01
MEDCOM - 575
DOD 003638
p39try.
eo)P
LABUMTORY RESULTS FORM Ba • hdad Central Detention Facili Hos ital Task Force Alcatraz
Subect to Priva Act of 1974 AST, FIRST, MI.
A)(6)-4
Reported b b)(6)-2 Date and Time:
physip;
Chemistry (i-STAT) / Green Top Chemistry (Piccolo Analyzer) / Green Top
6+ 7+ 8+ Glu Crea Chem 12 MetLyte8 BMP Liver X TEM—RESULT REF. RANGE
X TEST RESULT REF. RANGE X TEST RESULT REF. RANGE 4.8-10.8 x10(3)/uL
Na _ 128-145 mmoUL L— ALB 3.3-5.5 g/dt. WBC , q= 6
______ _ 3.0
4 2-6 1 x10(6)/uL
_LK 3.3-4.7 mmoUL IA ALP 4 53-128 U/L RBC 5-4 7 7 1 . . 10-47 U/L Hgb /7 / 12.0-18.0 g/dL
CI 98-108 mmoUL ALT unvuuurda. Id& pH 7.35-7.45 AMY Li a-14-97 U/L Hct CV-(, 35.0-60.0% MCV 2/. / 80.0-99.011
PCO2 35-45 mmHg 1-I AST 11-38 U/L
1 cl
1.6 mg/dL MCH o?86-27.0-31.0 pg
P02 80-90 mmHg Tbil C0 . 0.2TCO2 18-33 mmol/L BUN culvt.0...a.Acia-Qk 7-22 mg/dL L-MCHC 3/. 3 33.0-37.0 g/dL HCO3 22-28 mmoUL Ca 8,-3-8.0-10.3 mg/dL Pit ,359 130-400 xi 0(3)/uL
15.0-50.0%
sC2 9559% L-Choi' 5 l 100-200 mg/dL L LY% 7 2 0.7-4.3 x10(3)/uL
BEecf (-2) - (+3) CK 39-380 U/L L LY# 0- S
AGap 8-16 mmotll ,L /00 98-108 mmol/L Differential
t
Mono
n...ci ..• ' 1 .1.23 mmoUL ITCO2 02/ 18-33 mmol/L Segs
BUN 7-22 mg/dL R Creat o.7. I 1184.2 mg/dL Bands Eos
Glu 73-118 mg/dL L GGT 5 5-65 1.111_ Lymph Baso
Immature cells
Creat 0.6-1.2 mg/dL Glu 8 5 73-118 mg/dL A a Ly
Hct 35.0-60.0% K V. .3 3.3-4.7 mmoUL RBC Morph:
Hgb 12.0-18.0 g/dL Z. TProtein ---4--6.4-8.1 g/dL
Lactate 0.90-1.70 mmoUL Na -128-145 mmolit. Pit verify:
Spun Crit 35-60%
Urine ysis
..-4,,,,,,.. Color OW Straw/Yellow Mono Negative No Plasmodium Seen
RPR Negative Thin
Clarity Clear
Thick
No Plasmodium Seen
Glucose Al4.8, Negative HIV Negative Bilirubin /1/.1,8. Negative Meningitis Presumptive Negative Ketone ,(/` Negative Legionella Presumptive Negative Sed Rate Mr = 0-20 mm
0.5 ng/mL iii,• C..iiiitilitiiiNglifiiI0Kanalyzee
1.010-1.025 Troponin I
SG I 0 30
Blood 5.1„,,de Negative Myoglobin 80 ng/mL . ___ ---.-_ __ ._.__.._ _ _ __
5.0-8.0 RSV Negative ____ __ _ _ ____
PH .1: 0
Protein (00 Negative-Trace
Urobili 0, (-3 Negative Source:
Nitrite AJ Negative FecLeuk Negative
Leuko / V ppc.Negative Gram Stain
-
Negative
Urine`Microscopic WetPrep Negative Urine WBC Z-5 Epi it/o KOH No Fungal Elements Serum Negative Negative '• • : Blood Bank/ Purple int:Med -1.Top -.
RBC 0- 2 Mucus I. t OccBld
Yeast O&P No Ova/Parasite ABO/Rh
Bacteria
Casts: 1-1/,,,,( 0/e. Spermatozoa fikPv4\---Chlamydia , Presumptive Negative TIC
Crystals: Amorph Sed fiut..00-0 Strep A Negative L
Leishmania Presumptive Negative_
Other.
Other lab request to be sent out:
FORM 67th CSHLAB-1 08 Mar 2004
MEDCOM - 576
DOD 003639
V.
,t4TORY RESULTS FORM
Task Force A. .
(subject to Privacy Act of 1974)
Baghdad Central Detention Facility Hospital
Slb)(6)-4 Diagnosis:
LAST, FIRST, MI.
Physician: Ward: Bed: 10 -err Chemistry (i-STAT) I Green Top 6+ 7+ 8+ Glu Crea X TEST RESULT REF. RANGE 128-145 mmoVL
Na
K
3.3-4.7 l/L
-
CI 98-108 mmol/L 7.35-7.45
pH PCO2 T 35-45 mmHg
..
80-90 mmHg
P02
__I____
ITCO2
HCO3
s02
BEecf
AGap
iCa
BUN
Glu
Creat
Hct Hgb Lactate
Color Clarity Glucose
_ Bilirubin
Ketone SG Blood pH
Protein Urobili Nitrite Leuko
WBC RBC iBacteria
18-33 mmol/L 22-28 mmol/L 95-99% (-2) - (+3) 8-16 mmol/L 0.11-1.23 mmot/L 7-22 mgldL 73-118 mg/dL 0.6-1.2 mgldL 35.0-60.0% 12.0-18.0 g/dL 0.90-1.70 mmol/L
Urina ysis Straw/Yellow
Clear Negative Negative Negative 1.010-1.025 Negative 5.0-8.0
Negative
Negative
Negative
Urine Microscopic
I Epi Mucus Yeast
iCasts:. Spermatozoa Crystals:r Amprph Sed 'Other: Other lab request to be sent out:
STAT Specimen Date and Time: 1 Routine 19 1'0,6'4 °Li
Chemistry (Piccolo Analyzer G
Chem 12 X TEST ALB ALP ALT AMY AST _I Tbil BUN Ca Chol CK CL TCO2
* Creat GGT Glu K TProtein Na
Mono RPR HIV Meningitis Legionella Troponin I Myoglobin RSV
• Source: FecLeuk
Repfged IA : Date and Time: Vi ftW1 CLi IGLI CT
H : . - .. fy / Purple Top
CBC Malaria H/H
X TEST RESULT I REF. RANGE
WBC RBC
* Hgb
*Hct MCV MCH
gel4.8-10.8 x10(3yuL
1 6 .113 J-4.2-6.1 x10(6)/uL
I 12.0-18.0 g/d1.. 35.0-60.0%
54, 4 1 9o,1 1 80.0-99.0 fl
.2 l, .R 27.0-31.0 pg
MCHC 3a, q 33.0-37.0 g/dL
-
Pit LY% LY#
Segs Bands Lymph Atyp Ly
315" 130-400 x10(3)/uL i0.7
15.0-50.0%
0 ,, 0.7-4.3 x10(3)/uL
Differential _ Mono Eos Baso immature cells
RBC Morph: Plt verify:
MetL RESULT
23
0
Ti
9 5. Al
a.a
45 III I-15
5.1 1 ;(;)
L'
c-B REF. RANGE 3.3-5.5 gldL U/L 10-47 UIL 14-97 U/L 11-38 U/L
0.24.6 mg/dL 7-22 mg/dL 8.0-10.3 mgldL 100-200 mg/dL 39-380 U/L 98-108 mmol/L 18-33 mmoVL 0.6-1.2 mgldL 5-65 U/L 73-11B mgldL 3.3-4.7 mmol/L 6.4-8.1 g/dt. 128-145 mmol/L
Misc. Chemistry Negative Negative Negative
Spun Crit
Thin
Thick
Presumptive Negative Presumptive Negatives
0.5 ng/mL 80 ng/rni_
Negative Microbiology
Negative
Gram Stain WetPrep Negative KOH No Fungal Elements OccBld Negative
I--
No Ova/Parasite
O&P
,Chlamydia Presumptive Negative Strap A Negative Leishmania Presumptive Negative
-
Ju sCOV teAk
MEDCOM - 577
35-60% Malaria I Purple No Plasmodium Seen No Plasmodium Seen Sed Rate / Purple Top
Sed Rate I 1 hr = 0-20 mm Coagulation (waiting for analyzer)
HCG Urine Negative _ Serum Negative
Blood Bank/ Purple and Red Top
ABOIRh I I
. i
TIC ,1
-
,
2 8
DOD 003640
ooh -09 - CV.771
•
TESTES/
SPECIMEN TAKEN
DATE TIME
REQUESTED
RESULTS
b)(6)-4
b)(6)-2
O
SIM
Ra
O JO O -y n,
-A 0
-c z
. .
1
0 z 0 co -1
6
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MEDCOM - 578
DOD 003641
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Task Force AlcaL. az
LA tARY RESULTS FORM Baghdad Central Detention Facility Hos ita Sub ect to Privacy Act of 1974 ) ST, FIRST, M (b)(6)-4 SSN DOB RANK UNIT
ysician: b)(6)-2 Ward: V.„STAT Specimen Date and Time: Reported by b)(0-4 Date and Time: LT; Routine /7 Arty *V /615o 17(11(.x,/-1 t: C lunnouy try 1 AT) Chem shy (Piccolo Art er Hematology .:) 6+ 7+ 8+ Glu Crea Chem 12 MetLyte8 L v CeBc,) Malaria H/H I TEST RESULT REF. RANGE X TEST RESULT REF. RANGE X TEST RESULT REF. RANGE Na 128-145 mmoUL ALB 3.3-5.5 g/dL WBC _3. / 4.8-10.8 x10(3)/uL
_ LA 0 K 3.3-4.7 mmoVL ALP 7 9 53-128 U/L RBC 6.023 4.2-6.1 x10(6)/uL CI 98-108 mmoUL ALT 4 . ~ 10-47 U/L fl Hgb /8 ,? 12.0-18.0 g/dL .,--;,--
pH 7.35-7.45 AMY 6 5 14-97 U/L Hct ,,...), ( 35.0-80.0% PCO2 35-45 mmHg AST 027 11-38 U/L MCV 89, 3 80.0-99.011 P02 80-90 mmHg Tbil / / 02-1.6 mg/dL MCH , T/. 1/ 27.0-31.0 pg TCO2 18-33 mmoUL BUN IS 7-22 mg/dL L. MCHC 3,.. / 33.0-37.0 g/dL HCO3 22-28 mmol/L J Ca 7, 5/ 8.0-10.3 mg/dL Plt 373-130-400 x10(3yul. s02 95-99% Chol 100-200 mg/dL L LY% -20, 61 15.0-50.0% BEecf (-2) -(+3) CK 39-380 U/L L IN* 0. (L 0.7-4.3 x10(3)/ul AGap 8-16 mmo)/L CL —1*CT 98-106 mmol/L Differential
l'-.
iCa 0.11-1.23 mmol/L TCO2 . 00 18-33 mmol/L Segs Mono BUN 7-22 mg/dL i-f Creat 404 3 0.6-1.2 mg/dL Bands Eos Glu 73-118 mg/dL L. GGT 5 5-65 U/L Lymph Baso Creat 0.6-1.2 mg/dL llGlu 165 73-118 mg/dL Atyp Ly Immature cells Hct 35.0-60.0% il K 4-1,c9 3.3-4.7 mmoUL RBC Morph: Hgb 12.0-18.0 g/dL TProtein 7, , 6.4-8.1 g/dL Lactate 0.90-1.70 mmoUL Na /30 128-145 mmoUL Pit verify:
Urina ysis f. Misc. Chemistry . Spun Crit 35-60% Color Straw/Yellow Mono Negative Malaria (waiting for supplies)
:;lari Clear RPR ilbeit
3IUCOSe Negative HIV Negative 3ilirubin . Negative Meningitis Presumptive Negative Sed Rate etone Negative Legionella Presumptive Negative Sed Rate 1hr= 0-20 mm 3G 1.010-1.025 Troponin I 0.5 ng/mL Coagulation (wait ng for analyzer)
Negative Myoglobin 80 ng/mL
3lood
)H 5.0-8.0 RSV Negative
3rotein Negative-Trace Microb olo •
Jrobiii Negative Source:
Negative
4 itrite Negative PeCLeUk
HCG
Negative Gram Stain
Urine Microscopic WetPrep Negative Urine Negative KOH No Fungal Elements Serum Negative
.euko
NBC Epi
IBC Negative Blood Bank
Mucus OccBld O&P No Ova/Parasite ABO/Rh
3acteria Yeast
Presumptive Negative
:acts: Spermatozoa Chlamydia
Negative
stats: Amorph Sed Strep A
Leishmania Presumptive Negative
)then.
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FORM 67th CSHLAB-1 08 Mar 2004
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CERTIFICATE OF DEATH I NTERNI„)(6)4
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DATE OF BIRTH
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FIRST NAME OP FATHER
PLACE OF DEATH
PATE F DEATH •
CAUSE OF DEATH
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PLACE OF BURIAL
DATE OF BURT IDENTIFICATION OF GRAVE PERSONAL EFFECTS (To be fined in by Office of Deputy Chief of Staff far Perrronns1) RETAINED BY DETAINING POWER
FORWARDED WITH DEATH
_FORWARDED SEPARATELY TO CERTIFICATE TO ISPIIHD9
BRIEF DETAILS OF DEATH/BURIAL BY PERSON WHO CARED FOR THE DECEASED DURING ILLNESS OR DURING LAST MOMENTS
(Doctor, Nurse, Mintrtir of Religion, Fellow Internee).
IF CREMATED, GIVE REASON. at more apace 6 required, continue en revered aide).
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SIGNA
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SIGNATURE
ADDRESS
DA FORM 2889-R. May 82 EDITION OF 1 JUL ES IS OBSOLETE.
MEDCOM - 580
31
DOD 003643
THERAPEUTIC DOCUMENTATION CARE PLAN ( • 1 • 1 )
For use of this form, see AR 10-4071
MO. Yr.
CLINICAL RECORD ______
the Proponent *Finals the Office of The Surgeon General.
. I INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION
VERIFY BY INI77ALINO
DATE COMPLETED
NR
ORDER CLERK/ RECURRING ACTIONS, I
DATE NURSE FREQUENCY, TIME
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ALL ERGIESt O YES NO
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ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15
E 16 17 18 19 20 21 22 23
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EDITION OF 1 DEC 77 MAY SE USED.
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MEDCOM - 581 a 2
DOD 003644
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Mo os -
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Initialing (NON MEDICATION.,
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THERA • EUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, sae AR 40-407; Mo..Yr.
the proponent army Is the Office of The Surgeon General.
INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATIONVERIFY BY INITIALING .
HR DATE DISPENSEDORDER CLERK/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY
-
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DISPENSING TIMES
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USE PENCIL, CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
N 23 24 01 02 03 04 05 06
DA , TEng 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
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MEDCOM - 583
DOD 003646
Verify by Initialing THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. 0 5 Yr S */.
Order Data Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Dale to be Given Time to be Given Time Given Initials
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DOD 003647
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Task Force itraz BORATORY RESULTS FORM
Bar hdad Central DetentZh Facil Hos • Ital uti. t to Privac Act of 1974
b)(6)-4
b)(6)-4
DOB RANK UNIT
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6+ ED.8+ Glu Crea r' .Erieft. e8
RESULT REF. RANGEREF. RANGE
X TEST RESULT REF. RANGE X 1111RESULT X
4.8-10.8 x10(3)/uL
Na O a 128-145 mmoi/L ¦ALB IEMI 3.3-5.5 g/dL H WBC I . 6 K , b 3.3-4.7 mmol/L ¦ ALP MI 53-128 U/L ¦ RBC 5.08 4.2-6.1 x10(6)/uL
CI 98-108 mmoVL ALT IIIMMI 10-47 U/L ¦ H b I-12.0-18.0 g/dL pH -7. 13 7.35-7.45 ¦ AMY WM 14-97 U/L ¦ Hot /4(2. a 35.0-60.0% PCO2 (0 , I 35-45 mmHg ¦AST 1 4 a 11-38 U/L ¦ MCV 0,8 80.0-99.0 fl P02 6.1 80-90 mmHg Tbil I • 0 0.2-1.6 mg/dL ¦ MCH .2 8.1 27.0-31.0 pg
_ ,-,
¦TCO2 18-33 mmoUL ¦ BUN • • a 7-22 mg/dL L. MCHC 5 . i 33.0-37.0 g/dL HCO3 22-28 mmol/L ¦ Ca 8.0-10.3 mg/dL •Plt 27 3
130-400 x10(3)/uL
15.0-50.0%
95-99% 100-200 mg/dL BEecf (-2) - (+3) CK 39-380 U/L LY# 0, 7 0.7-4.3 x10(3)/uL
s02 ---4•°/0 ¦ Chol t.. LY% to •
-7" 3 1 (0
8-16 mmol/L 98-108 mmol/L Differential
AGap •CL "19 ¦
iCa 0.11-1.23 mmol/L ¦ TCO2 c? 0 18-33 mmol/L S S Mono
BUN 7-22 mg/dL Creat 0.6-12 mg/dL Bands Eos
Glu 73-118 mg/dL IGGT C S. 5-65 U/L L m • h Baso
Immature cells
Creat 0.6-1.2 mg/dL •Glu 73-118 mg/dL Aty Ly
Hct 35.0-60.0% K LI-4 3.3-4.7 mmol/L RBC Morph:
Hgb 12.0-18.0 g/dL •TProtein 4 . B 6.4-8.1 g/dL ¦
¦
Lactate 0.90-1.70 mmoUL ¦ Na 128-145 mmo&L •Pit verify:
¦
Urina ysis Spun Crit 35-60%
.
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Color Straw/Yellow Mono Negative y. 1 ,sI--. ITI
, L-w.u,,,.,= ..J&',IN
¦ Clarity Clear •RPR Negative Glucose Negative HIV Negative
3,;$1"' . f111M . ,. r
Bilirubin Negative Meningitis Presumptive Negative :F,;1,:.' .
Sed Rate 1 hr ... 0-20 mm
Ketone Negative ¦Legionella Presumptive Negative
Coa ulation wailin for anal
¦SG 1.010-1.025 ¦Troponin I 0.5 ng/mL • er
Blood Negative ¦Myoglobin 80 ng/mL
_
pH 5.0-8.0 ¦RSV Negative
,
. :„.
Protein Negative-Trace
¦ Urobili Negative ¦ Source:
Nitrite Negative FecLeuk Negative ¦
I
Leuko Negative Gram Stain
Urine Microscopic WetPrepj I Negative •Urine Negative WBC Epi KOH I i No Fungal Elements ¦ Serum • Negative
-r.‘i
Bacteria 1 _EYeast O&P 1 _ I No Ova/Parasite ABO/Rh
I
RBC Mucus OccBld -Negative 16.04ikinkr. I
Casts: 'Spermatozoa Chlamydia 1 !Presumptive Negative TIC
7 ' !-
Crystals: i . Amorph Sed Strep A'j I Negative
-
Other: i Leishmania Presumptive Negative
Other:
FORM 67th CSHLAB-1 08 Mar "'n04
MEDCOM - 585
DOD 003648
003i-ay-crovl . R3,47
ARMED FORCES INSTITUTE OF PATHOLOGY
Office of the Armed Forces Medical Examiner
1413 Research Blvd., Bldg. 102
Rockville, MD 20850
1-800-944-7912
PRELIMINARY AUTOPSY REPORT
b)(6)-4
Name: Autopsy No.: ME04-387 SSAN: NA AFIP No.: Pending Date of Birth: Unkown Rank: Civ Date of Death: BTB 19 May 2004 Place of Death: Abu Ghraib Prison Date of Autopsy: 1 June 2004 Place of Autopsy: BIAP Morgue Date of Report: 1 June 2004
Circumstances of Death: This male died while in US custody at Abu Ghraib prison. There is a verbal report only of pain.
Authorization for Autopsy: Office of the Armed Forces Medical Examiner, 1AW 10 USC 1471
Identification: By family members only, DNA sample obtained
CAUSE OF DEATH: Peritonitis of undetermined etiology
MANNER OF DEATH: Natural
These findings are preliminary, and subject to modification pending further investigation and laboratory testing.
E.c 5 38
-
M EDCOM 586
003k. 0E1- c 764 8L39 Ft
•
AUTOPSY REPORT 111E04-387 2
(b)(6)-4
PRELIMINARY AUTOPSY DIAGNOSES:
I. Peritonitis
A. 3 liters of cloudy brown liquid with feculent material and fibrinous adhesions
B. Dense peri-splenic adhesions
C. No perforations or injuries of the stomach, small bowel, or colon identified at autopsy
II. Pulmonary edema and congestion (right lung 1000 grams, left lung 750 grams)
III. Healing 3/8 inch abrasion of the right shin
IV.
Tooth number 8 absent due to decay (used by family members as identification)
V.
No significant trauma
VI. Toxicology and histology pending
b)(6)-2
i
b)(6)-2
MM, MC, USA
Deputy Medical Examiner
MEDCOM - 587 30
:2 5;-.0q • koc fr
ARMED FORCES INSTITUTE OF PATHOLOGY
Office of the Armed Forces Medical Examiner
1413 Research Blvd., Bldg. 102 Rockville, MD 20850 1-800-944-7912
b)(6)-4 T"'1SY EXAMINATION REPORT
Name:
Autopsy No.: ME04-387
SSAN: NA
AFIP No.: 292645
Date of Birth: Unknown Rank: Civ
Date of Death: BTB 19 May 2004 Place of Death: Abu Ghraib Prison
Date of Autopsy: 1 June 2004 Place of Autopsy: BIAP Morgue
Date of Report: 8 Jul 2004
Circumstances of Death: This male died while in US custody at Abu Ghraib prison.
Authorization for Autopsy: Office of the Armed Forces Medical Examiner, IAW 10 USC 1471
Identification: By family members only, DNA sample obtained
CAUSE OF DEATH: Peritonitis
MANNER OF DEATH: Natural
2
Ey
MEDCOM - 588
3,. 71'5 wma
AUTOPSY REPORT ME04-387
2
FINAL AUTOPSY DIAGNOSES:
I. Peritonitis
A. 3 liters of cloudy brown liquid with feculent material and fibrinous adhesions in the peritoneal cavity
B. Dense peri-splenic adhesions
C. No perforations or injuries of the stomach, small bowel, or colon identified at autopsy
D. Neutrophilic and histiocytic inflammation of the serosa (microscopic)
II. Pulmonary edema and congestion (right lung 1000 grams, left lung 750 grams)
A. Moderate anthracosis (microscopic)
III. Chronic thyroiditis (microscopic)
IV.
Healing 3/8 inch abrasion of the right shin
V.
Tooth number 8 absent due to decay (used by family members as identification)
VI. No significant trauma
VII. Toxicology (blood clot)
A. Meperidine 0.46 mg/L
B. Promethazine 0.23 mg/L
C. Diphenhydramine 0.37 mg/L
D. No ethanol (bile) or illicit substances
MEDCOM 589
-
po3 okf, -7?1. k3 9.?1/
AUTOPSY REPORT A/74 387
D)(6}4
3
EXTERNAL EXAMINATION The body is that of a thin, 74 inches in length, 160 pounds (estimated), Caucasian malewith an estimated age of 40 years.
Lividity is posterior, purple, and fixed. Rigor is absent.
The scalp is covered with black hair in a normal distribution. There is a beard and mustache. The irides are brown and the pupils are round and equal in diameter. The external auditory canals are unremarkable. The ears are unremarkable. The nares are patent and the lips are atraumatic. The nose and maxillae are palpably stable. The teeth
appear natural and in poor repair. Tooth # 8 is missing.
The neck is straight, and the trachea is midline and mobile. The chest is symmetric. The abdomen is flat. The genitalia are those of a normal adult male. The testes are descended and free of masses. Pubic hair is present in a normal distribution. The buttocks and anus
are unremarkable.
The upper and lower extremities are symmetric and without clubbing or edema.
There is early decomposition consisting of vascular marbling and skin slippage.
CLOTHING AND PERSONAL EFFECTS
The body is received nude at the time of autopsy.
MEDICAL INTERVENTION
There are no attached medical devices at the time of autopsy.
RADIOGRAPHS
No radiopaque foreign objects or displaced fractures are identified.
EVIDENCE OF INJURY
On the anterior right shin is a 3/8 inch red abrasion.
INTERNAL EXAMINATION
HEAD:
The galeal and subgaleal soft tissues of the scalp are free of injury. The calvarium is intact, as is the dura mater beneath it. Clear cerebrospinal fluid surrounds the 1350 gm brain, which has unremarkable gyri and sulci. Coronal sections demonstrate sharp demarcation between white and grey matter, without hemorrhage or contusive injury. The ventricles are of normal size. The basal ganglia, brainstem, cerebellum, and arterial systems are free of injury or other abnormalities. There are no skull fractures. The
atlanto-occipital joint is stable.
A 4
MEDCOM - 590
vv_sty. on • 113 7/7
A I T'TTY'PQV •rrt•nn•r iurr 04-387 4
NECK: The anterior strap muscles of the neck are homogenous and red-brown, without hemorrhage. The thyroid cartilage and hyoid are intact. The larynx is lined by intact white mucosa. The thyroid is symmetric and red-brown, without cystic or nodular change. The tongue is free of bite marks, hemorrhage, or other injuries.
The cervical spine is intact and there is no paraspinous muscular hemorrhage.
BODY CAVITIES:
The peritoneal cavity contains approximately 3 liters of cloudy brown liquid and feculent
material. The left pleural cavity contains approximately 400 ml of cloudy brown liquid
and has dense fibrous adhesions. The ribs, sternum, and vertebra] bodies are visibly and
palpably intact. The organs occupy their usual anatomic positions.
RESPIRATORY SYSTEM:
The right and left lungs weigh 1000 and 750 gm, respectively. The external surfaces are
smooth and deep red-purple. The pulmonary parenchyma is diffusely congested and
edematous. No mass lesions or areas of consolidation are present.
CARDIOVASCULAR SYSTEM:
The 300 gm heart is contained in an intact pericardial sac. The epicardial surface is
smooth, with minimal fat investment. The coronary arteries are present in a normal
distribution, with a right-dominant pattern. Cross sections of the vessels show no
significant atherosclerosis. The myocardium is homogenous, red-brown, and firm. The
valve leaflets are thin and mobile. The walls of the left and right ventricles are 1.3 and
0.4-cm thick, respectively. The endocardium is smooth and glistening. The aorta gives
rise to three intact and patent arch vessels. The renal and mesenteric vessels are
unremarkable.
LIVER & BILIARY SYSTEM:
The 1450 grn liver has an intact, smooth capsule and a sharp anterior border. The
parenchyma is tan-brown and congested, with the usual lobular architecture. No mass
lesions or other abnormalities are seen. The gallbladder contains a minute amount of
green-black bile and no stones. The mucosal surface is green and velvety. The
extrahepatic biliary tree is patent.
SPLEEN:
The 200 gm spleen has dense adhesions of the capsule.
PANCREAS:
The pancreas is autolyzed. No mass lesions or other abnormalities are seen.
ADRENALS:
The right and left adrenal glands are symmetric, with bright yellow cortices and greymedullae. No masses or areas of hemorrhage are identified.
MEDCOM - 591
• vir`P` V0-7ry
AUTOPSY REPORT ME04-387 5
b)(6)-4
GENITOURINARY SYSTEM: The right and left kidneys weigh 150 and 175 gin, respectively. The external surfaces are intact and smooth. The cut surfaces are red-tan and congested, with uniformly thick cortices and sharp corticomedullary junctions. The pelves are unremarkable and the ureters are normal in course and caliber. White bladder mucosa overlies an intact bladder wall. The bladder contains approximately 30 ml of red urine. The prostate is normal in size, with lobular, yellow-tan parenchyma. The seminal vesicles are unremarkable. The testes are free of mass lesions, contusions, or other abnormalities.
GASTROINTESTINAL TRACT:
The esophagus is intact and lined by smooth, grey-white mucosa. The stomach is empty.
The gastric wall is intact. The duodenum, loops of small bowel, and colon are
unremarkable. The appendix is present and unremarkable.
ADDITIONAL PROCEDURES
:b)(6)-2
•
Documentary photographs are taken by PH3
•
Specimens retained for toxicologic testing and/or DNA identification are:
vitreous, blood, urine, spleen, lung, kidney, liver, brain, bile, and psoas
•
The dissected organs are forwarded with the body
•
Personal effects are released to the appropriate mortuary operations
representatives
MICROSCOPIC EXAMINATION Heart: Sections show no significant pathologic abnormality. Lungs: Sections show moderate anthracosis, atelectasis, and decomposition. Thyroid: Sections show chronic inflammation. Gastrointestinal tract: Sections show mucosal autolysis. Sections of appendix show a mixed, predominantly histiocytic, infiltrate of the attached soft tissue. The muscularis of the appendix has no significant inflammation. Spleen: Sections show no significant pathologic abnormality. Liver: Section shows no significant pathologic abnormality. Pancreas: Section is unremarkable. Kidney: Section is unremarkable.
TOXICOLOGY Toxicologic analysis of bile was negative for ethanol and the blood clot was negative for illicit substances. The blood clot was positive for meperidine (0.46 mg/L), promethazine
(0.23 mg/L), and diphenhydramine (0.37 mg/L).
MEDCOM - 592
6
r
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AUTOPSY REPORT ME04-387 6
13)(6)4
OPINION This Iraqi male died of peritonitis. Significant findings of the autopsy include a large amount of pus within the abdominal cavity. An anatomic source of the infection was not identified. Although trauma cannot be completely excluded as a potential source for peritonitis this is unlikely given the absence of visible injury to the organs of the abdominal cavity. Toxicology was positive for medications used for pain (meperidine), nausea (promethazine), and an antihistamine (diphenhydramine).
The manner of death is natural.
(b)(6)-2
(b)(6)-2
, MD
MAJ, MC, USA
Deputy Medical Examiner
7
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MEDCOM - 593
761. rs-ror
DEPARTMENT OF DEFENSE
ARMED FORCES INSTITUTE OF PATHOLOGY
WASHINGTON, DC 20306-60430
RDPLY TO ATTINTION OP
AFIP-CME-T PATIENT IDENTIFICATION AFIP Accessions Number Sequence
TO: 2929645 01
OFFICE OF THE ARMED FORCES MEDICAL !VAMP 3)(6)-4
EXAMINER ARMED FORCES INSTITUTE OF PATHOLOGY WASHINGTON, DC 20306-6000 SSAN: Toxicology Accession Autopsy: 042888 ME04-387
Date Report Generated: June 28, 2004
CONSULTATION REPORT ON CONTRIBUTOR MATERIAL
AFIP DIAGNOSIS REPORT OF TOXICOLOGICAL EXAMINATION
Condition of Specimens: GOOD Date of Incident: 5/19/2004 Date Received: 6/17/2004
VOLATILES: The BILE was examined for the presence of ethanol at a cutoff of 20 mg/dI.,. No ethanol was detected.
DRUGS: The BLOOD CLOT was screened for amphetamine, antidepressants, antihistamines, barbiturates, benzodiazepines, cannabinoids, cocaine, dextromethorphan, lidocaine, narcotic analgesics, opiates, phencyclidine, phenothiazines, sympathomimetic amines and verapamil by gas chromatography, color test or immunoassay. The following drugs were detected:
Positive Narcotic Analgesic: Meperidine was detected in the blood clot by gas chromatography and confirmed by gas chromatography/mass spectrometry. The blood clot contained 0.46 mg/L of meperidine as quantitated by gas chromatography.
Positive Phenothiazine: Promethazine was detected in the blood clot by gas chromatography and confirmed by gas chromatography/mass spectrometry. The blood clot contained 0.23 mg/L of promethazine as quantitated by gas chromatography.
Positive Antihistamine: Diphenhydramine was detected in the blood clot by gas chromatography and confirmed by gas chromatography/mass spectrometry. The blood clot contained 0.37 mg/L of diphenhydramine as quantitated by gas chromatography.
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.PhD
Certifying Scientist, (b)(3)4 rector,
Office of the Armed torces Medical Examiner Office of rme orces • e• Ica xaminer
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MEDCOM - 594