Autopsy Report, Riadh Mohammed Abd Al Razak, Abu Ghraib Prison, Iraq (Natural) (0059-04-CID789-83991) (Death Certificate Included)

PATIENT IDENTIFICA.TION: ACTION TIMES lb)(6)-4 USE PENCIL. CIRCL E ACTION TIMES D 8 9 10 11 12 13 14 15 ~ Official Use Only I Law Enforcemen~ -itive 0059-04-CID789-8399I "' • 'I, ........ 8 DOD 003903 ~oSc" 0'-/-(107f(· tj311J 9 DOD 003904 .Ufficial Use Only I Law Enforcement~, ,itiVE! 0059-04-CID789-83991 \~~,:.;J \ ~. ... .. MEDCOM -842 DOD 003905 Official Use Only I Law Enforcemen Itlve Ep "'-1-cll-'tfS-e'I-' -lJ-~-IY-"'-l1t-'tJP-E'n-mf-:e-lem-~nt-~~"""'~~(~ve MEDCOM -843 DOD 003906 UttlCI31 Use Only I Law Enforcemen~"~ 'itive 0059-04-CID789-83991 . ~J~~J! .\ ", ." .. 12 fj. ~! '1 I.e:: r.,on· ,qQR-,~~,,{)t9:5,216 MEDCOM -844 DOD 003907 Official Use Only I Law Enforcement , ~ - --'---'---"----'--'--'-...;..;...;;...;;;..~.;.;..;;;..;;.;,;-~I&br Official Use OnlV I Law Enforcement Sensitive DOD 003908 For Official Use Only I Law Enforcement Sensitive .' ,...=., ~~v ........y '-c "' .....UI ....,II~:f:i~1f~.t'y. t:I/J/IJ'. J':jfJ/ Task Force J.. ~tl Z • j;\~TORY RESULTS FORM Baghdad Central Detention Facility Hospital (Subject to Privacy Act of 1974) r-oVJ-'fficfal Use Only I Law Enforcement Seri~;J~e MEDCOM -847 r Official Use Only I Law Enforcement ,~~sitive },;;,tj'3 -. lq§.~~ ,.- CERTIFICATE OF DEATH INTERNMENT SERIAL NUMBER Fw "Ma' thl, form .... APII 1to.... 1h. groggn.nr annElv lr DCBJIERi. FRCfIt: (b)(6)-4 L NAME (LuI, r""~ Mr) GRADE SERVICE NUMBER POWER SF.HVPO PLACE OF CAPTUR~INTIi~NMI!NT fiND I)ATI! DATE OF BIRTH Oi '}v" l'1i). NAMt:. AUUR~5S. AND REL.ATIONSHIP OF NEXT OF KIN FIRST NAME OF FATHER IDENTIFICATION Of GRAVE PEFISONA~ EFFECTS ITo~ fiUcd In by Of(UM at Dqu~ C~t.ftJfBlafi'o'hrw_l) _ ReTAINEO BY DETAINING POWER _ FORWAI! OED WITH DEATH _FORWARD!1;O SEPARATELV TO CePlTlflCATE TO ISp.clty) (8JHclI'Y) BRIEF DETAIL.S OF DEATH/BURIAL IIV PI!.RSON WHO CARED FOR THE DECEASED DURING ILL.NESS OR DURING L.AST MOMI!NTS (Do.tor, Nur.., Min"'" ofRoIII'on. ~.'.!o"' Jrttlf'ee), IF eREMATEO. GIVE REASON. (If ..O....qdO... ,..q..I",t!. conrl"u. on ~~r.:'14#). . {.. . ; /1 };, .,1 ; a~~i(,d q:~;.tt W·~~ C.lf~ ,·t/rc.',)-i lJ'1k L.,I··I-/, C:"'ll;tl( /.!J1./a ')4......"J, \..t",L,;(",''IJ ,!.., '1 .1 \,.....) \ l· J I ( r I II. "I ')1 ~/JK'J},Jtj "; ) ..,"!).j ((14,'.... ~,p:l. Lj'if-..,f'O.(··I.'~·"')' CU). ~"I'~r.I.'~"··l .'I!-("', \'/ T .~,,... I.'\' C-.-~\' .j ~I fl,i" d...,,!~ ~1 j'~ 1)'I.", . For Official Use Only I Law E ~ n orcement u:,.,..,f'FC VoZ.vo uV Ex II r Official Use Only I Law Enforcement sitive i z c '" '" Z Q C Z :j ]I 0 0 l: z 9 CD m 0 z p ~ 4 '.' -yo: f.. :t 0 c ill :j!:. m· d, 'TI 0' :11\ cf m :II' ',; :1 ., , .... .). For Official Use Only I Law Enforcement Sensitive _~ or Official Use Only I Law Enforcement nsitJve"­ (3054 -0«. CI(}7~ -f)[f/ 9bndard Form 504 CLINICAL RECORD HISTORY-Part I MaTOIIY OF PIIUENT ILLJlDSU (Continue on revene ~ido) I-ATIENT'S IDENTIFICAilON: (ro~ typed or wr;,un enl';•• ,iIl8: Nam.--/••" ~nt. . midtJ./.e; ~r.de; dlJra,' hOlpitlt1 or mad;t;.II.r::.iJily) IREGISTER NO. WARD NO. HISlORY-Part 1 Stand.rd Form 504 ·U.S. GOYllmmont Printing Office: 11191 -281·782120334 General Services Administration IU1d Ime"'8t:nc,Y CummlLt.ee [In Mt"dj!-'.I ~Un FIRMR 141 CFRI 201-45.5 Ootnber 1915 504-168 FofUfffCialUse Oniy7Law Enforcement Sen~iti~e --.-- MEDCOM -851 DOD 003914 h Q ~ ~ ~ ~ ~ - ~ c: Q) E CI) ~ .E c: w ~ C'I:J -I ~ c: o CI) II) :::) iii '0 !E o ~) WEIGHT REGISTER For use of this form. see AR 190-8; the proponem agency IS DeSPER NAf\.CE (lilt: I;rs: Mil INTE,~NMENT SERIAL NUMBER IX I J eiOod" D;,TE WEIGHT WEIGHT WEIGHT DATE DATE ------+-­ ._------~.---.---.--,------------­ ------,--------1 ---f---._-------­ .'."­ -------t--,----,-----I·----~-,---..-----­ --.-.------__ --.-. ---1---. __-'1_..._ . __..,. DA FORM 2664-R. MAY 82 EDITION OF 1 JUL 113 IS OBSOLETE USAPPC Y1.00 o C'\l :t­1Q)­t LO ...­m C") o o o o o ,I Q) :w-iii c: I\) (/) .... c: I\) E I\) u ~ .g S;; w ~ C'I:J -I ~ c: 0 I\) III :::) iii '0 IE 0 ... 0 U. N co co ~ 0 () 0 LlJ ~ r Official Use Only flaw Enforcement sitive .-.. .--.. -------------------_. CLINICAL RECORO . DOCTOR'S ORDERS For use of this form, see AH 40-66, the propulI"nt genoy i: 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. ·~. _ CLINICAL RECORD· DOCTOR'S OROERS 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. For Official Use Only I Law Enforcement Sensitive •..-...... ,.....,..,.,. • nne .tna.IJ'1A ,.. -. CLINICAL RECORD -DOCTOR'S ORDERS For use of this form, see AR 40-66. the proponent agency is OTSG THE DOCTOR SHAL.L. RECORD DATE, TIME AND SIGN EACH SeT or ORDERS. IF PROBLEM ORIENTED MEDICAL. RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW. fficial Use Only I Law Enforcement ------------ ------------------.---.. --------------·-·------c----';wr -rtt··-(t/Fijf----'I"-:#ft-.. l ~... .n f ......"" ..~ r~. r·...... ..-"\.. t"-"", .' ­" ...... .' ........ / .........\\,. ("'\.. --..,--';'" I " I '........... '}'.......... " '-.......... / '-....... I --........... ...... __ . t ................ """"'-:r '-: ,.,---"\.,.r-. "",. 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'f() MS¥J" k .£~ woJ~~ ~&;,.-.f,..,.J t. &.& C)!1It-j ,i"',H)rb../-,ud @ ~~ (; tit ~'h. ~~ fb)(6)-4 CONSULTATION SHEET I Medical Record STANDARD FORM 513 (REV. 4·96) Prescribed by GSAIICMR FPMR (41 CFR1101·11 .203(bI(101 USAPA VI 00 For OffiCial Use Only flaw Enforcement Sensitive Lx tl '-'" ·25 MEDCOM -857 DOD 003920 For Official Use Only flaw Enforcement Sensitive MEDCOM -858 orcemel'L jtive " .' . '. ~ w o D M E LOCATION OF WOUND .... _... • .......... I......... " ••• '~I.lJ \.II I "-Mvt III'I\] ,,,,Ullll APPEA/lANC~ -"--I--------.------..~.-'--.--.--"'--.---.--.--------­c -----------.. A R E --1'----------··_--_·_-­-.-.-.....-. -­.... SECTION IV -NOTES . TREATMENTS A.ND DRESSING CHANGE Ell ~)~o'-t Pl:. ~ w~"'q.. "~I= -.::."\ ~. i~.LOj~ d':l-:U~, so~ .~ ~p~ -c:. o.ck..,*"t­-~-~~. T.ql.~...J::.~~~~_~:-1t':-..b::. n'-'-'~'"t­o~-J,.Orn"'l m.clc.o....... 6fr9-R.. ~b)(6)-2 }=rc:..nt0 .______ 13co PJ::. ~'t-CfP4.\/'S;~ To\~:~::~:~~(}=--.-'::.'~.l:'-~-~-~ ..~~. ~:r-:(~----­rJu cJ.......:..h~. ~~1.'7'4-.A..UJ, """-'.;t..eL C. f'*= -+ .!;.4f-" II b.Il LY"\Jv-o~~/~C ___1b)(6)-2 ----J='~.0-~­__...___________'_1 /4CO ?k~~~b..r rnP·~. COI.c:;L...hooJ .st~. 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'--" --.....­--.-.---_..--.-.-----.,--------------_..._--_. 1-,;;;:--------------_._-_._--------_....---....­..­...-.-.-.----...--------..-------..---. ...... MEDCOM FORM 689·R {TEST! (MCHO/ M.JN~ka, use unly I Law Enforcement Sensitive Page 4 014 pages £x L[,.. -_ ,,\wi 28 MEDCOM -860 DOD 003923 \~Official Use Only I Law E t ~, n oree~",ve /' . -, ~\ 'T'!IClal use unlY J Law t::ntorcement • 'lye Page 2 of 4 pages \ MEDCOM FORM 689-R (TEST) (MCHOI MAR 99 For Official Use Only I Law Enforcement Sensitive DOD 003925 ':J~~Official Use Only fLaw Enforceme --.-~.. :D}.'l" DOD 003926 Theater Trauma Registry Record FcrUSOoflhiJ fOflll, _M4().66: 1h~~CPO_"CIICY i. OlSO A!lTllORlTY: SOME ltEOlILAnON PURPOSE: To provide .. $\aI)di.rd meaD.S of d~IXImbaI-. for cu." ecDeIoD.Il-3 For OffiCial Use Only flaw Enforcement Sensitive MEDCOM -863 ~~ 'Tt.lClal use unlY I Law t:nforcement ~}) we "{~t~;; 1:)~; Cause of Death al...,:.:_···-=--_..,.-.......' ANATOMIC: o Airway OHead 0 Neck 0 IJieSt LJAbdomen OPeivis 0 Extremity (UpperlLower) DOther PHYSIOLOGIC: _ o Brcathinc. DeNS OHemorrh~ DTota) Body Disruption OSepsis OMulli-organ failure OOlher For Official Use Only I Law Enforcement Sensitive MEDCOM -864 ,~~ Official Use Only I law Enforcemen itive L, l./ MeV) Oll C( .., MEDCOM -865 DOD 003928 "'ive UV) '1 -'--..., -L --• I • '-v DOD 003929 icial Use Only I Law Enforcement Se,,. . e -":;~{~\'i' Thaler Trauma Registry Record For usuflfdl fa:m. scc DA PAM XXX; llIe propo..... ~u ana Ob:savaliOOSlNotes (Holding, Eo route, ~ TIME BP PULSE RHSP SOOl DOSE ROUTE D1'O _ __, MENTAl Statw DRUG A V P U 1l."J"U~'..) Iffh\_~ /} 6 !sm~()l(-/f6S-A V P u IA~\ P/)i'1...t"1t ')J",,., -III):? A V P U A V P U f.c oC; 1/ 6 "il, ~~ 1-/ tf 1.. A V P U A V P U PMH: l' 're~t~ ~.,,;{- Allergies: Cause of Death at ___...,..----'-, ANATOMIC: oAirway DHead PHYSIOLOGIC: o Breathing DeNS 0 D Neck oChest oAbdomen OPelvis 0 ExtreHemorrh~ OTotal Body Disruption DSepsis mity (UpperfLower) OOther DMulti-organ failure OOther For Official Use Only I Law Enforcement Sensitive MEDCOM -867 ~Use Only I Law Enlo,c.ment~ t?:','.'J-" -C ('/ -(: '-J 13'1 -"6'"3,' UJTlClal use un y . I I L.i:lW t:IJIUIt;Io!III~I~J1rl~~ ';'1,CI,f/YI' '7.J), I ·cial Use Only I Law Enforcement S~ e -W--'---: --.jl.----------------··r ".. -".-,.,,~,,~ ,. '~"v''''''J ."''''''' ----r-HE-A-rM-E-NT-S--­ LOC;ATlDN Of WOUND Af"I'EA'\A"CE AND . MI DRESSING CHANGE O E lu ~~--------------+-------------.-~----------------- IN I-iM)"~ D ..-...! --.--..-------... ,I ,. ~--I------- R -'-1-' .------...--......--......,.. ,--.-..... I ---r­ [ ! SECT/ON IV . NOTES I~===-~=~--=-~=--~--­ !------_._-_._. --_. ----'---' -". 1------.-.--.-.--.--------" . \_._-_i ....... --...._-.. -. __ ..-._.. __.-_... _._---._. _. __ . ; ----------~-= ----=-1 I , .-. ---.. _....... _-_.._-_., ... ".' ... -.. --.. _-' ",.' .-_. -_. -,_. ! I ! i--I I ...~-.---. .. ----,--.--..-. __ .-.-_ .. " . ----------._".___ ..--·---~·-·~--_·-----I .. ._-_.-·-·- I - DOD 003933 'W I M AND TREATMENTS APPEARANCELOCATION OF WOUND o DRESSING CHANGE U ~-+--------------------~--------------------~----------------------'--4 N D --. --··---·-··--··------···-·.:;;~~2 c --­-------.----. -.-..-.--...... A R E ---._----_.__ ...._---_._-SECTION IV . NOTES 1---------------.---...------.....·.. .. ­....-------.....--.--. --...-----.--------------.---­-_.._-----_..__.... ­.. _._.. -..---. -­.... -_.._..... --....__._--_.. _--_._---_._-----­--------_._---------.-.­...._--_.. _...----_._._--''''''''----­._.._._-----------­---------------_._------..­---------­---_.... _......-_... _. --_.__.. ---"-'-"'-"-'--" --_.....----------_._--.----­1------··_--_.._·_----_·· .-----------.-­.,-.-.... -. -.-..... ..----------------...-----------­----------_.. _­-._.. --------. "'--'­... -_._._._--_.....__.._. -..... __.-_._--------------­1----·----·--·--..­..--------.--..-­....­.-.' ---_.._.-.--..._---------_._----I---------·--~--·-------­--'. 1-----·------------.-.. ---'--" --.......--­ [-=~~ ..--,-----------..--~-~.~~==..~.~-....~~-..~..=-=~.:-~.==~-=-=-=..=~~==~ I/----_....­ -._­ _.. _--_._-_..-"--­ ... -.-.. ' ....... --.-... "-'--'-'-"-.-..------------......_.. _.... 1__• _____________•__·__·_ --.-------.--. --=-"­ -......... "'" - -­....­ .• -----­.. .----t---.-_.-.. '--'---" ...... For Official Use Only I Law Enforcement Sensitive "r _.., v'.' 3 9 MEDCOM -871 Official Use Only I Law EnforC9ment~:~:~;lve ":,-:,', PAGE 4 OF t. DOD 003935 'cial Use Only I Law Enforcement Se e PAGE 3 OF 4 !r .... DOD 003936 ~ mctal use unly I Law Entorcement &.~~ ';ve k1:~V . !;;~~ ?AGE 3OF 4 DOD 003937 --, PAGE' OF 4 MEDICAL RECORD·SUPPLEMENTAL fJlEDICAL DATA For use of this form see AR 40-66' ..the proponent agency is The Office of The Surgeon G .. n .. ral REPORT TITLE OTSG APPROVED (Dale) QA Appr B~A.. r 89 INTENSIVE CARE NURSING FLOW SHEET I MEDCOM -876 f t Sg,,~'-v OCJ5"1-C.';-C-I07'6C, -'ifJ?'} I .~ tlelal Use Only I Law En orcemen ~~:'jj , e PAGE 2OF 4 NG P4 p STOOL .. u DRAINS Tr=TO~~~l7S==~~~~==~lor~U~~~I~a~,au~~~reIV~IIII~y~~g~~~~~M'~-~~~~==*=~==d tr~q ~1......___...1--1_...L--L-..--.. ' DOD 003940 MEDCOM -877 IIUI\;., ?;'::':: 30F 4 DOD 003941 F cial Use Only I Law Enforcement Se .~. PAG= 4 OF 4 MEDCOM -879 47 r:: .-,. DOD 003942 lficiaJ Use Only I Law Enforcement ~'~1, 've ·?!t.~7 PAG;:: 4OF 4 , ­ ' ,48 ._-------_... _-_...__...... " MEDCOM -880 DOD 003943 PAGE 1 OF 4 MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATAc:t%~·~1I·(1/)7{f· ~t;1J For use of thiS 'OPl1 see AR 40-66' the propol'ent agency is Th" Office of The Surgeon G",neral REPCRT TITLE I OTSG APPROVED (Calei OA Ap;r IIMar 89 INTENSIVE CARE NURSING FLOW SHEET INITIAL SHIFT ASSESSMENT I It~TIL,t."S .tikic o'&X) I IImLh'1b)(6)-211tJ1.1 0 I INTIL'fb)(6)-2 I~ Pt;FLlS fl CT2 L f-I­ JP~£J A- E S='~SORlur:' tl.Jo.x3. (p··~/'£~/;ff f' .4-0" ,~ , u R 0 R r:cSF:Rf..lI0:; F"ATTERI~ /IP.A a J.... /\ ... -'. j~ J. .J /t-}a",tJ/.fJ! IAI1/ab.d1hl E 5!:;':EPI~ ::';C''-..'\·::5 s Om (I{ fi~",,/ _A'J jJ~ ..fA.. ? 1/ 5=C:FET!(lNS ~ I /Jt1'U R A j u/V· 11 .., v (() I'VC'./ ..... 0 R Y COLOR T t.V'n..-L... uJ/V/.-. S K INTEGR:TY I w/l/L r~ LOCATION 1/.(· p;:;. tl) r-II- I COtJDITIOI~ v w/VG. . .{'. :;;/5"'/' l"Nk/1J cti1?TI iJLtrC/4 ,W./h.4A. h' a 5/'5/,t-'/.,...-,(!?!!l1t. J. j. ./l . Vj~.1..L S I t IlI)(cv 77d) I T E .~SDC·y.EN ~ G ~/1/T£) ..,. ? II/! fl'D A BO'NEL SOU:~DS A..:A. g1'V/-l{S (f) ~UJ t/ CL T t R 0 UF..:'E IjI]r// ''7 1/11 LWvv t4t Iz,' ~tL'~t':" :: d'./L~ G .l'f / COLORiCLAR'TY iilJz..uW,j ~I\ "k'/L. U .:7 c r''?"'iA(:RHYT:'I,~ -aiev.1le ,.u..j '..!--J"l", -I!I '::'t.ii ;.' (;,,(tf (-:;.J..~..~/ It:) /}v A-t.c '-2 JJ!":' D A R f ',,:...t':.,-'-, rZ/.:,,.. Lj Jjf VVIl'ft", 1. /~. h, "'-A1~ ::I" D I {i'I'. U./ L.l·C· .~c;., .( A L/ ~.,-Ifo ...-Icr t, ~ 0 'i-k,.' '.Gt: v -;' 1'1", ",./1 '-) ":1. '/1.. - A Cr • Creilill:n~IJ ICP • InlrA~rCir'l.'a~ Press..xeS S'A . Fractional C F, a -Frac:ion or i'lSjlirecl 0:, PC:'::' PI=tESSlJ=tE CJF ART~IAl co, SAl· Saluralion LEGENDU F 0 .. " 61CC1~bonale PE!:P • ;:;':5'1'\ e e'lC E1t:p:~e:C'1' P:eSS;Jle TRACH· IraC!leOSlonlY L A ib)(6)-2 \ R (Continue on rellerse) / \ IDEPARTr~t~E/CINC ~ ID~7 :)-L-A."'-0 ~writtenentries gille: Name Lasl, First, .; ospital or medical facility) 0 HISTORY/PHYSICAL 0 FLOWCHART D OTHER EXAMINATION 0 OTHER (SpeCIfy) OR EVALUATION D OIGNO_STIC STUDiES D TRETMENT ~(6)4 I ~v-49 For Officral Use Only I Law Enfor~M~Et!)~tiw5 (Redesignated) ~ :I 1 APR Qn (H~Xr. _ Nt)) _X MEDCOM -881 DOD 003944 'ficial Use Only flaw Enforcement ~~'·ve OOS'7-CY-{;.(·;,I,,,-,-~,),,' '~1jJ~ PAGE 2 OF 4 Use Only I Law Enforcement (56 )"1 -('4 -C i O?Z"; • PAGE 2 OF 4 Official Use Only I Law Enforcemen itive ?ASE 3·Jr ~ DOD 003947 C(»~-t.I/-Cil)7~('· 05' F~cialUse Only I Law Enforcement PAGE 4 OF 4 53 MEDCOM -885 ~ 'f!.cial Use Only I Law Enforcement ~~t 've PAGE 4OF 4 --54 ... ------~.-...-.-­ --------------'--,........ . ...._-_.._--...-...... .- MEDCOM -886 DOD 003949 Official Use Only I Law Enforcemen itive MEDICAL RECORD·SUPPLEMENTAL MEDICAL DATA .. For use of thIs form see AR 40-66 'he proponenl aaency is The Office of The Surgeon General REPORT TiTLE ~ I OTSG APPROVED (c:.re;INTENSIVE CARE NURSING FLOW SHEET QA Appr 8r~ar 89 _ WAMC OP 375 (Redesignated) MEDCOM -887 DOD 003950 cial Use Only I Law Enforcement Se "t PAGE 2OF 4 DOD 003951 ~) "ficial Use Only I Law Enforcement ~'ve D05"1-t)'i-O()7'17 _ 'iJ 39'' / PAGE 2 OF 4 MEDCOM -889 Official Use Only I Law Enforcement itive ~~.(?4·Ctf)?i ''i'JIf/ AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD PROGRESS NOTES DATE NOTES RELA TiONSHIP TO SPONSOR SPONSOR'S 10 NUMBER hL~A:SSTT-------i-____,..,.....~__~r---------"M-I----! (SSN or Olh.r} PROGRESS NOTES Medical Record STANDARD FORM 509 {REV. 5/19991 Pr.5cnbed by GSAf/CMA FPMR {4 I CFR! 10 1·11.203{bl! 101 USAPA v1 00 58 For Official Use Only flaw Enforcement Sensitive &.4 MEDCOM -890 DOD 003953 "~ "ficial Use Only I Law EnfOrCemID)t~· "ve clq..;.... "'. i· . , AST NAME I t FIRST NAME MIDDLE INITIAl'D NUMBER - DATE flu j~ ~I -~ v -- NOTES ~.'Sk-,~"l, ~ {) ~ 0 b)(6)-2 .T::~ :. .. :~ :' .­-. .. / -. lO:'j ,;0",' ... .:.~ .. - ----- ---------------.-. -TANDARD FORM 509 (REV. 511999) BACK /" .. 'USAPAV 1.00 ------L------;;F::orOfficial Use Only I Law Enforcement Sensifive EY l{ MEDCOM -891 DOD 003954 f...CMl o&....t.oIou 1-3 '. ROunNE USES: ThD"B1uIket Reub U ....... sot fadh altha1IeciJmial oflhe Azmy .....b'i"'l of systems ofl~notice apply. DISCLOSURE: This Is DrOICCIed bcallh iD!DmIIIiOJl. HlPM IaWl UlIIlv For Official Use Only I Law Enforcement Sensitive DOD 003955 F -ial Use Only I Law Enforcement Se ._---". MEDCOM -893 E" Y 'I r....~ DOD 003956 ~~.'l. 'ficial Use Only I Law Enforcement ~'ve \f"'l~ ~.,iD~'W~Pt ~. "._---­ ..... '.. ~ •• iC';',t, :. , -.. --.. .... . rrY' .. __ .. rr ______\ rlA.L.. __ ~ '. --------_•..__._ .... __ MEDCOM -894 . DOD 003957 ~;:~~~. EMl fNCY RESUSCITATION RECORD -PAl For USB of this form see MEDCOM Cir 40-5 ~. ClVI· C,,7n· Nfl( Complete this report within 2 hOtJrs following the arrest/evant. Place the original In tho patlent's record and pro\llde a copy.to the Nursing SUpervisor. 2. LOCATION OF RESUSCITATION EVBIIT 1. DATE: 'CJL{f\l !(X.J--/ 3. WITNESSED ARREST7 o MICU o SICU o CCU o NICU ~ED o PACU o OR o WARD: DYES !!J NO o UNKNOWN o DIAGNOSTIC I PROCEDURE AREA: MONITORED AT ONSET? 0 OUTPA1 lENT CLINIC; DYES ~ NO o OTHER (Specify): 4. INTEllVENTIONS ( ./ -IN PLACE AT START OF ARREST) I .I -INSERTED DURING ARREST) COMMENTS ; 9'"IV Access o Time: ..r{!.!,c,-kJ ill f..ll ; 0'Endotrachael Tube o Time: .t:~~(rtcJ :" r;.I! o MeChanical Ventilation o Time: : o Arterial Une o Time: : o Central Venous Une o Time: : o Pulmonary Artery Catheter o Time: : o Nasngastric Tube o Time: : o Pacinll Device (Specify type): o lime: : ~plantBble Defibrillator I Cardioverter o Time; : Other (Specify): '~uc,!;OI\ g"Time: l'l~-S-: 6. IMMEDIATE CAUSE OF ARREST I EVENT e. RESUSCITATION ATTEMPTED 7. INmAL CONDITION (Chttck one) CONSCIOUS [&J YES (Check all thet were used) ~ Chest. Compressions 0 Lethal Arrhythmias DYes ~ No 0 HYPOtension BREATHING tl DefibriUation If) Airway Management0 Respiratory Depression DYes !!l No 0 Metabolic PULSE o NO (Chsck one) 0 False alarm/arrest (BLS I ALS not needed) 0 Myocardial Infarction or Ischemia o Ves I1l No Site: 0 Do not attempt resUSCitation (DNAR) o unk~wn . 0 Considered futile o Founddead E1" Oth . CAr ~~u.((~,:~"q A({(~~_ . 9. EVENT TIMES 10. GLASGOW COMA. SCALE mm.. ere requited to co!cul.... the Am.~c.n HIWt AN'n and 8. INITIAL RHYTHM (Po......._Uon) IJJ Vontricu)ar Fihrillation 0 PerfuSing Rhythm European RMUSCIta~cnCoundll.,.hotopl1ol chain of aurvival.1 CIrcle Ipproprftlte scares, then to1ul. .. oun MIN a'E OPENING 4 • Spontaneously o Ventricular Tachycardia 0 Bradycardia : 3 -To voice Collapse I Arrest Onset: o Pulseless Electrical Activity 0 Asystole RETURN OF SI'ONTANEOUS CIRCULATION IROSC) CPR Started: ±~pain 1 -0 rcopon£o 1st Defibrillation: o Returned at: -o Never achieved -:--( Airway Achieved: o Unsustained ROSe: 0 20 min 0 20 min VERBAL RESPONSE CPR STOI'PED AT: 1st DosB Epinephrine: : J:L: S f;l 5 -Orientad, converses 4 -Disoriented, converses CedB Team Called: 3 -Inappropriate responses WHY: o ROSC o DNAR o Considered futlie 0"'Death JiQ Ves o No Time:~:~ ~comprehenSible sounds PATIENT DISPOSmON: 1 -0 response Code Team Arrived: I~- Time: l~: IJ MOTOR RESPONSe o Ves o No 6 -Obeys verbal commands ~fjJ 5 -Localizes painful stimulus I II PIS~~Ef'f(g)~ION 4 -Withdrllws from pllin "timllius AGE: 3 • Flexion, decorticate posturing I 2 -Extension, decerebrate GENDER: 1,,\(t.'l.t~ oposturing CL\1"~) ?~\SSe, '\ L \ HEIGHT (in); 1 -No movement WEIGHT IIbs): 3 SCORE: .. MEDCOM FORM 679-R (TEST) (MCHO) AUG 99 PREVIOUS EDITIONS ARE OBSOLETE MCV2.00 For OffiCial Use Only I Law Enforcement Sensitive '-. ·63 Ex '"I MEDCOM -895 DOD 003958 MEDCOM FORM 679-R , I t:,) I IfM"NVI AUG 99, Back . ~ ·,64 QEf' .~. .. -Ie ~ I~i Sb T(jO:~H~J I A;t( r( iO( C ()~h. ~~O £" ',. r). I CJ.1f V I Vel F r Official Use ~ (aw Enforcement Sensitive MEDCOM ... 896 DOD 003959 . -h \ Iq Sb TOO:-W;;H~J p'f i Or C r), . ~()OO 9;r'11A1 F r O~iCial U~~Q~a~::~~rcement Sensitive MEDCOM -897 DOD 003960 .~r Official Use Only I Law Enforcemen~nsitive 0059-04-CID789-8399J ARMED FORCES INSTITUTE OF PATHOLOGY Office ofthe Armed Forces Medical Examiner 1413 Research Blvd., Bldg. 102 Rockville, MD 20850 1-800-944-7912 FINAL AUTOPSY REPORT Name: b)(6)-4 Autopsy No.: ME04-435 National Detainee Reporting System b)(6)-4 AFIP No.: 2931952 Date ofBirth: 7 January 1952 Rank: Iraqi civilian Date ofDeath: 10 JWle 2004 Place ofDeath: Abu Ghraib, Iraq Date ofAutopsy: 19 June 2004 Place ofAutopsy: Baghdad, Iraq Date ofReport: 22 September 2004 Circumstances of Death: This 52 year-old male Iraqi civilirul collapst:d while speaking to other detainees while in US custody at the Baghdad Central Confinement Facility in Abu Ghruyeb, Iraq, and resuscitative efforts were unsuccessful. Authorization for Autopsy: The Armed Forces Medical Examiner, lAW 10 USC 1471. Identification: Visual and documentation accompanying the body; fingerprints and DNA sample obtained CAUSE OF DEATH: Atherosclerotic Cardiovascular Disease MANNER OF DEATH: Natural For OffIcial Use Only I Law Enforcement Sensitive DOD 003961 'r~f)0r Official Use Only I Law Enforcemen~1~nsitive 0059-04-ClD789-83991 AUTOPSY REPORT ME04-435 2 ~b)(6)-4 FINAL AUTOPSY DIAGNOSES: I. Atherosclerotic Cardiovascular Disease a. Severe coronary atherosclerosis with calcification i. Left main coronary artery, 50% luminal narrowing by fibrocalcific plaque II. Total occlusion ofproximal left anterior descending artery (LAD) with healed plaque rupture and organized thrombus; 75% narrowing ofm'id LAD by fibroatheroma; 65% narrowing of distal LAD by fibrocalcific plaque; total occlusion oframus intennedius by healed rupture with fibrointimal thickening and smooth muscle proliferation iii. Total occlusion ofproxirnal to mid left circumflex artery (LCA) by organized and recanalized thrombus; 70% fibrocalcific narrowing ofdistal LCA; 90% narrowing of obtuse marginal artery with fibrointimal thickening and smooth muscle proliferation iv. Right coronary artery (RCA). 25% naJ."Iowing ofproximal RCA by fibrocalcific plaque; 40% narrowing ofmid RCA by fibroatheroma; 70% fibrocalcific narrowing ofdistal RCA; 95% narrowing of posterior descending artery by fibroclcific plaque and smooth muscle proliferation b. Healed transmural myocardial infarction i. Involves anterior, septal and lateral left ventricle mid ventricle to apex ii. Microscopically, transmural fibrosis and fat replacement in anterior, septal and lateral waIls ofleft ventIicle iii. Aneurysmal dilatation iv. Epicardial fibrous adhesions at apex ofleft ventricle c. Cardiomegaly with biventricular hypertrophy i. Heart 666 gm (predicted normal value 343 gm) ii. Left ventricular cavity diameter 60 nun Ill. Left ventricular free wall thickness 10 mm iv. Microscopically, biventricular myocyte hypertrophy with subendocaridal and perivascular interstitial fibrosis d. Moderate to severe atherosclerosis of the aorta i. Diffuse calcific intimal plaque formation ii. Focal plaque rupture with associated hemorrhage e. Pulmonary edema i. Right lung 965 grams ii. Left lung 818 grams II. No evidence ofany significant trauma a. Abrasion, 4 x 3 em on back of ri ght forearm b. Contusion,7 x 4 cm on back of right hand --.. 67 For Official Use Only I Law Enforcement Sensitive DOD 003962 £rtiPr Official Use Only I Law Enforcemen nsitive 0059-04-CID789-8399I l\,~!.J1 AUTOPSY REPORT ME04-435 3 ~b)(6)-4 III. Additional Findings a. Subcutaneous lipoma ofanterior left side ofneck b. Right renal calculus (kidney stone) c. Prostatic hypertrophy d. Symmetrically enlarged thyroid gland IV. Medical Intervention a. Endotracheal tube in place b. Three adhesive EKG tabs on body V. Early to moderate decomposition a. Diffuse marbling of body b. Corneal opacification VI. Toxicology (AFIP) a. Volatiles: Heart blood and urine negativt: for ethanol b. Cyanide: Heart blood negative c. Drugs: Heart blood negative for screened medications and drugs of abuse For Official Use Only I Law Enforcement Sensitive MEDCOM -900 DOD 003963 i r Official Use Only f Law Enforcemen~iJnSitiVe 0059-04-C!D789-83991 AUTOPSY REPORT ME04-435 4 [b)(6)-4 EXTERNAL EXAMINATION The body is that ofa well developed, well-nourished male clad in a previously cut, white long sleeve shirt-dress ("dish dash") and white boxer shorts. The body weighs approximately 170 pounds, is 71" in height and appears compatible with the reported age of 52 years. The body is cold, the temperature that ofthe refrigeration unit. Rigor is waning. Lividity is present and fixed on the posterior surface ofthe body, except in areas exposed to pressure, and is especially pronounced on the face. Early to moderate decompositonal changes are present, consisting ofdiffuse marbling and discoloration of the body and corneal opacification. The scalp is covered with black and grey hair in a nonnal distribution, averaging 4 cm in length. Facial hair consists ofa dark mustache and grey facial stubble. The irides appear dark, but are partially obscured by corneal clouding. The sclerae and corijunctivae are congested, especially on the left, with no petechiae. The earlobes are not pierced. The external auditory canals, external nares and oral cavity are free of foreign material and abnonrial secretions. The nasal skeleton is palpably intact. The lips are without eviclent injury. The teeth are natural and in good condition. Examination of the neck reveals the trachea to be midline and mobile. There is a palpable 3 X 2 cm .subcutaneous nodule on the anterior left side ofthe neck. The chest is symmetric and well developed. No injury of the ribs or sternum is evident externally. The abdomen is slightly p~tuberant and soft. The extremities are well developed with normal range of motion. There is a 4 x 1.5 em scar on the upper anterior aspect ofthe right forearm, and there are irregular scars over the left knee. The fingernails are short and intact. No tattoos are noted, and needle tracks are not observed. The external genitalia are those of a normal adllit circumcised male. The testes are descended and free ofmasses. Pubic hair is present in a nonnal distribution. The buttocks and anus are unremarkable. There is an identification tag on the first toe ofthe left foot. EVIDENCE OF THERAPY There is an endotracheal tube in place secured with white tape around the head, and there are three adhesive EKG tabs on the body, two on the upper chest and one on the left thigh. There is a band-aid on the right antecubital fossa over a needle puncture mark with surrounding ecchymosis. EVIDENCE OF INJURY There is a 4 x 3 em abrasion on the back of the right forearm and there is a 7 x 4 cm contusion on the back of the right hand. On external and internal examination of the body, there is no other evidence oftrauma. 69 £X~ For Official Use Only I Law Enforcement Sensitive ---_.__..•.._.•... MEDCOM -901 DOD 003964 AUTOPSY REPORT ME04-435 5 Kb)(6)-4 INTERNAL EXAMINATION BODY CAVITIES: The body is opened by the usual thoraco-abdominal incision, und the chest plate is removed. There is approximately 50 mI of serosanguinous fluid in each pleural space, and there are mUltiple pleural adhesions of the right chest cavity. No adhesions or abnonnal collections of fluid are present in the peritoneal cavity. All body orgfll13 are present in the normal . anatomical position. The subcutaneous fat layer of the abdominal wall is 4 em thick. There is no internal evidence ofblW1t force or penetrating injury to the thoraco-abdominal region. HEAD: (CENTRAL NERVOUS SYSTEM) The scalp is reflected, and there is no subgaleal hemorrhage or skull fractures found. The calvarium of the skull is removed. The dura mater and falx cerebri are intact. There is no epidural or subdural hemorrhage present. The leptomeninges are thin and delicate. The cerebrospinal fluid is dart: with decompositional change, most prominent over the occiput; however, there is no evidence of any subarachnoid hemorrhage. The cerebral hemispheres are symmetrical. The structures at the base of the brain, including cranial nerves and blood vessels, are intact. Coronal sections through the cerebral hemispheres revealed no lesions, and there is no evidence of infection, tumor, or trauma. Transverse sections through the brain stem and cerebellum are unremarkable. The dura is stripped from the basilar skull, and no fractures are fOW1d. The atlanta-occipital joint is stable. The brain weighs 1180 grams. NECK: On dissection of the soft tissue of the neck, there is a well-circumscribed yellow 3 x 2 cm nodule just under the skin on the anterior left side of the neck, adjacent to the thyroid . cartilage. On sectioning, the nodule is uniformly fatty, consistent with a lipoma. Examination ofthe soft tissues of the neck, including strap muscles, thyroid gland and large vessels, otherwise reveals no abnonnalities. The anterior strap muscles of thc ncck an;; homogeneous and red-brown, without hemorrhage. The thyroid cartilage and hyoid bone are intact. The larynx is lined by intact white mucosa and is unobstructed. The thyroid gland is large but symmetric and red-brown, without cystic or nodular change. There is no eviucm;c of infection, tumor, or trauma, and the airway is patent. Incision and dissection of the posterior neck demonstrates no deep paracervical muscular injury, hemorrhage, or fractures of the dorsal spinous processes. CARDIOVASCULAR SYSTEM: There are dense apical adhesions of the heart to the pericardial sac, and there is marked anewysmal dilatation of the left ventricle. See "Cardiovascular Pathology Report" below. A moderate amoW1t ofepicardial fat is present, and the heart weighs 666 grams. The aorta and its major branches arise normally and follow the usual course. There is diffuse moderate to severe atherosclerosis ofthe aorta with extensive calcific intimal plaque fonnation and focal plaque rupture with associated hemorrhage. The venae cavae and their major tributaries return ~o the heart in the usual distribution and are free of thrombi. For Official Use Only I Law Enforcement Sensitive MEDCOM -902 DOD 003965 0059-04-ClD789-8399 I ,t:;pr Official Use Only I Law Enforcemen~f~sltlve .J,;r.iP' .~,. AUTOPSY REPORT ME04-435 6 ~b)(6)-4 RESPIRATORY SYSTEM: The upper airway is clear of debris and foreign material; the mucosal surfaces are smooth, yellow-tan and unremarkable. There are scattered pleural adhesions of the right chest cavity. The pleural surfaces are otherwise smooth, glistening and unremarkable bilaterally. The pulmonary parenchyma is red-purple and edematous, exuding a moderate amount of bloody fluid; no focal lesions are noted. The pulmonary arteries are nonnally developed, patent and without thrombus or embolus. The right lung weighs 965 grams; the left 818 grams. LIVER & BILIARY SYSTEM: The hepatic capsule is smooth, glistening and intact, covering dark red-brown, moderately congested parenchyma with no focal lesions noted. The gallbladder contains 5 ml ofgreen­ brown, mucoid bile; the mucosa is velvety and unremarkable. The extrahepatic biliary tree is patent, without evidence ofcalculi. The liver weighs 1498 grams. ALIMENTARY TRACT: The tongue exhibits no evidence of recent injury. The esophagus is lined by gray-white, smooth mucosa. The gastric mucosa is arranged in the usual rugal folds and the lumen contains 100 ml of dark fluid. The small and large bowel are unremarkable. The pancreas has a normal pink-tan lobulated appearance and the ducts are clear. The appendix is present and is unremarkable. GENITOURINARY SYSTEM: The renal capsules are smooth and thin, semi-transparent and strip with ease from the underlying smooth. red-brown cortical surfaces. The cortices are sharply delineated from the medullary pyramids, which are red-purple to tan and unremarkable. There is a single dark calculus in the right renal pelvis. The calyces, pelves and ureters are otherwise umemarkable. White bladder mucosa overlies an intact bladder wall. The urinary bladder contains 50 ml ofcloudy, yellow urine. The prostate gland is enlarged but symmetrical with lobular. yellow-tan parenchyma and no nodules or masses. The seminal vesicles are unremarkable. The testes are free of mass lesions, contusions, or other abnormalities. The right kidney weighs 207 grams; the left 235 grams. RETICULOENDOTHELIAL SYSTEM: The spleen has a smooth, intact capsule covering red-purple, moderately finn parenchyma; the lymphoid follicles are unremarkable. The regional lymph nodes appear normal. The spleen weighs 278 grams. ENDOCRINE SYSTEM: The pituitary and adrenal glands are unremarkable. The thyroid gland is symmetricalIy enlarged, but free ofnodules or masses. MUSCULOSKELETAL SYSTEM: Muscle development is normal. No bone or joint abnonnalities are noted. -·.,71 r For Official Use Only I Law Enforcement SenSitive [X~ DOD 003966 ~,rOfficial Use Only I Law Enforcemen~~sitive ()059-04-CID789-8399I AUTOPSY REPORT ME04-435 7 ~b)(6)-4 MICROSCOPIC EXAMINATION Heart: See "Cardiovascular Pathology Report" below, Selected portions of other organs are retained in fonnalin, without preparation of histologic slides. CARDIOVASCULAR PATHOLOGY REPORT Department ofCardiovascular Pathology, AFIP: "AFlP DIAGNOSIS: ME04-435 1. Severe coronary atherosclerosis with calcification, three vessel disease 2. Healed transmural infarction with aneurysmal dilatation, anterior, septal, and lateral left ventricle 3. Cardiomegaly with biventricular hypertrophy History: 52 year old male Iraqi detainee, 5 '11", 170 lbs, found dead in bed Heart: 666 grams (predicted nonnal value 343 grams, upper limit 453 grams for a 170 lbs male); focal epicardial fibrous adhesions at apex ofleft ventricle; closed foramen ovale; aneurysmal dilatation ofleft ventricle: left ventricular cavity diameter 60 mm, left ventricular free wall thickness 10 mm. ventricular septum thickness 10 nun; right ventricle thickness 4 rnm; endocardial thickening in left atrium and left ventricle; unremarkable valves; healed transmural infarct, anterior and septal walls ofleft ventricle, mid ventricle to apex; subendocardial hyperemia, anterior and lateral walls of left ventricle; histologic sections show biventricular myocyte hypertrophy with subendocardial and perivascular interstitial fibrosis; transmural fibrosis and fat replacement in anterior. septal, and lateral walls ofleft ventricle. Coronary arteries: Nonnal ostia; right dominance; severe calcific atherosclerois: Left main coronary artery: 50% luminal narrowing by fibrocalcific plaque Left anterior descending artery CLAD): Total occlusion ofproximal LAD with ,healed plaque rupture and organized thrombus; 75% narrowing ofrnid LAD by thin capped fibroatheroma and 65% narrowing of distal LAD by fibrocalcific plaque; total occlusion oframus intermedius by healed rupture with fibrointimal thickening and smooth muscle proliferation Left circumflex artery (LCA): Total occlusion of proximal to mid LCA by organized and recanalized thrombus, 70% fibrocalcific narrowing ofdistal LCA; 90% narrowing ofobtuse marginal artery with fibrointimal thickening and smooth muscle proliferation Right coronary artery (RCA): 25% narrowing ofproximal RCA by fibrocalcific plaque, 40% narrowing ofmid RCA by thin capped fibroatheroma, and 70% fibrocalcific narrowing of distal RCA; 95% narrowing ofposterior clescending artery by fibrocalcific plaque and smooth muscle proliferation," For Official Use Only flaw Enforcement Sensitive DOD 003967 ,t~r Official Use Only I Law Enforcemen sitive D059-04-CID789-113Y'i I ·",.~J;,i AUTOPSY REPORT ME04-435 8 Kb)(6)-4 ADDITIONAL PROCEDURES Full body radiographs are obtained and show no evidence oftrauma. Documentary photographs are taken by OAFME photographers Specimens retained for toxicologic testing and/or DNA identification are: vitreous fluid, heart blood, urine, and bile The dissected organs are forwarded with the body Personal effects are released to the appropriate mortuary operations representative OPINION This 52 year-old male Iraqi civilian in US custody in Iraq died of atherosclerotic cardiovascular disease, with severe coronary artery disease and a healed myocardial infarction (previous heart attack), extensively involving the left ventricle. There is no evidence of any significant trauma. The manner ofdeath is natural. [b)(6)-2 LtCol, USAF, MC, FS First ChiefDeputy Medical Examiner 73 fx")./ For Official Use Only I Law Enforcement Sensitive DOD 003968 ~~:~r Official Use Only I Law Enforcemen sitive 0059-04-CID789-8399I DEPARTMENT OF DEFENSE ARMED FORCES INSTITUTE OF PATHOLOGY WASHINGTON. DC 20306-6000 REPLl!TO "TIniTIDfI 0 .. AFIP-CME-T PATIENT IDENTIFICATION AFIP AccessloDs Number Sequence TO: 2931952 01 Name OFFICE OF THE ARMED FORCES MEDICAL ~b)(6)-4 EXAMINER ARMED FORCrs INSTITUTE OF PAmOLOGY SSAN: Autopsy: ME04-43S WASlUNGTON, DC 20306-6000 Toxicology Accession #: 043003 Date Report Generated: June 30, 2004 CONSULTATION REPORT ON CONTRIRUTOR MATERIAL AFIP DIAGNOSIS REPORT OF TOXICOLOGICAL EXAMINATION Condition of Specimens: GOOD Date of Incident: 611 0/2004 Date Received: 612212004 VOLATILES: The HEART BLOOD AND URINE were examined for the presence of ethanol at a cutoffof20 mg/dL. No ethanol was detected. CYANIDE: There was no cyanide detected in the heart blood. The limit of quantitation for cyanide is 0.25 mg/L. Nonna! blood cyanide concentrations are less than 0.15 mg/L. Lethal concentrations of cyanide are greater than 3 mgIL. DRUGS: The HEART BLOOD 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: None were found. tb)(6)-2 /7 Kb )(6)-2 IPhD /_______ LX:-;D"'AB--.r:;-;FT '-S=.~p~h..... Certifying Scientist, Forensic Toxicology Laboratory Director, Forensic Toxicology Laboratory Office of the Anned Forces Medical Examiner Office of the Armed Forces Medical Examiner For Official Use Only I Law Enforcement Sensitive DOD 003969 10 DOD 003970 HR OA TE COIolPLETED ORDER CI.ERKI RECURRING ACTIONS, DATE NURSE FREQUENCY, TIME ·3 FI ~ ~ 7 '? 'i 10 It Ii Il ]" PRIMARY D.It,CNOJiIS= .... oor"rION ...L. P ACe:. IN V:lC;ALLrtRc:1I1i:SI ~Y'£3 0 NO DYE. DNQ 1trJ I=) A.GE NO: ~ ... il £NT IOENTIF'IC.J,'TIO,,",: /.' ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES· ; . •••. D a 9 lD 11 12 13 14 15 E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 t.,_,'ION Of" 1 CEC 77 WI 1.1.. BE USED UNTIL EXHA,_ ',0. ;"v 11 MEDCOM -908 DOD 003971 __ \Ju 12 ----_..__........ . MEDCOM -909 DOD 003972 Task Force Alcatraz LABORATORY RESULTS FORM C{"'\Ol. 13 MEDCOM -910 DOD 003973 --..._. _ .. _. .-_._._---_._. _. ---. -. .. _ ~ "h'S, .6~/' C!IJ7rf' ~'1r?/ ..-. Task FOf'Cl :atraz \DIRA TORY RESULTS fORM Baghdad Central Detenuon Facility Hospital (Subject to Privacy Act of 1974) LAST. FIRST .... J L-~--:17 (b)(6)-2 I DOB RANK UNIT /(b)(6)-2 Lv L Pt" Kb)(6)-2 I '!:l!N!}i-r-K1):i'/U ISpec/m:~_.p~t~na TIme: Repot1~ Date and Time:,-­ q~0 Routine 13 ::Ju/,-,[)Y /iOD J~)(6)f__ l"lUUD'1. \'i'1'j Chemis[tyji-STAT) ~h..mistry (Piccolo Analyzer) Hematology 6+ 7+ 8+ Glu Crea !C Chem 12.J.} MetLyteS BMP Liver (CSC '.Malaria H/H X TEST RESULT REF. RANGE X TEST RESULT REF. RANGE X TEST ·TJ{ESUL.T REF. RANGE 128-145mmollL ALB 4 I 3.3-5.5g1dL WBe I i:i"".l 4.8-10.8x10(3)ful -a. 3.3-4.7mmol/L ALP tal ~M RBe 5":~7 4.2~.1 xlO(S)/uL _. K__--r-_-----+_------t _ CI ___ . _. 98-108 mmollL AL T I "K 10-47 Ull Hgb _~!.:.L.__1_2,0-_'_8.0_g/_dl_ fu IpH 7.35-7.45 _!#Y ~~ ,4-97UIL Hct 5'~ 35.0-60.0% PC02 _____.______35-45_m_m!:!.Q__ ,_ AST ~t1 . 11-38UIL . _ _ M9~__ _11.y. 8Q.()'99.0fl __ l--f-P~Oc::;2_'-I1 8O-90mm~!l Tbil :2, ~ I O.2.1.6mg1dl MCH J"J ,(. I 27.()'31.0pg ITC02 16-33mmol'l -I-=.BU::..:Nc:....._-I--.I_'I.\'-:--I 7-22mg1dl MCHC 31./ __ ~~37.0.!!.~1:.. I--f-H.::.:C:..:O;.;:3_t-__-7---'-22_-2_8_m_m_oVl'--I_--I-"-C~a_---c~--+-....:B::..:.0-'-'1..:;;O..;;.3.:.:..;mg/"",dl=_-f Pit ..1Q$" I. 130-400 xl 0(3)I~1 I-~S:.:::O=2---1----_+I-_--=95-99:.:...:.::..::%-=----I--FC::.:hO:.:.I--l_=::::__.__+--":.::()();::..::200===-::m!j{dl LY% ~q. I 15.().SO.O% BEecf (.2)· (t3) CK '1,? 39-380 Ull LY# ~ "' •. _LQ,7-4.3 x10(3)Jul AGap 8-16 mmoVL ./Cl IOl\ 98-108 mmolJl C Differential \ ­ I-~~--t---.-+_~~~~--i 1-.j.:..IC::..::a"-----'~--+---'-O.-',.--1-.23-m-mo-Vl_-i--tT-C"'-a'-'2~_t__=\_':;q-_ l~mmolll.. Sags 29 Mono 5" I-t-=B:..;:Uc:..N'---+-__-+__7_-22--'-m..:=.gId_L__I._+C-f6......c.;8t"---_t_O"''''•...o.'K-+--O,;...6-,;..I'--.2_m"""gJc...dL-"'-_IBands Eos :;; I--f.=G:;.:IU~-+__-+--=73--=--:...I,:.:.8.:.:cmg/=dL:..-.-t--+G::..;G::...T:..-.--+-..L ~ Baso--~ I\~.?x::-_+_-=5-S:.=..5.:::UJ=..L--ILymph f Creat 0.6-1.2 mg/dL Glu '10 73-118mg1dL A~Ly Immanl"'''''", I--i-=H:!.."ct=--+---+--=:;c:35....::.0.s0~.=O%-=--I-"rr----4.~lr 3.3-4.7 mmolll.. JRSC Morph: I Hgb 12.0-16.0gldl TProtein '1,~ 8.4-8.1 g1dl ..-..»rrn.\)(i+i't./"'~r~__(_~~ Lactate 0.90-1.70 mmo1JL " Na 1~1 128-145 mmoUl. Pit verify: Urinalysis Misc. Chemistry Spun Crit 35-$% Color StrawIYeliow Mono Negative Malaria (waltin for supplies) __ CJ~~,___I_-_ _f_---"CIe=a::.:.r---f-f-'R=_P~R-_t_-_-t---_---f--+---+--_I--... _. ___ Glucose Nllgatlve IHIV Negative 1_+=B~i/.:.:..;iru:..;:b~in~_____-+___~~B_w-a--_-~~M-Dn~ln~~-'-·~----.~~p~~~~~·~~~riw~·=~~____-.__~S.:::~::..;R+~::..::e-=--____ Ketone Negative legionella Preaumolive Nag81 ..... Sed Rata 1hrlfl"· O!!O mm ._+'S;..:G'----_t--___+-_1.010-f .025 f-"": Tropan/n I . {).!i 0.5 nglmL Coagulation (waiting for analyzer) BIDOO, _+--~~~~~.--I--rMy~~~I~n+_-----r---~~~~~m~l__1--l---__~_____4--------­pH .--T -------+_--......:5::::.0-3:.:::::.0::-..__+_-FRS:.;V~_.......__.J.__....;.NoogRtiva=;;.;·;;:.._f_+-___+-___+ _______ Protein Negative-Trac:e Microbio~ -~~~4------r-~~~~.~r----,~~~~------~~----+---~----.-----. __ ~~~i__ ~----r_-~~a~t~~e~--Ir_~S~O~u~~~:~--__--r_----__---I~~--__L---__~_________ _ Nibite Negative FecLeuk NegaU~ I_-~:L=e,;..u-k=o==:~~=-~-r--_~~~:=~.~__-__-__.~~G~m~m~s=~n~___--t_________ r-+____~____~H~C~G________ Urine Microscopic WetPrep Negative IUrine Negative ---+------.~~~~·~~~----l~~~~r_----~--~~~--·~~~~+-----~----~-- WBC Epi KOH No Fungal Elements Serum Neg8llv& .~~~~----~~~~ 1__f.'-R:;::.BC~_~---~I_"'M'-u...;..cu_s_.-..-.---_--I--t=Occ-=B:.::Id=--t----f-.-.:..:Neg=au::..:ve~__ t--+-___-r-_BI_ood-,,-B,...a,-n;....;k___ .Bacteria ........ _,..:.Yea:::::::.::s:..:,t___ .__.I--+'o:..;&;;;..p__-+-_____ ___ . No OValParasite ABOlRh ___ -i________ .... ICasts: i .. 1Spem1a1oxo~ Chl:lmyllQ rmaumplivC NegaUve 1 I I-tcf)lS!a'~:l-'----. IAmorph Sed StrDp A ·------t'---"':..:=N"-'eq.:...;ac.:.tiVe=~+--r_·--I------.;------. -.--. -­-Tother: ----. leishmania --+-p-res-u-'m:':':p"""tIve=Neg'---ativ-'e ~---.. _-L_______ --_L--.-----. -. Other. DOD 003974 IOtl1er lab request to be sent out: FORM 67th CSHLAB-1 27 May l4 vu15 MEDCOM -912 DOD 003975 t)Of,~·t8· (1/J7f7. vrr; INTEANM[NT SaAIJlL NUIllISCA CfRTIFICATE OF D~TH 'IX UN o' thh '0"", M. "'" 110..; tit. pt'Dpon.nlepr1I1V b DCBPIA, FROM: TO; f)':N fb)(6)-4 eClfY\. f' fJ iS;~Cn l..\ L NAME (L..,. '''''~ MI) GRADE SERVIcE NI,IMn:.. powell ,SRVED PUCE OF ¢ArTUfl~INTI:IIN"'!NT AND DATI: DAn OF BIRTH 0,1\1' 1"1"'). NI\M~.AOD.~55. AND III:.LATIONS)uPOF NEXT OF ICIN FIRST NAUE or PATH!!R IDENTIFICATION OF QRAVE _ RETAINEDBY DETAININcpoweR _ FOIIWAAO&OWlTH DEATH _FOI'IWARDiDlIiPARATIiLY TO CellTI,.CATf TO IS,..1h1 lo.-lhJ ~nl or "., "'UI ur u ....TH/auIU... L DT rO::R50N WHO CA"'~D FOR THE DBCEJlSED DUlliNG ILLNESS Oil DUftlNO LAST IoIOM~NTIi (Dodo,. II.,.•. MI.u,..'.(II.llIto... l"d...... .hJ'_'. IF CAEMATiO,CIV; REA90N. (lfM.rolll..,w_lrrd. 040''''''. 0" ..~'""/. " U11i(..1 -'1~fi.Lt V\i~~ C.ff!-e!li("J-i V'lJ.. · 1,...,"'1, C~,l""I( 11. 'd;: . 7~... ~·.;J. Vi'·,' ',:(~ I:,; ~.'I../'./J"I J;./,;, .," "1 \ L' J j ( I I 1\ -I J; .~i'l()l",JI(; ) .,:/1, (,11.,'" J....I:;L. L.f:"",,,,{~,(,,, ••.~! "'I. _" ,10,· /.,.•"1 "I' (""I, \, I ..,.-.",.... ~'.' ~" " j",I~ ttl",.,} l'1 .j'~p.I."-I. I 16 ----_...............-........ MEDCOM -913 DOD 003976 SECTION C -RECORD OF AUTOPSV ~ ". 1/1 - ..1 DOD 003978 fJ~'o'i·CIf)7ft· ?Jff/ Stutd..d Form SOoI CLINICAL RECORD HISTORY-Part I HISTORY OF PIllDUIT II.Ula.Q r'I(61 -2 "ATlI:NT"S IOe:NT'",ICA'TICN'4 'Dr typed 01 WI;"_" _n I.i•• I'-"e.. N.rn.~ ·1••,. AI'.'. j R£CiI,.TER NO. WARD NO. middJ.c. 4,~d.: dde: nCl,pi/lll 01' lT1.d;ull~c;J."y' HISI'OIlY-rart 1 Stan".rd fann 504 Generlll ServiCM Adminu.traLiDn anel .~ S. GO"'lrnmtm pmlln9 OtU,* .OG'I -281-782/203:)4 Int.ert.pncy Commjlt.M on. M.dical Iboeardao FIRMR t41 CFRl 2Dt-&5..Ci October'tT5 !tOC-lOa ~ .. ··19 MEDCOM -916 DOD 003979 h ~ ~ ~ ~ ~ )~ WEIGHT REGISTER For use-01 thi$ form. SBI!!II AFt 190-6; the proponenl agen.,::y ~---- DATE j 1------+-----1---------­ -1-----­ 1---­ , __ 1.______ ._· _._._____ .··_1 ___ ____1 __ _ • __ _ --"---.--.. ,--_.----' ..--.... -..---1--------_.-1------.--­ ..___ .-__---1---_____ ~_. . ___ ---.1_... _ .­ -_... _---­ ..---1 ,_ ._.••--_.-. 1$ DeSPER. lWERNMENT SERIAL NUMBe~ ------WEIGHT r--~---­ ~ -------,------------ DA FORM 2664-R. MAY 82 EDITION OF 1 JUL 83 lS OBSOLETE U5APPC VI.00 ::;­ o C'\l ~ I'­ ..­ (j) o ~ () Cl W ~ o ex: m C") o o o o o "._._._.. ___-----~._._______________ ._____.________ Q(Mf .'/Lv:' (I/ll![:. f JffL_ CLINICAL RECORD, DOCTOR'S ORDERS Fo' use of this form, soe 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. REP'-ACES EDITION OF , JUL. n. WHICH MAY BE USED. DOD 003981 .,..-.... .---- CLINICAL RECORD· DOCTOR'S ORDERS For use of [his f(]lm. tietJ AR 40..06. the PlopuliGul t!yoncy I~ OTSG THE DOCTOR SHALL RECOHO 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. MEDCOM -919 DOD 003982 ,. , CLINICAL RECORD· DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG At.joI'LAC1:S t.OITldN Or-1 JUL II, WHIt.=H MA..... Si:. US1:U. DA ,':..~~~g 4256 b)(6)-2 6)-2 MEDCOM -920 DOD 003983 .. _____.____.________ , ______ ... -.-------.. -..-.-.-------. --OlJf'DI:f'-CtPJff·· Y'jffj .-. /....~....... r, ,', , , , ,r~... ,. .... / ....., \.. ; "\. ­ ~ -, . ... .-... '-.... -, ,, '-,, .... _ ,j........ r '\. r... :,...' .... ....J ......~r "--..,....,j, "-., , --"­ --....] ~} ....... .... {\. ;-'. I ...., " xt. 'J. "'J '\.,_.1 .\~ j '. , " " • ______•••• ______•••• R •• ~ ....__._.-.-.-.".::..~!.-.---_., ...-_..._-_.­ _...._-;-----------------,­ . ___i._~ ',--. -'--'-"--' ...:::~-=----~--,-------......... " (': -=--":":'-"=--'.j"' .~ •.•..•-. ," .~ '. , , '", . , \-. ; , -,. , ~~~ , 'v,r'''", , . '-.J " ., , '"--, "-~, , , , , V , 1,r,; 1j , ----, \ I \ ~1 " -~ u .., uo.......:. ,IA.. ­ .._.._._,__.L,. _.. ,_._-...-_...... I':' j'­ ., .1\:; n ,. ~; : n· dU\, PI'( f\h ...1." I; ~ f~.. 'J~. '" ,j" ·1...:.., 1-' , r--!·~\.f" I '\ r, '!-:~\l '\' ·r~~.. " \.-' .~: r":" ~ , .. ~';;?'i; ,-"".1 "Ji"I: .~.---.-..-: .. -_..--:--.. _.-----~. __.:.... :­ -F'="~,'" ,J-,". , . f .-.. ' .. "." , ,-" -~ -~ / ..... ; ; .... ., ... !'--.. \--\ r ..... \ r ----, :' :............··\.1 '0., r", \ ....... --. 1­ \ r· " I ~: \ 1 ------,'.' '-..--~ ICl \ .I ,,-' \, , '...i ....-~=~.... '.-' _..........=:-:.. .. _. __ 1-:~ ...._ ~.. ) _._._" ~ \:...} ...:\ ....: j, n It R ,~. ,iV¥1 . JYrI J'" ,~. -" , ,~., .I~t. ... , ......,. , 1"1 '1.:-.... J '---. .. '---,. J \,-..... "f ~"J~ , .. -_.... ..--..., , , r-o. ,. 'r­ "' ~--. . ._.... ,-'-_.. .:; " !I DOD 003984 TO' t FROM: flltJqu..,ing physician or «wiry} DATE OF REQUEST ,{, T, tb)(6)-2 RE5~'~i;u1'C·mplc7o··dnnS~1tT of ~Rf~rH J ~lflfJ ~,~ S"NC( Lt+! r, I TF 1-/"l( 1tT A-'ITPc.t... ~ If\¥.r:s ~'4cP N1 I ' oil. D) N \ ~A, ';;; i)y ),,0 f.~""c: ,;.-1 I PROVISIONAL DIAGNOSIS DOCTOR'S SIGNATURE APPROVED oBEDSIDE 0 ON CALL PLACE OF CONSULTATION BROUTlNE ~TODAV 72 HOURS -0 EMERGENCY CONSULTATION REPORT RECORD REVIEWED 2P -JI~/90f 9"2­ f{ -Ib (Continue on rp.vp.,~p. .irl"J . . ~. CONSULTATION SHEET Medica' Record STANDARD FORM 513 (REV. 409B} Pr••cribodby GSAIICMR FPMn 141 CrRIIOT·" 203(blllO} USAP"A .." 00 25 DOD 003985 DOD 003986 - Theater Trauma Registry Record Fr \lie oflhll tam. _ AJl~G.66; !he p~1IC1lt;)' U OlSO AtmlORITY: 50M£!tEO IJl..ATION PURPOSE: To pcOYid•• Jt.uIiIord -.uor dCSUDe.llllA& tOmbaI _ for cu. II .ciooIoIIs \·3 ROUTINE USES: -no.. "Blanke, It.,,,,tiDe U,Ol" ... feeth &l1IuI b.,wiq: ofIhc Ann)' compiJ.Wo. of ,ysto .... clr.ca'diI DoticO apply. DISCLOSlJRE; nu. i'IlI"Dlc:\.cI hcallh i..rcmoliOlL HlPM law. 0l0I' MTF OBSIGNATION: ~\1!,:,~':t' Arrive ALMlmlOD: WALKED ~CARRIED o NOII·MEDAIR o OTHER.______.....___________ WoundDTG: WOUNDED BY: o ENEMY a FRIENDLY PiA U CJVJLIAN (Hoo\ Country) a 'ffiAIN]NO 7 a SELF ACCIDENT a SELF NON·ACCIDENT !:l SPORTI·RECRF.ATION DOrnER: z..'lECHANISM OF INJURY: 0 MVC BURN I' 2" 3" __ o OSW/BlJUEI' 0 AIRCRAFT CRASH CRUSH a Bl.UNTTRAlJMJ\ Q KNlFBIEDOB C FALL o SINOLEFRAGMENT a CBRNE OIED C OTHER.'--______ o MULTI FRAOMENT 0 BLAST Unit '. --,,29 MEDCOM -926 DOD 003989 MEDI'_ ;-\L RECORD· PATlENl' ACTIVITIES FLO,. ~HEET MEDCOM FORM 689-R !TESTI (MCHOI MAR 99 ?8;:VIOlJS eDITIONS AilL CBSOL E'I E Page ; vI 4 pr::lyl.'S ,'t: c. U(. D L/ 30 MEDCOM -927 DOD 003990 ..., TION III • PATIENT INTERVENTIONS & TEACHII_ o SELF 0 COMPLETE IIiJ SELF 0 COMPLETE {!) SELF COMPLETe o IlA1H{ORAL CARE w. ' A IJI ASSIST 0 TOTAL I Q ASSIST 0 TOTAL 0 ASSIST 0 TOTAL D ~----------~~~~~=-~~--~=-------=---~---+~~~--~~~--~ BtoREST 0 SElF ;~_ 0 SELF BWR~ST 0 SEtr AMBIJLATE 0 ASSIST ~0 ASSIST I--iifs'i'trm--. 0 ASSIST TYPE OF ACTIVI1V 5 ICIIOIP. RII rhar apply) :~~ # TIMESfS~1IFT I :~; # TIMESiSHIFT :~; # rJMES/SrllH CHAIR : f:HAIR r.HAIR TIME: INITIALS: !TIMF: INiTIALS: ITIME: INiTIALS: _.. _--­ '~~-T-EN-J----.--. -·--·----r;:;N-;-.. ICONTENT· ,. O"•. _e I,:) "' ....'-0. I i T i i A c I H I I N G I i o Patit!nt/Family Verbali7.cs Understanding I0 Pallenr/Famlly Verb.lizes Understanding 10 Palient/FafT'.ly Verbalizes Ulldersland.n9 Dr,TIEN r IOENTIFICAnON INITIALS SIGNATURE ISHIFT lSI 1.).'1 f)(6r t b)(6)-2 1,.•,' r--'I ~S(ji ~~,~~________________--J I. I i MEDCOM FORM 6B9-R (TEST) (MCHO) MAR 99 Page 3 of 4 psg'" . ~ -31 MEDCOM -928 DOD 003991 . ~ . ~ 32 DOD 003992 P:..GE '. Of 4 -' MEDICAL RECORD·SUPPLEMENTAL MEDICAL DATA F or use "f 11';5 form sea AR 40,66' Ina proponenl agoncy is The Office oi The SU'9!;On G"n"rai . -' REPOP1 T l~cE INTENSIVE CARE NURSING FLOW SHEET INITIAL SHIF"f..ASSESSMENT ;IU:O: -,-:-,-'l ~,~ d I/o 0 I N",L~Kb)( I n-·! ';",( : 1··;-"~b)(6) '-"'-- N PLJ?l!S h-rlLA' 71~--,rL A- E 5=r\l5Q?!l::,'~ r' -ifn ,,'1., a 01 0 A~" (~ 'G)'7~1 'l iV u R 0 Iu.:M-t.·t:,1'r il.~LYjL(;'P/u.if ~e5PI~,l.! I:)l,,"i-'.&' nERN R /1~ ~" 7:.A J. L .) E eC::E..A T'l-i S ~.' )\:C·S ,1, rti (py s . J1"" ~J 1-)./'/ AA p 5::Gf:;E7!C!..:S f .c (U?-'. U.,( nL;;c(l d,~~-t R I IY .J 'I ~:'\ l';"{c T A -, a R Y COLOR ~l' uL-I"flr; A.P.. ..i..-£. 'Vrvl S K I,jTEG'IT" I c.vYl..--J r: 'I: I~ LOCATIO!" IL') t:A-'!Uff-r v I cor~DiTIC'. Iv ,,~J_ . ~i ",,"j;d ~C{:{+t'fl t () 51", ,7:' J;"") ~_7 ..... -f!. J~JA·;:-k.. I flM.(~.Hr!vt /,'1 fj /'/.:iITatib·/ . 7 f T ( I T 5 E A6DC':.EtJ G ~N'/rr) ............ C' Sl,-tJ..4(y, (I' :'-.1c'riZlid A S ao'/vEL SOl~DS I({) AU! -2).?~J_ rBt::.; ,U0Y ,.I~i9iflfa t h ~";' T ~ 7 r:.:-:' ',-"r'l" .~. (Y .".;,,' ,r' R 0 .~·fp~1'1 J", ''-"'J-/f -p,. ~~ '.1 • L:RI!,E I!od(, s' /d~ Ir:,." ,~·Il f_: /1}. ~ ."L./J,. .7-L G COLOR/CLARITY ()JJ (JU,' lyJkC·f-J AA~ "" l'L V" U J 7" C CARDIACRHvrHNI ,041/ /t,].A ~ J"4 \/ nl.-.r k. c.. A R Ccc..a~~I'·U;U:· Fkr_/ ) 1/ t.-b QI.o ~-::-i. "-J D I It1i.lc...- .. t.~.J,~~'!(fu£ ._­ -, ----._---.­ 0 V A Cr ' Cra~llnlne l:;P . 1.,lrc..:'r,n·sJ f'1t;SSJ~e S S!A· Fra.::,o:r:al C F,O· f'BctiDnofinS;JI,ed 0 1 iI:;O .. " PRl:S:ia...."lf. OF .&..~'!~.,.~ CC, SAl -Sal:Jra:JOn LEGENDU F', 02~ 8ICiln..on'J!e i-'E='~ • P~S,ll\t e~cJ ~.(;J:H:llv'Y Pr£:S5j!8 7F,"'Ci-:· ;raC"'leO~40"':t L A R (Confinue on reverse) b)(6)-2 ~L~ IDEPARTrv1ENT/SER~E/CINC TDA~~ PATIENT'S IND~CATIONS (For typed or ",rfHen enlries give: Nome Last. Firs!. middl.; g"d.; da,e; h05pil'" or mOdlcal facility) 1(61I -4 I OTSO APPROV!:D !~a:e; QA Apilr ell,at 89 I le( 7-.L-C-' 0 HISTORY/PHYSICAL ~~OWCHART 0 OTHFR EXAMINATION 0 OTHER (Sf)ecIfYI OR EW\LUATION 0 DIGNOSTIC STUDIES 0 TRETMENT DA FORM 0 WAMC OP 375 (Redesignated) r::, L! 1 MAY~8 470 1 APR gO IHSXr. N l Jl LX --. 33 ----------------_..-..-.. _--------­ ... - MEDCOM -930 DOD 003993 34 DOD 003994 '----'''';"GE " ::JF ., MEDICAL RECORD.SUPPLEMENTAL!"EDICAL DATAct%4~~t/,(1)?f!' ~'i"il Fe' use of th,s form see AR 1.0 66' 'he propo"enl 9gon"y's , - ,.,. Ott,'·--of The Suroeon ,-,,~ne·al ~ ~ .' R£;-..)ORT'LTLe OTSO ,",PPROVCD W.roJ QA Appr BI.ia' 89 INTENSIVE CARE NURSING FLOW SHEET I 0 DiGNOSTIC STUDiES 0 TREH/ENT DA FORM WAMC OP 375 (Redesignated) Ex l.t ~ 111/:/878 4700 1 APR 90 (HSXC· NU) -.. ,·35 MEDCOM -932 DOD 003995 36 MEDCOM -933 DOD 003996 ·­ /. MEDICAL RECORD·SUPPLEMENTAL MEDICAL DATA For ~se or 'hs for." see Ai'! 40·56 'ne propo"ent ao~ncy is ,he Olke of The SurgeD" Gene,al .-... .... - i~E~OR"T TITLE 0TSG -,\PPROVEO c;;~.: QA A:::pr 81!.ar 89 INTENSIVE CARE NURSING FLOW SHEET I WAMC OP 375 (Redesignated) . ' ·37 MEDCOM -934 DOD 003997 ~s-b4 °Cr;)7}{ otjJHI AUTHORIZED FOR LOCAL RePRODUCTION r-----------------~S~,ON~ RELATiONSHIP TO SPONSOR "--_____.-__--'1---------------.:-::---1 {SSN or orn", l.A.ST L______~~~~~~~------~==~~=-~----- _____ DEPART /SERVICE I HOSPITAL OR MEDICAl. FACILITY I )A.TJENT'S IDENTIFICA nON. {For f}'ped or wr;"dfl enuic:l. gl'o't!: N.me -las!. /Jist. middle; WAR!] NO. iD No 01 SSN,' Sex: Dtll~ 01 Bifltl; l1oJnI./Gfaar:! PROGRESS NOTES Medical Record fiTANDARD FORM 609 !ti£'1 (i"gr;.o;., Ple!.cr:bed l.Jy GSAJ:CMR ;P,·..,R tf. !C;',R) IQ1· ~ ~. :WJ,t;. (I Jj US/,PJ. Y I 00 38 MEDCOM -935 DOD 003998 TI. .ter Trauma Registry Reco For I'M of Ihl.l {DOlI, _ AlI."~;1M ~CCDCJ II OTSG AtrIHOiITY: SOMBllSGtlLATION PUUOSi!: ToJlO'rilkalWldard _ofdon1nwNlac tembIl_fClrClnl"eIIIkIDIl-3 .. ROUl"lN£ USES: n.. "llJubt RIIIIi» U""-JaI. forth all!. ~ofilia NrA'I ~at I)1OII1D11 aC~aotlco apply. Olsa.OStJRE: n;, Ia __4 heallh WQDBJIIOIa. WPM Ia.... udY ·39 MEDCOM -936 DOD 003999 ,­ ---..- ENCY RESUSCITATION RECORD -PAl EMl For use of this rorm see MEDCOM Cir 4D-5 '~.(Iff. CID7if· 'tJ11( C""""aIO Ihb ~,.;t!rin 2 h ...... following ,no an_levent. "'_ the OffgNI In the patient's reawd _ prOY1de a oopy to the Nursltlt Sup¥Vioo. 2. LOCAnON OF RESUSCITAnON EVENT 1. DATE: fC.JL;N! 2eXJ'-' 3. YilWESSED ARRESTl o MICU o SICU o CCU o NICU ~ ED o PACU o OR o WARD: DYES IE NO o UNKNOWN o DlAGNOsnc I PROCEDURE AREA: MONITORED AT ONSET7 o OUTPATIENT CUNIC: DYES ~ NO o OTHER /Specify/: .. IHTERVEHTIONS I ./ ·IN Pl.ACE AT START OF ARREST) I ,/ • INSERTED DURING ARReln COMMeNTS Uirlv Acceu o Time: : J";15r-kJ ill r~l~ iffEndotrachaal Tubo o Tlme: : I:"'~(rkJ ;.., r;.,! o Mechanical Ventilation o Timo: : o Art.rill Une o Tlme: : o Centrsl Venous Una o Time: : o Pulmonary Artery Catheter o Tune: : o Nasogastrlc Tube o Time: : o PacinIJ Device (Specify type): o Tims: ._-:--­ 2t:pla~table Defibrillator I Catdioverter o Tlme: : j.,,..;---­ -: Other (Specifyl: ~UG!;'" g'Time: 6. IMMEDIATE CAUSE OF ARREST I EVENT 8. RESUSCITATION ATnMPTED 7. INJTlAL CONOITlON ICheck_J CONSCIOUS 00 YES (Check til char ~usrrdl o Lethal Arrhythmia& III CheSt Compressions DYes fi2I No BREATHINGtJ Dsfibril/ation o Hypotension o Respiratory Depr8s.~ion i!I Airw/l'f Management Dyes ~No PULSE o NO (ChBck one) o Metabolic o Mvocardial Infarction or Ischemia o False alllfm/arteSl IBLS I ALS not needed) Dyes ~No Site! o Do not anompl nosuBcitation (DNAR) e(Oth •I etl,~~u-i'C'lpI;~~ Ar({~J­ o unkc;wn 0 Considered 'utile o Foond dead - 9. EVENT TIMES 8. INITtAL RHYTHM 10. GLASGOW COMA SCALE (l'lTNII ..r ..... lrecl to Ulctttt.1tte AmwicI;n HNf1 _'n .nd I",,","~ l:...r"'P..... ~..... c • ..-.oJI ~eh.Nftnf_wvfo.MI J I!l Ventricular Fibrillation o l'erTUBlng Rhyttlm r:lrl'.J. ~..r. MII'''.1:hsn lo~. HOUA EYE OPElllING o Ventricular Tachycardia o BrlKIYcardia 4 • Spontaneously 3· To voice Collapse ( Arrest On:sot; : ­ o PulseI"•• Electric&1 Activity 0 Asystole IICTUflN OF SPONTANEOUS CIRCULATION IROSCI CPR St2rtod! ------ ~;po;n 1· 0 rosponse1st Defibrillation:o Retumed al: o Never aehlewd -: J. - o Unsuotained ROSe, 0 20 min 0 20 min Airway AchiDVed: VERBAL RESPONSE ---. --- CPR GTOJ'IIiDAT. ~:s5 1 ... n""B Epinephrine: : 5 • Oriented. converses 4 • Disoriented. converses Code Team ~Iled: WHY: o ROSC o DNAR 3 • Inappropriate responses JKJ Yes o No Tim.: .-J1:"\0 o Conaidered 'utJle 0"'o8alh ~,comprehensibl8 ,()unds PATlENT DlSPOSmON: 1· 0 response Coda Te.m hrlvod, - Tlme: 1": t..1.!1- MOTOR RESPONSE 6 • Obeys verbal comltl8nds 5 • Lncalizes painful stimUlus o YBS o No Cfj) PISN~lbl(6)~21O" 4 • Withdraws from pain stimulus AGE: 3 • Rexion. decortiCB1e posturing I 2 • Extension. decereblate GENDER: t,,\,":lL. Dposturing CC\\1\\J '(J'S\C-\ \ L\ HElGHT (in): 1 No movement WEIGHT 1100): 3 SCORE: MEDCOM FORM 679-R (TESn IMCHO) AUG 99 PREVIOUS EDITIONS ARE OBSOLETE Me V2.00 40