Medical Report: 17-Year-Old Iraqi Male Detainee, Basim Mohammed Hussein, Abu Ghraib Prison, Baghdad, Iraq re: Minor Injuries Incurred While being Apprehended(0014-03-CID919-63732)

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PATIENT'S IDENTIFICA TION.
CHRONOLOGICAL RECORD OF MEDICAL CARE
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Diagnosis (From Page 1)

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BACK PAIN, HX OF KIDNEY STONE S, UNABLE TO URINATE X 1D o T-98.0, BP-157/84, P-109
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POSS KIDNET STONE P REHYDRATE, TEST URINE
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BP 145/60, P-111 0154: 30MG IVP KETROLAC 0207: INITIATED FOLEY CATHETER, UR;J;NE OS LIGHT YELLOW 0220
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SPG-1.005! MOD BLOOD (NON-HEMOLYZED)
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CIPRO IV 49MG OVER 1 HR
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Internment Serial Num.
Diagnosis (From Page 1) (b) (6) -4
S
KIDNEY PAIN UNRESPONSIVE TO CIPRO

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PT ARRIVED 10 JUNE, TREATED W/ CIPRO, HAS NOT COMPLETED TREATMENT DIAGNOSED W/ UTI

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CIPRO IV 400MG IN 200ML 5% DEXTROSE (R) ARM 18G.

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Diagnosis (From Page 1)
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S: injuries at abu gharib in Ma~injuries to neck, back, chest c c1ubs, inju--r~i-e-s--t-o-wrists c hand cuffs, injuries to rectum c gigalo
0: lungs NAn, ms -walking bent over, positive tenderness over back and L neck, COR-RRR, Lungs CDA,
A: injuries c hematuria
P: report case
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Diagnosis (From Page 1)

S: "kidney pain" x 1 d, able to urinate, says cipro no effect
0: t 97.7, bp 140/68
A: Possible UTI
P: Transport and test
I: 0636: u/a SpG 1.030, blood non-hemolyzed, pH 5.0
E: UTI, Bactr4m 960 bid x 7d
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Diagnosis (From Page 1)

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s: with back pain, f/u for uti med allergy to pcn. Pt has taked cipro bactrin with no relief back pain still strong vomitted upon arrival to aid station.
0: bp 148/69 p10? spo2 98 t 98.3
A: Kidney pain
P: IV 1000cc n.s. phenergan i.v. 25 mg.1cc n.s. im lu quad of buttoks 1000co lr iv d/c 1415
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Internment Serial Num.
Diagnosis (From Page 1)
S: UTI flu, pt c/o LUQ pn radiating to shoulder
0: t-98.78, 169/79, p-96 no RQ pn, urine test-moderate blood
A: possible bladder infection
P: NKDA

currently taking Cirpo 500mg Levaquin 500mg QIDx7d
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EPW/CI Medical Report Last Name First Name, MI
Internment Serial Num.
rb)(6)-4 I
[b)(6)-4 1b)(6)-4 I
I
EPW/CI Location BirthDate
Sex
Height Weight C-IN CAMP
1986/01/01
M
66 163 Physical Condition Religion
Education
Marital Status F-FAIR B-ELEMENTARY SCHOOL
33-SUNNI-ISLAM S-SINGLE
I
Distinguishing Marks: Remarks Hair Color
Eye Color
Race IBlood Type IDiet X-OTHER
-.
Examination Information
Examination Number Date Time 16551-06 2004/07/11 11:30:01 AM Diagnosis Please see attached page I Disposition Type Disposition Date 2004/07/12 I Exam Category Type of Case A1-TO BE DEFINED BC-TO BE DEFINED Comments Please see attached page Disposition Time 12:00:00 AM
.-Immunizations . ... .
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S: he had
pt states he had artian ficial up North while incarcirated,anuspenis put into his
bleeding following this
0: Anus exterior hemorroid, oval fistula akso present by ~b)(6)-2 lexam.
A: anal fistula ,
P: I refer for further eval.

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Comments (From Page 1) '!"b)=(6)~-4----~
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EPW Medical Screen Form
39th Brigade Surgeons Office
Date: Time: I £J'W-"'"1 &"{ / "Ie 0 j Name: fb)(S)-4

Interpreter Present

Yes 0 No
Understands English?

No 0 Yes o Fluent 0 Basic Married o Yes 0 No
Estimated Height: _____ Weight: Age: {'
Any visible wounds/injuries/deformities: ____-+-_________________
Any visible scars/tattooslldentifying marks: ___--!....._________________

o Other _________
General Appearance: o Healthy , o Malnourished ./dIll
Past Medical History:

, ""'Alfergies:
'-.--'
Medications:
VS: Pulse: g() SIP: I ")(,(7Lj
HEENT: '(..!wI...
Chest:

CV:
Abdomen: UElLE/Splne: Neurological: General assessment: Follow up needed:

Signed:

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fb)(6)-4

C-MED PATIENT SURVEY
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MDIPA

DATE\~~D~
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EXHIBIT II
MEDCOM -647

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Bri8ad~Suraeon
39th Briaade Combat Tea.m
1st Cavalry Division

DETAINEE MEDICAL SCREENING FORM
DATE:~ 0dIJr
bj(6)-4
NAME-Lb)~(6~)-4__________,--_AGE: 254 HEIGHT: ___WEIGHT; ___
ALLERGIES: }it/NO 0 YES: ______-'--__________
MEDICATIONS: VO( 4A-'(~ hV) I
MEDICAL HISTORY: 0 If'lHMA, 0 DIABETES, 0 HEART DISEASE, 0 TUBERCULOSIS, 0 OTHER INFECTIOUS DISEASES:&-: &it-t(? )::;h ~5, 0 OPIUM USE SMOKER: 0 YES 0 NO c9 j:::' ck., ~ ~$-(..{ 2-06 0
EXAM: I '1 -r-9P'
P: lit.. BP: (~QO APPEARANCE: o HEALTHY, 0 MALNOURISHED~L
HEENT:f/~M Cr~ &t'c~JU! c .be$? .j;. t..,C~.j.~

CHEST; -CV; ~k--ABDOMEN: .f /ttT I . Ms:Me -S eJol SKIN: W/])
DENTAL: _______________________

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GENERAL ASSESSMENT:
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OFFICER: -----L-mror.-n ..... m'T.rC11::-...::-~'--/i-G--SICK CALL: ifM. ~c) 'f
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(~oq-AID ~Y/Vi{)J1$ n1.7 ~dF6)-2 ·I fL-)(_6)-_2.__---'[ j,j'c 5P DISCHARGE NOTE:-VNO CHANGE IN HEALTH STATUS DATE: .
II~oy ..... -.J {Z4-04 '-~. C /1'-./~ ~~ &4. 0 ~ ~...-~u---{..-.J.;

(MC, DC, MS)
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