Medical Report: 20-Year-Old Male Iraqi Civilian, Baghdad, Iraq re: Gunshot Wound to Pelvis

• -- Cc 5-
1. REPORTING MTF . MTF LOCATION
ADMISSION AND CODING INFORMATION
(Stele or
1 2 3 8
(b)(3)-1 For use of this him, sue AR 40-400; proponent agency .s OTSG
Code) I
3REGISTER NUMBER masa= 1 I e.e 0I.r Ae:ridle I HI I 1 4 .PAY GRADE S. SEX
WM-4
9 10 11 12 13 14 15 16 17 1 8 It13)-4
5 DATE OF BIRTH (YYYYMMOD) 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION 19 20 21 22 23 24 25 26 27 28 29 30 5firekrNo
10 LENGTH OF SERVICE ETS 11. FMF 12. SOCIAL SECURITY NUMBER 32 33 34 35 36 44 45
Iromirurim 42 Ell
X0/-4
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS I HOUR OF ' BRANCH I CORPS ADMISSION 46 a07)
1 14 FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61
1
17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY ADMISSION Country Code)
YEAR
6 2 1 63 64 65 66 67 68 69 70 71
Lri
NO k-)3 20 SOURCE OF ADMISSION/ AUTHORITY FOR WARD
NAME RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION
72 1
ADDRESS OF EMERGENCY ADDRESSEE &chide ZIP Coate
I
eA/C2j
: ATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
113)-1
21 TYPE OF DISPOSITION TO22. MTF TRANSFERRED 23. DATE OF DISPOSITION (YYMMDD)
73 7 4 gl/P C- 75 76 77 78 79 80 81 82 83 84 85 86
.3 0 S-- 172-i ,g-
24 CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMDD)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 117
g A-11-21 LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 0 b--0 C 0 29. DATE INITIAL ADMISSION (YYMMDD)
(BaItle Casualty Only)
103 104 105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE • _ ._... _....... ..._...._ .___......---MIMI icy ...5--5, ••c-` . i

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ADMITTING OFFICER (Signature, as required) b)(6)-2
DA FORM 2985, MAR 89 Luilluriu IA MEDCOM -5812
DOD 13024
REPORTING MTF MTF LOCATION
ADMISSION AND CODING INFORMATION
oldr, 0,
Fr 8
13113)-1 Country
Fat use DI Ibis le en, sett AR 40.400: ptelionent agency ,. 0. 15(1
e
Code)
(WGISTE11 NUMBER ,t c%. ^e Middle
Initial) PAY GRADE . SPY
1/)(4/1---,--1-)2,14 -
q I III 13 15 16 17 18 4)(6 )-1
__A
--g----•
0 DATE OF BIRTH (YTYYMMOD) 7. AGE AT ADMISSION . RACE 9. ETHN C RELIGION BACK-
19 20 I ;!1 22 2324 26 27 28 29
25 ROI
GROUND
im
: INTil fillEdINCIIIIM .
SOCIAL SECURITY NUMBER
10 I.F.: NGI i OF SERVICE ETS 12.
, I 9 111=2"
3,' 31 34 37 38 391 40 41 42 9 1 4-1 45
NEI
KIR'
ORGANIZATION (Aceye Duty On/y) 13. MARITAL STATUS
i FL PING STATUS
_ ._......... _____

4 49
1 Y.UNIT LOCATION (Slate or Country Code)
.'
SE ir
15. BENEFICIARY CATEGORY a 51

pmAllitilkfil
18. MOS
64 65 66 67 68 69
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70 SOURCE OF ADMISSION/ AUTHORITY FOR WARD
----ADMISSION

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2.1 CLINIC SVC • ADMITTING
81 1.01 89 0
pt
27.LOCATION OF OCCURRENCE -------1—"-(Rattle C.i.watty On/y)
I I. ; I ..1.1 ,1
FOR LOC A L USE
eyCV1/
Vol
nUrAll-riNC; OF FILER (Si9natore. a S
I
DA FORM 2985. MAR 89
19. TRAUMA 70 71
b%3)-1
21 TYPE OF DISPOSITION 22. MTF TRANSFERRED TO
........_. ..... ..._ 111111111111111111 ao
0X3I-1
671‘ C—
25. MTF iRANSI-ERHtu r-Hum
91 92 93 94 95 96
28. MTF OF INITIAL ADMISSION 105 106 107 108 109 110
tric
-
FE1
S-7 ES-
HOUR OF BRANCH I CORPS ADMISSION
d0-1)
16. ZIP CODE OF RESIDENCE
53 54 55 56 5758 59 601

etilkillArellrara Ale,
PREY ADMISSION YEAR
NO
N
f--. M NAME RELATIONSHIP OF EMERGENCY ADDRESSEL
ADDRESS OF EMERGENCY ADDRESSEE (filcimle ZIP Coati!
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
23. DATE OF DISPOSITION (Y 1' Al M 0 DJ
81 82 83 84 85 86
26. DATE THIS ADMISSION (Y 1' M M 0 0)
97 98 99 100 101 ID'
2
29. DATE INITIAL ADMISSION (YYMMDD) 111 112 113 114 115 116
ATRE OF ADMITTING CLERK
req nred)
WM-2
Ce
MAY /W0n011, IL
MEDCOM - 5813
DOD 13025

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14Cc4 oV.7.i.44 -1
ja Le; Gy0.3/ 1.r0/ VI.1..lerI
TRANSFER MANIFEST

A-1 EXECUTIVE DIVISI

X3)-1
PPO AE

b)(6)-2
Postal Code: 09566-4008 country:
-.

Transfer Order 4:.T4624603124-1
. .

Planned Date: 2003/05/04
Issue Date: 2003/05/04
Actual Date; 2003/05/04
Issuing EQ:, Prop Ship Date: 2003/05/04
TransMode: •-AIR

Receiving Date:
TransType: •1.7-US CAMP

Ackidg Date:
Rec Org 0)(3)-1
Ackldg source:
Rec Auth: Shipping Addr ess'
Reason for Transfer:
I for further medical evaluation.
Going to [NCH
postal Code country
Phys Cond Pwr Srvd/National

ISN En/Cmp

Name Rank/Status Arm
F-PAIRIIZ-Iraq
El Al
Total Records on the Roster:

'MPH

b)(6)-2
Manifest Prepared By:
Change of Custody Record
bX6)-2
b)(6)-2 bX6)-4
SAA.Pry

1) Print Name/Signature* Jnit:_ Date:
,b)(6)-2 b)(6)-4
Z-47,114/.03
Date:Unit:
2) Print Name/Nignatur

Date:
3) Print Name/Signature' Unit
Date:
4) Print Name/Signature' nnit.

MEDCOM - 5814
DOD 13026

.PATIENT TREATMENT RECORD COW.. .iHEET
For use of this form, see AR 40-40Q; the proponent agency is OTSG
IF
:8)(3)-1
b)(6)-4 3.GRADE ADMISSION REMARK`,
b.
AGE :RACE RELIGION .LENGTH OE SVC 9.,ETS
10.PREVIOUS ADMISSION.
11.FMP
b)(6)-4 13. ORGANIZATION
14.VVARO
CI
tUk3
S. FLyiN6 16.RATING/ 17.DEPT,/ 18. BRANCH/CORPS 19.UIC/ZIP 20. TYPE
sTATus DSC BEN(,) CASE
SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
122. 23 CLINIC SERV( E
ADMISSION

24. NAME/RELATIONSHIP.OF EMERGENCY ADDRESSEE
25.TYPE ot..•817OBIT101.1 2B . 04,018p0BiTION
27a. ADDRESS OF EMERGENCY ADDRESSEE IlocIude ZIP Code)
276. TELEPHONE NO. 8.DATE .0 ,HIS ADMITTING OFFICER
ADMISGIO
N
29. NAME. AND LOCATION OF MEDICAL TREATMENT FACILITY
3d , ,DATE:O.F.:1 32.. UNITS OF WHOLE ELOOU , COMPONENT TRANSTusrD
b)(3)-1
IRAQ
SELECTED ADMINISTRATIVE DATA
Check it Conontied on. Revnnn,
33. CAUSE OF INJURY
DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
It 1
(c

6,q&;i(v
35. Total Days This Facility
ABShN I blIA UATb
bOTHER DAYS CONY LV/COOP SUPPLEMENTAL DAYS — fTO-TALNks DAYS
1
CARE DAYS CARE DAYS BED
316. Total Days All Facilites
a.ABSENT SICK DAYS b.
OTHER DAYS C.• • CONV..LV/COOP SUPPLEMENTAL
CARE DAYS

BED DAYS TOTAI. SICK GA r':;I
CARE DAYS •
b)(6)-2
S GNATURE OLEO OR h4Fnir agynnrsc )(6)-2
r

1.1SAI'PC V 1.111
MEDCOM - 5815
DOD 13027

(b)(6)-4
NAME
;b)(6)-4
ss#

CASS ICD-9 AND CPT CODES
ICD-9I CPT
-751- l-
ci o
v (-1,1.1s 9
MEDCOM - 5816
DOD 13028

..4PATIENT TREATMENT RECORD COVER SHEET
For use of this form. see AR 40-400; the proponent agency is OTSG (b)(6)-4 3. GRADE ADMISSION REMARKS
8. LENGTH OF SVC
9.ETS 10. PREVIOUS ADMISSION
13, ORGANIZATION 19. WARD_
le.410
15FLYIN16.RATING/ 17.

DEPT./ Ta. BRANCH/CORPS 19.UIC/ZIP 20. TYPE CASE
STATUSDSC BEN
-27—BoURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22. HOURS OF 23. CLINIC SERVICE
ADMISSION
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
25. TYPE DISPOSITION 26. CDVI:41'6ISPOSITION
vrm. yr Ularls/JI HUN
'a ADDRESS OF EMERGENCY ADDRESSEE I Include ZIP Code)
276. TELEPHONE NO. IS
ADMITTING.OFFICER
ADMISSION
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
30.DATE OF IF
32. UNITS OF WHOLE 81.000.
ADMISSION
COMPONENT TRANSFUSE() AUMINII, I RA I IVE DATA
(b)(3)-1
Check 11 Continued on Reverse
33.CA
f(p 6:&
c\1
35. Total Days This Facility
— CONV. LV/COOP d. SUPPLEMENTAL e.BED DAYS I.TOTALK DAYS
AbbEN I blIA DAYS b. OTHER DAYS C.
CARE DAYS
CARE DAYS
36. Total Days All Facilites
ABSENT SICK DAYS b.
OTHER DAYS CONV. 1V/COOP • 81lf'LISTRTA L BED GAYS
CARE DAYS TOTAL SICK DAYS b)u(6)R-21_
I c
ginner) Inc no ne n nn •• ¦ •
k_vr
OT1M 3647, MAY 79 EDITION OF 1 A
USAPPC VI 10
MEDCOM - 5817
DOD 13029
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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DEPART./SERVICE HOSPITAL CR MEDICAL FACILITY . . RECORDS MAINTAWED AT

PATIENT'S IDENTIFICATION: I FOI typed or written entries, give: Name - last, first: middle; !REGISTER NO.
WARD NO
ID No or SSN: Sex Date of Birth; Rank/Gradel i
PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5-99)
Presenbed by GSAIICMR FPMR (41 CFR) 101-11.203(b)(10)
MEDCOM - 5818
.11411.1••
DOD 13030

DATE NOTES
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MEDCOM - 5819
DOD 13031

AUTHORQED FOR LOCAL REPRODUCTION
MEDICAL RECORD PROGRESS NOTES
DATE NOTES
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LAST FIRST
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entnes, give: Name - last, first, middle; REGISTER NO.
WARD NO.
ID No or SSN: Sex; Date of Birth; RanklGradel
(b)(6)-4 I
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV. 5-99)
Prescribed by GSNICMR FPMR (41 CFR) 1 01-11.203(bH 10)
MEDCOM - 5820
DOD 13032

AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTESMEDICAL RECORD
DATE NOTES
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PATIENTS IDENTIFICATION: 'For typed or written entries. give: Name - last, first, middle; (REGISTER NO.
WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Gradel
(b)(6)-4
PROGRESS NOTES Medical Record
STANDARD FORM 509 (REV 5-99) Presulbed by GSNICMR FPMR (41 CFR) 101-11 203(b)(10)
MEDCOM - 5821
DOD 13033

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FPI LEX a Printed on Recycled Paper STANDARD FORM 509 (Rh-v.5-99) BACK
MEDCOM - 5822
DOD 13034

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.
PATIENT IDENTIFICATION DATE3F ORDER TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS
SIGN
:1*6)-4
b)(6)-2
ZW144.41.,
NURSING UNIT ROOM NO. BED NO.
,b)(6)-2
L

PATIENT IDENTIFICATION DATE OF ORDER
TIME OF DR gen —
13)(3)-1
4-17/m.-p td oit-e_tios
b)(6)-2
NURSING UNIT ROOM NO. BED NO.
b)(6)-2
PATIENT IDENTIFICATION DATE F ORDER TIME OF ORDER
HOURS
b)(6)-2
NURSING UNIT ROOM NO. BED NO.
1 PI/j111
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
NURSING UNIT ROOM NO. I BED NO.
REPLACES EDITION OF t JUL 77, WHICH MAY BE USED.
DA 1 FAMM4256
79
MEDCOM - 5823
DOD 13035

CLINICAL RECORD • DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD TEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
TENT IDENTIFICATIONDAT,,Ei OF ORDERI TIME OF ORDERI LIST TIMEIDENTIFICATIONI
ORDER
NOTED AND
41 4111-1/ HOURS SIGN
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IENT IDENTIFICATION DATE OF ORDER ¦ TIME OF ORDER
HOURS
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IENT IDENTIFICATION I ; ftcf.0y 7-Zas R.7DATE OF ORDER / TIME OF ORDER d
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FORM REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
, APR 79 4256
MEDCOM - 5824
- • - - • • • _ • _
DOD 13036
THERAPEUTIC DOCUMENTATION CARE PLAN (NON-MEDICATION) I
For use of this form, see AR 40-407;
CLINICAL RECORD II2r10.6C-Trr. 0'/`
the Frornont army Is the Off les of The Surgeon General. —
VERIFY BY INI77ALINO A I INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

HR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
DATE NURSE FREQUENCY, TIME

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DOD 13037

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MEDCOM - 5826
DOD 13038

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
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DA FORM 4678, 1 FEB 79

EDITION OF 1 DEC 77 WILL RE USED UNTIL EXHAUSTED. MEDCOM -5827
DOD 13039

THERAPEUTIC DOCUMENTATION CARE PLAN I .Yr.
Verify by
(MEDICATIONS) J.
Initialing
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Time Given Initials
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MEDCOM -5828
DOD 13040