Medical Report: 22-Year-Old Iraqi Male, Baghdad, Iraq re: Gunshot Wounds to Left Leg

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MEDICAL RECORD-SUPPLEMENTAL MEDI,
-,or use of this form, see Ali 40-66; the proponent agency is the Office of The Surgeon General.

OTSG APPROVED (Date)
REPORT TITLE

INTENSIVE CARE NURSING FLOW SHEET QA APPR 08MAR89
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[11 HISTORY/PHYSICAL . FLOW CHART
. OTHER EXAMINATION . OTHER apead OR EVALUATION
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111 DIAGNOSTIC STUDIES
DA FORM 4700, MAY 78
. TREATMENT
USAPPC V2 DO
MEDCOM - 16442
DOD-029831
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DOD-029832
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,.:AL RECORD-SUPPLEMENTAL MEC ..,ATA
For use of th.._..orm, see AR 40-66; the proponent agency is the Office -. he Surgeon General.
OTSG APPROVED (Date)
REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET QA APPR 08MAR8
INITIAL IF ASSESSMENT
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.
DA FORM 4700, MAY 78
USA PPC V2.00
MEDCOM - 16444
DOD-029833
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CD

DOD-029834

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RECORD ­SUPPLEMENTAL MEL DATA
For use of form, see AR 40-66; the proponent agency is the Office......fhe Surgeon General.
REPORT TITLE
INTENSIVE CARE NURSING.OTSG APPROVED /Date/

',V SHEET QA APPR 08MAR8
INITIAL SHIFT ASSESSMENT
Time:
Pupils Initals:
Sensorium

1-e6P rJs
LOC / GCS
C Cardiac Rhythm
_
A PRI: / QRS: R Pulse Strength D
Cap Refil / JVD I Edema A
Chest Pain
C
Respiratory Pattern
Breath Sounds
Secretions
Cough

Color
Integrity
Backside

Access Devices
Location
Condition

P DEPARTMENT/SERVICE/CLINIC ICU3, or written first, middle; grade; date; hckspitafrpr medical facility)entries give: Name —last, . HISTORY/PHYSICAL . FLOW CHART
. OTHER EXAMINATION OR EVALUATION . OTHER [Specify)
. DIAGNOSTIC STUDIES
DA FORM 4700, MAY 78 . TREATMENT

MEDCOM - 16446 USAPPC V2.00
DOD-029835
VITALS 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 05
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DOD-029836
TEMPHRRR Sa02 77,;] P15,'
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INTAKE 06 1 07 08 09 10 11 12 13 14 15 16 171Total 18 19 20 21 1 22 23 I j o 02 04 L_J IVFIVPBNGT
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OUTPUT 06 07 08 09 10 I 12 13 14 15 16 17 Total 18 20 21 22I 23 I00 of 02 03
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MEDCOM - 16447
Total
1 ..REPORTING MTF 2..MTF LOCATION
ADMISSION AND CODING INFORMATION
1 2 3 4 5 6 7 8 afore or I Country
For use of this torte, see AR 40-400: the proponent agency is GSSG
A Code.)
fl' ; , :

3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX 9 10 11 12 13 14 15 16 17
,),,

'CO') ( c.t) -LI expo
6, DATE OF BIRTH (VVVYMMO 01 7. AGE AT 8. RACE 9. ETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 31 BACK­GROUNDa -z-2_ Ez (9--q7 LA. A..)1(...__.
10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER 32 33 34 1 35 36 37 WI 39 40 41 42 43 44.45
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF BRANCO-11 COR •--ADMISSION
46 10 ( c_ - Li
14. FLYING STATUS 16. BENEFICIARY 16. ZIP CODE OF RESIDENCE
um
CATEGORY
47 48 49 50 53 54 55 56 57 58 59 60 61
17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREV, ADMISSION
in
Country Code)

YEAR NO
62 64 65 66 67 68 69 70 71
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE20. SOURCE Of ADMISSION/ AUTHORITY FOR WARD

. ...
..

ADMISSION lit AN.,72
ADDRESS OF EMERGENCY ADDRESSEE (Include .VP Code)
.i',C(A. 5
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NAM TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
2 . TYPE OF DISPOSITION , _ SFERRED TO 23. DATE OF DISPOSITION (V VMMOD1
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0 42 1 ?
24. CLINIC SVC . ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (YYMMOD)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102
Pc- E Pt- ft" (1) 3 (1) 9
27. LOCATION OF OCCURRENCE 28..MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IY VMMDO)
103 104 (Battle Casualty Only) 105 106 107 108 109 110 111 112 113 114 115 116

FOR LOCAL USE
U1 (u 1 i -1-13
b Cc.6- Q

ADMITTING OFFICER (Signature, as required/
DA FORM 2985, MAR 89 USAPPCV1.0
MEDCOM - 16448
DOD-029837
•
.

INPATIENT TREATMENT RECORD COVER SHEET
b(C52, For use of this form, see Ali 40-400; the proponent agency is OTSG
1. REGISTER NUMBER
2. NAM La First. Mt
4,791,A)
.. DE

ADMISSION REMARKS
411.111111
4.
SEX 5. AGE 6.
RACE 7. RELIGION 8tENGTWOF SVC 19. ETS
1 . PREVIOUS

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13. ORGANIZATION
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TYPE CASE ,...,..---.
STATUS DSG BEN
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21.
SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22. HOURS OF 23. CLINIC SERVICE ADMISSION

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24.
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
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26. DATE OF DISPOSITION i \ .
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27a.
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
27b. TELEPH• NE NO. .
28. DATE OF TH‘4 ADMITTING OFFI ADMISSION
a fLif-- 61 /7.1C. pe,
29. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY /161-u403,
30. DATE OF I AL 32.

UNITS OF WHOLE BLOOD/ADMISSION COMPONENT TRANSFUSED
3 1 . SELECTEO ADMI NIS
Check if Continued on Reverse
33.
CAUSE OF INJURY

34.

OlAtNOSES/OPERATIONS AND SPECIAL PROCEDURES
.69,() czo CailA04it
35. Total Days Tis Facility
a. ABSENT SICK DAYS b.
OTHER DAYS

C. CONV. LV/COOP d. SUPPLEMENTAL
BED DAYS t.

TOTAL SICK DAYS
CARE D CARE DAYS
0 e 3
36. Total Days All Facilites
ABSENT SICK DAYS b.
a. .A\3
OTHER D YS

CONV. LV/COOP d. SUPPLEMENTAL
BED DAYS I.

TOTAL SICK DAYSCARE DAYS CARE DAYS
SIGNATURE OF ATTE NG MEDICAL OFF
DICAL RECORDS OFFICER

• DA FOR
MEDCOM -CI,V1/1•1 rsr • • -nne•on•
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DOD-029838

MDICAL - RECORD .
• ---ABBREVIATED-AEDICAL--RECORD-- •

PERTINENT 14ISTORY.i.."FnErCOMPLARVLAX
ON ADMISSION f F:atir rifift of
(
PliYSICAL EXAMINATION
:

PROGRESS
, 1•:ater dote of •if,filarge Grp/ distino.in

SIGNATURE OF'PHYSICaff
• -

DATE
IDENTiriCATION i 0.FAGANiZATiON

PATIENT'S IDENTIFICATiON
(For typect ot written entrieb peer
.midelle, &ids lasr. firer.

Name
dAte:
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wARID NO.
(A. -
ASBREVIATED MEDICAL

RECORD
Standard 797311 dad
GENERAL SERYtCES AbmiwTRATION ;ANDINTERAGENCY COMMITTEE ON MEDICAL
RECORDS
FIRMA i41 CFR` 201-45,5C5. OCTOBER

MEDCOM - 16450
DOD-029839

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
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REGISTER NO.

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• Medical Record

STANDARD FORM BOO.(REV. 6.97)Prescribed by GSAIICMR FIRMR (41 CFR)201-9.202.1 USAPA V2.00
MEDCOM - 16451
DOD-029840

DATE
ISATIOD-))

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SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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USAPA V2.00
MEDCOM - 16452
DOD-029841
( 2 )
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AUTHORDID FOR LOCAL REPRODUCTION
MEDICAL RECORD I PROGRESS NOTES
DATE NOTES
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MEDCOM - 16453

DOD-029842

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PROGRESS NOTES .
DATE NOTES
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STANDARD FORM 509 (REV. snsas) Prescribed by GSAIICMR FPMR 14ICFRI 101.11203041W
USAPA VI 00
MEDCOM - 16454
No( (fl'H

DOD-029843

MEDICAL RECORD PROGRESS NOTES
DATE
:fi r.41.i - A A • /A._ IL- we& A •,..• . MI!. 0.A . •• Imre...d • a ,
2-_-5.-e--, 14,14,6 4 cr -4 Po,5, e eet."--peD .. gr-ik--141 5Q. B s .0 x) Ai tc-1,,,k Peri 1ei•
61,1,J. Prvir 4.—Q e, )1,9_, , 3 , Pe541-47. 1. p-71 +0 Cs C., otAj, E. r 1,,,p I ,
CIAA) 5-P C-c)&s.-2, , Aa, h, Q_ 1, Or*. --C n (p tArti/c± I pr/4-,.d r-o_
1 t...-, P a.5.6) grA-L.i, ifs 1 1-1/4r,---or ------5- -V
• 41 . f Pe C . A. W.A._. /IN.Ai ¦.¦.m.._.P.....0., ,

P
p I

t • 4 • !..... __Ai Ng ... . ...,
.1 • I A ...... . . A ..-y II, .01-7Cf'
• 111

.i, I . • A_./___. ¦ 1 I I" Al.!AAA& 4_A Age.f AA •.I I ILL.°.gi.e I e, ..
_ II 0......i . A IA.a lli.4.44
IP I
070. i 4
I A , ,_IA it 2 i I. .u. AI ..‘ i . . I_ .4.4.r., 1 i I
IL '.A.4.0 V AA i .4 i A 4A1 ' I • 1 XL!. $ . A ik - .I • 9 0 .. "A1.4 Atti, . gr t
¦Ii..
let. / . 1' i.At La k ig. AP 1444... • . ,„ I. AAA • • A #44.• -- A ".. . iiiiA.f
1

..OL,-Lr
.
sifYiYIAAA"'I.

PATIENT'S IDENTIFICATION (Continue on reverse side) (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility) REGISTER NO. WARD NO.
PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR 141 USAPPC V1.00
MEDCOM - 16455
DOD-029844

yr
.1.2."..1r2to
OA..41...p.....1°.crl
4 NRIMNIMMOMPINIMMOIMMIIMMIMMINININ
.,aiNI
•¦•11

CHRONOLOGICAL RECORD OF IIM3OICAL CARE
MEDICAL RECORD.
bat Sat. mai= NM or SS* Se=

PATIENT'S 1111301i1CATINt rue tweet ar memo esurka. Ow= Mobs -.13gase of Sith; 01011115)0000
CHRONOLOGICAL RECORD OF MEDICAL C Medical Record
STANDARD FORM 60D akEv_ 6-971
Peaseas4 by -66ANCINI
g2.

-
FIRMA 141 M* 1 20/-9,202-1
MEDCOM - 16456

MI11111.011
DOD-029845
NSN 7540-00-634-4176
I
AUTHORIZED FOk LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTONS, DIAGNOSIS. TREATMENT REATING ORGANIZATION (Sign each entry)
4)YN:56,-:-C-
`1 • . 1 x . .- - 5 1 ? .SOC"­
t_1SS (It-GSAOca(k-1A-k. le----Yce_--P,--ta-e asr.c ei./ Y-e-leir io¦ ,--a d fe,.SS \ il E-S
_ate-Co c----\6 r....1"re-Ax-es_s ' , N-5 %I. S uk r k \
tiNDou,,AAs gcci,L,L0C+/—e-^—
I.

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT
SPONSOR'S NAME SSN/ID NO.
RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; REGISTER NO. WARD NO. Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600 (REV. 6-97)Prescribed by GSA/ICMR

E 11111/
FIRMR (41 CFR) 2014.202-1
MEDCOM - 16457
air
DOD-029846

NSN 7540-01-075-3786
LOG NUMBER TREATMENT F CI
EMERGED CARE MEDICAL RECORD AND TREATMENT
RECORDS MAINTAI AT

(Patient)
AO 2.) -7-/

PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL
STREET ADDRESS DATE (Day, Month, Year) TIME
14A-Vel 0 3 10 5
CITY STATE ZIP CODE TRANSPORTATION TO FACILITY -
SEX DUTY/LOCAL PHONE , MILITARY STATUS A4,4/A-c., THIRD PARTY INSURANCE
?...d..... AREA CODE NUMBER ITEM YES NO N/A ITEM IYES NO
PRP ADDITIONAL INSURANCE
AGE HOME PHONE FLYING STATUS DD 2568 IN CHART
AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY

CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT WHEN (Dare) DATE LAST VISIT 24 HOUR RETURN
ITEM YES NO
0 YES n NO
IS THIS AN INJURY? WHERE TETANUS ALLERGIES INJURY/SAFETY FORMS DATE LAST SHOT COMPLETED INTI IAL SERIES i 0 YES 0 NO
CHIEF COMPLAINT
s.._..-
CATEGORY OF TREATMENT VITAL SlithrTS TIME TIME
. EMERGENT BP NV V)
PULSE
c?
1:1 URGENT INITIALS RESP
it
TEMPRNON URGENT WT
LAB ORDE RS
CBC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT CXR PA & LAT/PORTABLE C-SPINE
URINE C&S UA MSCC/CATH CHEM:
BLOOD C&S X
SM3OU0
Ab1:1 -X

ACUTE ABDOMEN LS SPINE
SINUS HEAD CT ANKLE R/L
ORDERS
ri-RULS E OX MONITOR ECG
TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS n HOME n FULL DUTY n 24 HRS. n 48 HRS. D 78 HRS. MODIFIED DUTY UNTIL RETURN TO DUTY
CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE lop. TO WHEN
REFERRED
• IMPROVED UNCHANGED
.
• DETERIORATE TIME OF RELEASE I have received and understand these instructions .
PATIENT'S SIGNATURE
PATIENTS IDENTIFICATION (For typed or written entries, give: Name — last,first, middle; ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record

STANDARD FORM 558 (REV. 9-96)
Prescribed by GS/VICMR
FPMR (41 CFR) 101-11.203(b)(10)
USAPA V1.00

MEDCOM - 16458
DOD-029847

NSN 7540-01-075-3786 TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD I
(Doctor)
TEST RESULTS
WBC Check if read by
q
ABG/PULSE OX RADIOLOGY
radiologist
U H/H SUP 02 PH P02 RESULTS

3,6 A 711 -
?ErAff

PLT PCO2 SAT -- • OTHER '
A 7.'4N
PT DIP
EKG INTER RETATION

APTT BHCG ETOH MICRO
PROVIDER HISTORY/PHYSIC
FPA-1)
tr f,,eple•
S/7 ( Vt° di/
5'. eassof
z
'0-
I/ :6
65a.9
-F9
7--
/,14-4144-
/t, .s-4‘,0752_
Abti 0-toe
Mtal
RAZ--
Scarte---
-cee-a-
.4 7z 9, et.,
5, 6- k
kci
t
5.A G SK-
-es

CONSULT WITH TIME ACTION REST DENT/MEDICAL STU IGNATURE AND STA
P
DIAGNOSIS
6,-4,, c /-1-4 0-ca
0
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name — last, first, middle; ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record

STANDARD FORM 558 (REV. 9-96)
Prescribed by GSA/ICMR
FPMR (41 CFR) 101-11.203(6)(10)
USAPA V1.00

MEDCOM - 16459
DOD-029848

4TH FORWARD SURGICAL TEAM PATIENT RECORD
,... f ..1
DTG IN: -"1 / (3 I AIRWAY: ORAL
J
TO OR: ,---' TIME OF INJURY: , NASAL
NAME: ilk DETAILS OF INJUR TNT:

gLO
SSN: NI Je UNIT: NbIrVI. (111(11 CalS
CHEST: itcmtac ,scarc
Or

WT LBS: WT KG1.\
-
ALLERGIES: TA GAL
t-OkhO erctrikt@t.
RIGHT BS=
NEURO: GCS=

TIME IV SZ SITE
ft+-0

/ MIMI tM711S,111 , CS PRIOR TO ARRIVIAL= .
. _ .
4.12.0 2 11111Lii HEAD, FACE, & NECK:
a0

CiS-
ITERS OF FLUID IN:

4 BDOMEN:
t /..g. I L'Dp C,c,e9/0---\. 4_. ---' )( L( %OAS Y.)
UNITS OF BLOOD IN:
PE
& DOSE

lcil,c7, Atl i -UPPER LEGS:
-squp.ramiL,„
m ,TIME INTERVENTION

LOWER LEGS:

I 4) 3/-Si
' OXYGEN ON & RATE: ep„,1s2_,--ptA9.4e_. +.0 i di 0-4112.4
ETT SIZE:
1 I •
SURG. AIRWAY
ARMS:

CT #1 & SITE: 4a luD a,/-"W‘
TR.: Pa•k
CT #2 & SITE:
FOLEY
POSTERIOR: ir f
GASTRIC
OAR 4AC14-1,431:71,v(161 0
TIMES MEDICATIONS •FLUID-TOTALS VITAL SIGNS
ix IN: MIDAZOAM 4TIBIOTIC: CRYSTAL: ---TIME: q I S .3b i -

(;) INC [SION: PENTOTHAL COLLOID: BP:
ETOMIDATE )5 e3 / 3g ,PROC. END:
EBV :
FENTANYL REVERSAL: HR: .. 9' EN
cn TO AC W:
44 MSO4 EBL: RR:
¦ 11,
1 illirThil

= ANESTESIA TECH: SUCCINYL.
E. UO.: Sp02: w. q MI
(et) MAC: ROCURONIUM OTHER:
W DRAINS. TEMP:
VECURONIUMZ REGIONAL:
-*I AGENTS:
GENERAL:
•
L'146 4 FiD 4k)C4
TIME IN: 02 VIA

IV SITE RE-EVALUATION POST-ANESTHESIASURGEON(S): .i. 1.\(.3 6)-7 IV SZ SITE RATE
AB IN

RECOVERY SCORE

wan BAG
PROCEURE:
Ig irk w. ',AI& ADMIT=
1 '. 1)4" bg S

30 MIN=
x, IfC,1 ILI " en4-1 Y 1" e,y.. ) f
DIC=
11 i ' •A 6..4. S..:.•.LA Q

12 A IW.
.. di - ALM
VITAL SIGNS
'RES GS:
POST-OP MEDICATIONS ADM IT D/
KVAIIMINIElraMMICEEMMEI TIME MED & DOS ROUTE

BP: INEMIleja P
., fami iiriA7mumm
a Ponen= HR: MIAIIEVAI

fra RR: wom m in
0 41 TEMP: 7 7
U
w
g g20 2 q k ' I.1 CUMULATIVE I & 0
TUBES: INTAKE OUTPUT
1

SOURCE AMT SOURCE AMT
/
P W
ailarglir
I
DRAINS:
TCY1' A T =
TOTAL=niim-v-srInn _ I RA Pll
DOD-029849
i -STAT EG?+

Pt: 00 Pt Name
Ha 140 001/L
K.4.0 mmol/L

TCO2.27 mmol/L
iCa.1.21 mmol/L

HCL 45 '.PCV
Hb*.

15 g/dL
*via Hct

At 7C

PH.7.424
PCna.

38.8 mmHg

P02.62 mmHg
HCO3.25 mmol/L

6Eecf.1 mmol/L
s0a*.

*calculated

Sample Type_:

14FE803.

14: a2

Oper• 0000000

Physician: .

l'Ser# fillip

Ver: JRMSO44C
CLEW R89

MEDCOM - 16461
JAO LOT 98 / 8bT 86 ZS 00:0T
AJO ETT BB / E9T 66 ES 05:14
JAC VTT E6 / 6ST 96 S6 SS:17T
AJO !MT 08 / EST 56 66 00:ST
AJO TOT 08 / EtT 86 L8 90:ST
AJO 90T T8 / 5bT 15815 88 OT:ST

JAC.

96 Co ST:ST
AJO.66 68 OE:ST

1011135.

HMS.
AJO 46.

41. / OET 0 Z8 TEST
AO 96.

9L / BET 46 SB SO:ST

sHuu.

% WIR WW:HB

HO.

NIL

BB NUN - UI0 / SAS ZOdS.

ON32l1 EIBIB

E0/0T/80.

•

DOD-029850

•
NSN 7540-00-634-4124

511-119
MEDICAL RECORD VITAL SIGNS RECORD
•

HOSPITAL DAY t POST-DAY
1..,
•
%'5 IL. I3.
MONTH-YEAR DAY 1
-i
19 HOUR
•

I• 0-
T : .
•
.
•
(AluoapualaiakiJoj 's4ualeAlrib3apai pao) • .
(...) .
0.....n 0cn 0co 00 0 0 0
° °
02:co O .1. CN 0 N.-1-1 CO 0
o ci ai cd cd N: r.r-:ca ai Lei tri w .4-tn c-n co cn me)CO CO CO CI I--
•

PULSE TEMP. F . 45
. .
(0) (-)

.
•

g7
. . . . . . . . . . . . . . . .
. . . . . . . . . .
. .
•

. . . . . . . . . . . .
180 104° . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c
170 103°
. . .
. . . .
....
. . . . . . . . . . . . . . . .
. . . . . . .
. . . . . . . . .
"
. . . . . .
160 102° • • • . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
• • • • • • • • • . . . . . . .
. . . . . . . . . . . . . . . . . .
150 10 . . . . . . . . .

• •• ....
. .
. .
. .

. . .
. . . . . .
*Qs•
. . .
•; •
....
..
'
140
100
•
. . . . . . . . .
.
.
..
•
. . . . . . . .
. . . . . . . . .
. . i ii . le . . . . . . . . . . .
• if• ° • • • •-----
130 9
. . . . . .
' " " P• ii • ' i .•
120 8° : . . . . . . . . .. . . . . . . . . .
"
•
.

. . . . . . . .
. . . . . . .. . . . . . . . . . . . . . . . " •• •-' " ----• •• •• •• •• ••
. .
. . .

110 7°
00 • "
• •
. . . .. . . . . . . . .
. . . . . . . . . .

•
100 96° . ,
. .
. . --• • •• •• •• "
....
' • "
•
....

. . . . . . .
'
90 9
•• • ....
.... ...

" • • • • - • - -
....• e) : : : : 0 :.
LA • ;•,t •

0
.. • • •
80
70
. . . .
.... I
:
.

. . . . .
.
: :
•
. .

•
•• 0 • ' N' '
•
•. .•
•• •A
. .
•A /•• •
. . . .
. . . . . . . . . .
. . . . . . . . . . . .
. . . . . . . . . .
" •• " •• •• •• •• •• ••
60
: :
. . . .
. . . . . . . .

. .
50
. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
i

40
4 RESPIRATION RECORD 8
..S
IS, / in Iv
0,0" Il trqp,
?vim,
BLOOD PRESSURE
ash&
'Record special data only when so ordered
1 Ytt
p Oh) ,2,114,
*x
% Ci'' qs,i, /5, ci-1-Q-7 Cil-
HEIGHT: WEIGHT .--1.
.

PATIENT'S IDENTIFICATION (For (SSN typed or written entries give . Name—last, fist, or other); hospital or medical facility) middle; ID No. REGISTER NO
\c) VITAL SIGNS RECORDS Medical Record

STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1

MEDCOM - 16462
DOD-029851

-

Ward/section: -REQIX.. ;17-.t.i..A.-:„.7,___ ...CHEMISTRY_RESULTFORIYI
. -,
: ! :11. :.
11.i (f: 7. r' 7''il9'...7 ' 14' -...' . (Stil)r i to the Privacy Act of 1974) (:;::= ' 1,1; ._
DATE.. T13.a - ,, SSN/PSEUPO S ..,i .. i...Ji 1.;'4,! i
LAST,.FiRS., .
,b1 '.
.. . :
... P 1 .., 4; , 1*. _ ,et! . *-;oci,p, t ,,,„,
...--,,,....
:r. ..4., ,,
,,,,, :-,, ..), ,.::,.:c.... -
TEST RESULT . __REE RANGE . __TEST_ I1 __RESULT I_REF. . ..: _TEST.::.:..R.ESULE , &INGE _ 'i i . :,.' . -LI i 1 ...1"; • ' ; 1 1 • LI ZiAirr•ii I -". ...i -: : 3A 1 13,.._;
...

_ ...
• 138-146 rnmp1/1-- ,, r ----73-118 mg7c11".•
a
'
3.5-4.9 %Ili:41914y' -7.77------'---; --7;22 eig/dl -­
...

PI CCOLO
1 CA++ :. ,...4, 1 r 8.0,10:3 nie/d1 -7
Cl -,,,. ?8-Ig9 mm°vL 14/08/03 17:26
0.6-1.2 mg/dl..__..

—... .-. -. -7..31-7.45 -- --REFERENCE RANGE :
pH MALE
PCO2 35 45 mmHg (T. PATIENT # :111111 .::) IL.c.)) Li ,' -i 128-145 rntriotil
4i-51 miajg (yea)

METLYTE 8
1 +
80-105 nunlig lam, 3.3-4.7:mnolt1
PO2
14/A (vela'_::..'': .._ DISC LOT # : 3152AA4 i 23-27:Mniotil. Carr 0F;ER ft : 1.11 9.8:108 mmol/1
TCO DR #: 000
24-29 InrnoUL (vet
22,..24 minwoo SERIAL #:

3LNIAL
HCO3 18-33 111117104 .1.::;
2S.-28 nupol/L (vct
s02 95-98% ... -'''L
FAA - t- OA'
GLU 94 73-118 MG/DL
. .. „
-

BE-ed --• (-2):.-(t3) --;-;--BUN 11 7-22 MG/DL TEST --. RESULT REF:RANGE
-
-

___....., 1 mn°11-; CRE 1 0.6-1.2 MG/DL ___ _T , _3 3.5 5 _edi .__,.._ _
__ . ..

10-20 -amnia: ' ALB
AriGap • • --CK 824* 39-380 U/L I., , ; . -73.: , , V.12-1.32 mmobi NA+._ _26-84 a/A__ ____
Ca . ¦ ., , 133.128-145 MDR._
8-26 rag/di Ki 4.7 3.3-4.7 MM0f/L T 1047 ail

BUN
__, .... ____ ... _._.... .,.. ._._...
CL-99 98-108 11101?/L i •-• ' ; 14-97 till• •
GLU '.-' 70-105001 tCO2 19.18-33 11102/1._ AMY 1
11-38 u/1
Creat 117-1.5 'g/di.I NST GC: OK 01-EM GC: OK AST
0.27 1.6 rag/d1
Het 38-51% PC11.1--EM 0.,.LIP 1+ ,.ICT 0 TBIL
__..__. 5-65.1uAL . _

Hgb .• ..
.. ,...........- 4-1-17. ea_ SST....._._

1 . .

6.4-8.1 gidl ... .
i TP.; -..
..7:::% .•:¦.',
'• • -­

•TEST , RESULT. REF.jRANG ..: . 616itile'ctiti e .
Tropirt-1 ---.—"—;:'i77 REF: RANGE
! -1284,45 mmol/1 --=
Drug of -;:::,.::::.
Abuse .i.: 1.r." -IU-. :', .1 ' i L

3.3-4.7 mmol/i
) ?:' .-. , , ., : ¦ ,. , _ CL.-. ---- ,..-;----, ..21710111R.111.1J1-_,
Ty .-11 .. :-,i 4.4. 1 !
ko I

.__ ..___ _ --1 I WO ------18 -33 torno1/1 _
1-
I 1-..'11

,..----- -- - - ---
REMARKS: ;.-2, , Z.:b
.
_ . .

. ;;t .., ....-z, -.,..7-.
REPORTED BY: ------- - • - - -DATE:- -- -.' --LAB ID NO.: .-------- -- .----1,------..
...-.1.-i ::-...1.r: 1,

i.-..7-. q-,-Z-. -....
.• 71:7/. r....., --. . . .
MEDCOM - 16463

DOD-029852

Ward/Section: L. REQ IAN: 1\0
LABORATORY RESULT FORM
(Subject to the Piivaeji A:a-01,1974)LAST, FIRST MI.
DATE TIME SSN/PSEUDO SSINT:
c.
Misc. Serology.- -
;;4114'gY)
(TEST RESULT REF. RANGE TES RESULT.-:REF.-TRANGE TEST RESULT REF. RANGE
"Color RPR-Negative
App N/A. Mono' motive
Glu Negative
Microbiology
Bili Negative .
.S.curce. 1 1
I ; -••
•Ket Negative Gram-
Staik "'" SG Oce Sid Negative:
r •

"Bld Negative , ;
H. pylot IlegaqY9 ": ; pH WA —
Parasites • Prot -Malaria -
Negati .; -
Urob 0.241.0
0 & P —

ympti Baso Nit Negative
Other .._

Atyp --Imm Leuk Ne
F9ropic

RBC -...Negative
Morph

Spun 42-52% (M)"
CSF IllogiBaqk
Hematocrit 37A7/0 (F) •. •1 -..•
• ,.4...

Sed Rate
, MUST. STIOI4t.j.0.50 WITRCount -EVERY UNIT REQUESTED
Other Diectigen Negative ABO/Rh
Coagulation Studies Blood. Bank thiit ST SUBMIT SF,SIBWITil gy.mx_Oar
:..14,EQUESTED)
TEST_ RESULT REF. RANGE _ _ UNIT TYPE .
r CROSSILITCH
PT 9.8-13.6 secs ­
'

AM 21-34 secs
D dimer 20 ug/ml
FDP 10 ughni
REMARKS:
REPORTED BY: LAB ID NO.: . ---

Millignel DATE:
MEDCOM - 16464
DOD-029853
‘tk

b ( z ek
‘) C0141-CAL RECORD . DOCTOR'S ORDERS
For usn-of this toren, see AR 4D.;8.6., the priiparierrt agency is crrsp
00,c.."
RECORD DATE TIME AND SIGN- EACH SET•OF ORDERS. IF PROBI_EM ORIENTED MEDICAL RECORD
SYSTEM. IS USED., WRITE PROBLEM
NUMBER IN COLUMN, INGICATED BY ARROW BELOW. _.......
•I'T..1F.NT LOENTlfreATION.:: • •,' ••••
DATE 90.
:'0-1'1601':: ... TIME:.::00, Ll TI Tf
impgru.

4::
1 .A.A.1 . :...:0 `..-3, _ ,,.,:, •,,. -..-...... .• - • , -..:. : ,.,..*-1664it. -14.0TEO AND
stoN.- •

. e f. 0-..:.• - .
_Art...„-J4---.:- • ., , ,..•...d......
. 5 c., s / . .6D. C...-Q-;'•
D.

...L.-.
:...•:-.44.7.t."...'''''' H'
: .' -1..

ROOM
. PATIENT'
C

. .
1110:I? NURS.UNIT ROOM.-NO Jc-L 61)• •PATiEN T. TOBN•TIFIC:ATION
[
ROOM NO. alp
•PATIE•NT 1.00.NTT•teArt.0N.
A4TE.•:-00-000.Eft:
:TYfME OF. ..0ROEFI:'}'
-
•

NURSING UNIT
REPLACES ern
-riots' OF ,t-JUL- /7,1 WHICH MAY RE USED MEDCOM - 16465
DOD-029854
• - Uuric DOCUMENTATION CARE PLAN -ML,iv-ME:D/CATiON)
CLINICAL RECORD. For use of this form, see AR 40-407* A4.0..DO-3
the proponent agenc is the Office of The Surgeon General. -
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MEDCOM - 16468
DOD-029857
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MEDCOM - 16470