Medical Report: 24-Year-Old Iraqi Male, Abu Ghraib, Iraq re: Leg Injury (0222-04-CID259-80256)

For Official Use Only OZ22·6'4.. e-U)"S~" ~a~s~ Law Enforcement Sensitive 0080-04-CID789

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DOD 003883
Law Enforcement Sensitive
MEDICAL RECORD
CHRONOLOGICAL RECORD OF
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DETAINEE IN-PROCESSING MEDICAL SCREEN
. \

SUBJECTIVE: AGE F DOB: ANY NEW MEDICAL ILLNESS OR INJURY? f)-..;' ()
IANY HISTORY OF TB? YES I @ IF YES, WHEN AND HOW WERE YOU TREATED?
-
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COUGH 2 WEEKS? YES/~
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COUGHING UP BLOOD: YES/@
-____0 •• ANY WEIGHT LOSS? ~/NO IF YES, HOW MUCH AND IN WHAT TIME FRAME? 1 k ([-
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ANY HISTORY OF HTN? YES/@ ANY HISTORY OF CAD? YES / @'§ IF YES, ANY HISTORY OF MI? YES/NO WHEN? ANY HISTORY OF DM? YES/@ IF YES, HOW LONG?
-
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ANY CHRONIC MEDICAL CONDITIONS NOT MENTIONED ABOVE? YES/@
--_.-
CURRENT MEDICATIONS:
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MEDICATION ALLERGIES:
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ANY MISTREATMENT SINCE BEING DETAINED? YES/@)
HISTORY OBTAINED THROUGH TRANLATOR? @/NO . NAME: ~b)(6)-7
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DEPART ./SERVICE IRECORDS MAINTAINED AT HOSPIT AL OR MEDICAL FACILITY STATUS
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RELATIONSHIP TO SPONSORSPONSOR'S NAME SSN/IO NO.
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I IWARD NO.
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For Official Use Only
USAPA V2.00
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MEDCOM -822

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. ' ULLL-U4-LIUL~8-~UL56
Law Enforcement Sensitive
0080-04-CID789

Description:
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ooaO-04-CID789
Plan:
Provider Signature: Printed Name I Stamp:
Routine Exam Form
Name: _...:-________ Date: __________
[SN: __________ 008: ______________ AGE: _____
Chief Complaint:
HPI:
PMH:
MEDS:
Allergies:
Physical Exam:
VS: BP P R 5a02 Weight
HEENT: Normal/Abnormal
CV; Normal I Abnormal
PULM: Normal I Abnormal
GI: Normal/Abnormal
GU: Normal/Abnormal
OB/GYN: Normal I Abnormal / NA
MS: Normall Abnormal
NEURO: Normal I Abnormal
DERM: Normal! Abnormal
ENDO: Normal! Abnormal
PSYCH: Normal! Abnormal

Comments / Findings:
--------I-Imp1'Cssion:
Disposition:
.~. 24
4
For Official Use Only

EXHIBIT;
Law Enforcempilt ,~.,n";thT"
MEDCOM·824
Cornplaillt: Acute:
PMH: OM HTN STn TB
Hosp: Surg: A:7fj' ft,....,,·, I
Allergies: rv'f-oQ"

For Official Use Only UUL.vV Law Enforcement Sensitive
0080-04-CID789
History and Physical Exam Form
Kb)(6)-4

Name:Ll___--.--_____~-----'
ISN:-k,__________
vs: BP: i"ji'-;,..

Pulse: ~'-, DOB: "7.-}7 ?;rO AGE: 'd-s. Resp: '1)$
Temp: Gender: @IFemale Height: CoI,..­
Weight: '''u \.......

Sod-Ix: Tobacco
EtOH

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CV: rUI r.
PULM: -+II ® GI: " .',
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PPO: Date placed: Date read: __mm

Immunizations: (given at this time)
MMR Td Typhoid Polio Influenza Meningococcal

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MEDCOM -825
DOD 003888
For Official Use Only U!L '-Uq-L.lULn~-t1U ,~.:: ~1 0080-04-CID789 ... ,,,J
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USE THIS PAGE IF NEEDED. IF THIS PAGE IS NOT NEEDED. PLEASE PROCEED TO FINAL PAGE OF THIS FORM.
J
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STATEMENT OF _--L-____ TAKEN AT
----'-_____ ~\M Cl(A. f'"c;..:\ DATED ~\G.-'C-w' 0"
9. STATEMENT (Continuedl
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INITIALS OF PERSON MAKING STATEMENT
I PAGE I OF I PAGES' -2 6
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PAGE 2. DA FORM 2823. DEC 1998
For Official Use Only
Law F.nforcpmpnt ~pn~itjvp
EXHIBIT: "7
MEDCOM -826
DOD 003889

for UIIlClal use vmy Law Enforcement Sensitive 0080-04-CID789
HEALTH RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE

I

SYMPTOMS, DIAGNOSIS, TREATING ORGANIZATION (Sign each entry)
PRE-TRANSFER MEDICAL ASSESSMENT
IS .·~l\Jt
"LIST ANY YES RESPONSES IN RAMARKS SECTION ON REVERSE SIDE OF FORM
AGE:~
(Y) (N) (Y) (N)
( ) (XL Allergies ( ) c,j'Recent i1lnosslinjury ,-­
( I ( I [Jentat Prob·lems (-'T ( 1 History ol'psychological problems (Date; ? ._. ( ) cl ~!V po,itive (:'J( ) Chmnit.: health problC!ms or intt:(;(iuus Ui.s!.:ilSCS
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( ) Prel'iolls SUicide I\ttempts (Datc) ( ) ( j Females only; Are you pregnant? N/4 _Jf------'--'-.
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4. Night sweatsI
s. P",in
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7. LiceiO(hel" inf't::;;tation
8. Contagious disease in the past 12 months')
I
B. Other:
+*... ,
i FOR MEDICAL PERSONNEL USE ONLY DETAINEE'S INITIALS '-___1
-HIV,TUBERClJLOSIS QU ESTiONAIRE
Do you ha ..'c LI hi.s:CJry or, or do you presently have .Iliy of tht: following symptoms or conditions:

1=
-(VJ ( ) PersIstent cough/shortness or breath (t.1" (, ) Cough wilh blood and/or dry cough
m IN) (Y) (N)
.
I.) I v1 ync'plained weight loss/diarrhea X 2 lVeeks (0' ( ) Unt!xplnined persistent r~\/er
----/
( ) ( .{ Night Swellts ( 1 ('"1 / Swollen glanu,/Iymph nodes I' --.-~0, I;rolonged r""glle or run -clown i"eclll1g I ) (:or Loss of appetite anu or whil t:: patches In muuth _1_(_)... /1:1 Rl!t:cnt exposure 10 Someone with TB ( ) (11'"P1SI abnllmlal X -Ray (Dute)
-
1-----() ( ) Hepatitis 8 series completed l ) (vr'Pre.vious Til infection or Ircat"wni
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( ) (Vl Stomach surgery, Kidney railu re, Btood disord~rs
( ) I ) Scars, birlhmark~, tailcos: ~l'"E ~I"""-(I-~"""" F(;rL U~v-ih( i
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PATIENT"S IDENTIFICATION lU.~ Lhls space for Mt:~lulllctll lml,rlOd RECORDS MAINTAINED ~ AT:

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-
SPONSOR
----_.-
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DETAINEE
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SPONSOR'S NAME ·1 ORGA~IZATIO'"
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DATE
SYMPTOMS. DIAGNOSIS, TREATMENT. TREATlNQ OFlGANIZATION fSiQn NCh 6fltryj
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ANY NEW MEDICAL ILLNESS OR INJURY? N t!)
ANY HISTORY OF TB? YF.SJ~ IF YES, WHEN AND HOW WERE YOU TREATED?
,
COUGH 2 WEEKS? YES 1&
-_...
COUGHING UP BLOOD:
YES®
-ANY WEIGIIT LOSS? f!!j./NO IF YES. HOW MUCH AND IN WHAT TIME FRAME'? ~ k I LOltli ANY HISTORY OFHTN'! YES/@ ( ANY H1STORY OF CAD? YESI@§ IF YES. ANY HISTORY OF MI? YES I NO WHEN? ANY HISTORY OF DM? YES® IF YES. HOW LONG? ANY CHRONIC MEDICAL CONDITIONS NOT MENTIONED ABOVE? YES/~
-
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MEDICATION ALLERGIES;
~'KA ABLE TO WALK UNASSISTED? ~NO ABLB TO FEED YOURSELF? @I NO
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-
HISTORY OBTAINED THROUGH TRANLATOR? NAME:
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HOSPITAl OR ,..I;:PICAl FACI1.ITY I
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rEGISTeR NO. IWARD NO.
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Medical Record STANDARD FORM 600 (AN. (;·971Pr.scriblld by GSAJICM ~ F1RMR l41 CFA) 201-9.202-' U~A"'~ QO
For Official Use Only
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MEDCOM -829
OOBo-o4.:crD78~\wi" '-IV
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DATE
SYMPTOMS. DIAGNOSIS, TREATMENT TR~T'NG ORGANIZATION (Sign filCh flfWyi OBJECTIVE: HEIGHT: f(: ~ WEIGHT: J1!C' 02%: TEMP;
SP:"okc PULSE~ RBSP~ I ~
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REFER TO PA OR MD
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CURRENTLY HAVING CHEST PA~N. ABNORMAL MENTAL STATUS OR ANY OTHEJt CONCERNS
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DOD 003895
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History and Physical Exam Form
""~b~)(6~)-~4--------~~~--~1
Namt:~l______~________________~.

ISN:~I__________________
VS: BP:'-""/7'"l... ruhe: ~~I DOS; 7--il-} );1) AGE: ~s Resp: fj( Temp: Gclllder; A/Female fteigbt: fpV'
Weieht: ['lrV i-.... Compla!nt: Acut~: PMH: DM HTN STU TB Cbro'llk; "~\.3.·,,,,, /~;""'-1~h HMP:
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CV: 1?7r_,
PULM: l!T! r&;
Cl~ ,
GU: ~ )I·.~r: ":' ~ t.?

01llGYN: "l,. "-
MS: r~l. "-,
NEURO:,-If'­DERM: 0 .......,/
ENDO:" PSYCH;
Phy,kal Rum: HEENT:
CV;
PULM:
GJ:
CU:
OBIGYN:
JIIIS:
NEURO:
DERM:
ENDO:
PSYCH:
Comments / f'llIdinp:
=" ,Attnormal Abnormal Or 1Abllorm.l
'e
~I Abnormld ~/AbnoTm:rl.1 Normal I Abllorm~11 ~Abnormal
Abn.ormal AbllormaJ

I Abnormal
Su.rg~ I"rf;i Pc "'''q AlLrl"glu:
,vl--::...
CXI2.: Normal / Abnf)rmlll
Findillgs:
PPD: Dllte plao:'cd:
Date ~ad:
_mm Imnlllllizalfolls: (giVt'R at tilb tim c)
MMR 'fd Typhoid Polio
NA
Pboto-gr&ph

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MEDCOM -833
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Plio.:
Prnvider Si&D9.'llre~ Prlnteii Name' Stamll: Routine E-xam F1lrm Na~t: __~____________
Da'~: ____~____ ISN: ___________________ 008: ____________ AGE: _____
Cbief Complaint: HPI:
PMH:
MEDS:
AlIer&ics; Physka] Enm:
vs: 8P p R Weight
»tENT: Nurmall AbnoTlul
CV: Normal I Abnormal
PULM: Normal} Abnormal
GI: Nonnall Abmormal
au: Normal' Abnormal
OBKlYN; Normal I Abllormsll NA
MS: Narmall AbnGrmal
NEURO; Normldl AbnorDl81
DERM\ N-ormslJ Abnormal
E:NOO: Normal I Abnormal
PSYCH: Ncirm\llll AbllClrma'

ComlDl!Rts Jricdings: Impru51C1f1:

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MEDCOM -834

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Description:

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Lllw EnfONement Sen!oitivc ---0080-04-cr076'
HEALTH RECORD DETAINEE PRE-INTEROGATION EVALUATION

FaMily Practk:e Physician

For Official Ulle OnJy
Law Enforcement Sensitive

MEDCOM -836
·' --\ ~aw Enfon:e.meot SCDsjf4vf. ---~. oi!0e0-04-C1D7f19
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